In recent years, the Asthma Society of Ireland (ASI) has reached out to asthma sufferers around the country with the intention of helping them to better control and self-manage their condition by inviting them to speak directly with an asthma nurse on all aspects of their asthma care, free of charge. Dozens of free regional clinics have attracted significant numbers since they commenced in 2010. During the past year, this initiative has been extended to community pharmacies with tremendous success.

The overwhelmingly positive feedback from the many hundreds of attendees, both at the pharmacy and regional clinics, is proof that there is a great need in the community for nurse-led asthma education. Now, with the support of GlaxoSmithKline (GSK), the ASI expects the number of pharmacy asthma clinics to increase substantially. 

“The pharmacy clinics have really taken off this year. They are a very important part of our service,” said Sharon Cosgrove, the ASI’s new chief executive. “As of August, we’ve had 43 pharmacy asthma clinics that were supported by GSK and 27 others independently booked by pharmacists, so that’s 70 pharmacy days so far. 

“During those clinics our asthma specialist nurses have seen 241 adults and 126 children. That’s a tremendous amount of work and it all brings us that bit closer to our goal of optimising asthma control in Ireland.”

An ideal vehicle

Pharmacists are well placed to deliver this complimentary service to their patients and can make a significant impact on the overall management of asthma in the community. 

The Pharmaceutical Society of Ireland maintains that community pharmacies have the potential for relatively high penetration into the population, given that there are more visits to the 1,600 or so community pharmacies around the country on a monthly basis than to any other element of the primary healthcare service.

A recent survey reported that three-quarters of the Irish adult population use community pharmacies at least once a month, with more than 10 million visits/consultations a year.

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The overarching aim of these ASI pharmacy asthma clinics is to give patients access to good quality information from a specialist respiratory nurse so that they are fully empowered and confident to embrace self-care of their asthma. 

“We’ve been running these clinics for a while now on a request basis where the pharmacist contacts us and we arrange a time and date that suits them and our asthma nurse. We use the same team of specialist asthma nurses for these pharmacy clinics as we use for the regional clinics,” explained Niamh Kelly, the ASI’s corporate affairs and programme co-ordinator.

“At the end of 2011, we started a programme with GSK, in which they part-fund the asthma nurse for these clinics. GSK has reps in each region and they go out to the pharmacies and discuss with them the opportunity of hosting an asthma clinic. The pharmacists can still book and arrange a clinic through us, but it is a big boost in this economic climate to have the cost subsidised.

“The pharmacist will then advertise the clinic in his store or in the local primary care centre, and take bookings from interested patients. The majority of pharmacies have a consultation room on the premises, which offers comfort and privacy, perfect for the one-to-one patient consultations with our nurse. 

“We have some information materials for these GSK days that are co-branded. The pharmacist is provided with posters to promote the upcoming clinic, and they also receive an appointment schedule that they can record the individual’s name and details, and an appointment card is then given to the patient. We also send them a box of our literature, which would include some posters and most of the ASI’s main booklets. These can be distributed to patients on the day of the clinic if they need some additional information.”

Patient empowerment

When enrolling interested patients, the pharmacist asks them to bring their asthma medication with them, and any spacer device and peak flow meter, if they have them. The ASI asthma nurse will also have placebo (dummy) inhalers and spacers available for demonstrations. 

To ensure that each patient is allotted sufficient time with the nurse, the clinics run to a set formula. The day commences at 10am and continues until 4pm, closing for an hour around mid-day. Patients have 20 minutes for a personal consultation with the nurse and no more than 18 patients will be seen at any one clinic.

“It is very important that the nurse has time with each person so that their level of control can be properly assessed and that, when they leave, they feel that they can now understand and more effectively manage their condition,” Niamh added.

Frances Guiney, the ASI’s director of patient services and an asthma nurse specialist, feels strongly that people with asthma should be educated about their condition and how to control it. 

“This is a comprehensive asthma review. Our clinics give the person with asthma an opportunity to talk to an asthma nurse specialist and have their asthma management reviewed. Basically, the nurse can establish how controlled this person’s asthma is and can then advise how to better manage their condition,” she said.

“We would look at how they’re taking their medication: are they taking their controller inhaler regularly or are they relying on the reliever inhaler? We would also look at their inhaler technique. Quite often we find that people are not using their inhaler correctly and therefore not getting sufficient medication into their lungs.

“The nurse will also test their lung function using a peak flow meter, and give them a tailored consultation around their asthma management based on their level of control, asthma triggers, medication and so on.

“She would then run through an asthma management plan with them and if there was any need to be referred back to their GP, she would do that also,” said Frances.

“Occasionally we might find that a person has difficulty using their inhaler properly, so we would look at using an adjunct, such as a spacer device, for better delivery of the medication... Other determinants, for example, if there are any known allergens that trigger their asthma, then avoidance measures would be reiterated or would be explained to them. We would encourage them to get the flu vaccine, if the nurse felt they would benefit, and smoking cessation would be discussed, if that were also an issue.

“Most importantly, some form of management plan would be instigated so that they recognise any signs that their asthma is deteriorating and they would know what to do about it.”

Train the trainers

Frances mentions that most pharmacists also avail of the onsite expertise, brushing up on the correct use of an inhaler with the asthma nurse, so that they can clearly demonstrate inhaler technique to their patients, if required. 

The ASI believes it is essential for pharmacy to play a supporting role in delivery of asthma care. Study results of the Finnish Asthma Programme, which involved pharmacists, GPs and practice nurses, demonstrated a 54% reduction in hospitalisations, 90% reduction in mortality and a 36% reduction in the cost per patient per year. The education of these healthcare professionals was delivered by a simple, cost-effective train-the-trainer approach. The ASI is now working with GSK on a similar train-the-trainer programme for pharmacists in Ireland. 

“We would see a small number of pharmacist advocates being trained by our nurses to go out and train other pharmacists. Although some would have a good knowledge of inhaler technique, this training will reach those pharmacists who may not, as well as instructing them on asthma management and emergency plans, and a refresher on trigger avoidance and smoking cessation,” said Niamh.

The ASI closely monitors feedback from the clinics, as it helps it to better gauge the level of asthma control in the community and highlights concerns of patients and professionals alike.

Positive feedback

The overwhelming consensus of pharmacists and patients who took part is that this initiative is helping people with asthma to take better control of their condition.  

“Anybody who saw the nurse got great benefit out of it and were very pleased with the nurse,” said one pharmacist. “Worthwhile exercise, patients and staff pleased with the way the day went,” commented another.

“We would encourage more pharmacists to participate in these clinics. Once we have at least a month’s notice, we can source the nurse and send down the promotional and information materials to the pharmacy,” Niamh said.

“Most pharmacists find it very easy to recruit patients to the clinics. People are becoming more interested in bringing their asthma under control and self-managing. There is a big push in the Department of Health to encourage patients to self-manage their chronic conditions, with the support of primary care professionals. In the long run, it improves health and it saves money. The pharmacy asthma clinics are an important part of this movement.”

Frances stressed that the feedback from their asthma nurses is that many people are not in control of their asthma. 

“It’s very sobering in fact, we’re hearing that the lack of control is frightening. Our nurses are telling us that a significant number of people are not using their inhalers correctly; reliever therapy was excessive and inhaler technique was very poor. Some didn’t know the difference between their blue and their brown inhalers and some had never heard of a peak flow meter. They were unaware of deteriorating signs. There was a lack of self-management plans. Without a doubt, there is a huge need for these pharmacy clinics and we would urge any pharmacists with an interest in running an asthma clinic to get in touch with us,” she said.