Development of an implementation package for Asthma Medication Optimisation in the Emergency Department (AMEND) - an evidence, theory and person-based approach

This paper describes the development of the AMEND implementation package, a theory- and evidence-based intervention utilizing a person-based approach to support the transition from salbutamol to Maintenance and Reliever Therapy (MART) for adults discharged from the Emergency Department with uncontrolled asthma.

The Gist

The Big Picture: The "Teachable Moment" in the ER

Imagine you go to the Emergency Department (ED) because your asthma is acting up. You're wheezing, you can't catch your breath, and you're scared. The doctors give you a quick fix to stop the wheezing right now (a "reliever" inhaler), and then send you home.

The Problem:
For years, the standard practice was to send patients home with just that quick fix. But many people keep using only the quick fix and forget to use their "preventer" medicine (which stops the asthma from flaring up in the first place). It's like putting a bucket under a leaking roof to catch the water, but never fixing the hole in the roof. Eventually, the bucket overflows, and you end up back in the ER.

New medical guidelines say: "Stop just patching the hole; fix the roof!" They recommend a special inhaler (called MART) that acts as both the bucket and the patch. But, doctors in the busy ER often stick to the old habit because they are rushed, unsure of the new rules, or worried about confusing patients.

The Solution (AMEND):
The authors of this paper created a "toolkit" called AMEND (Asthma Medication Optimisation in the Emergency Department). Think of AMEND as a GPS navigation system for doctors and patients to help them switch from the old, leaky-roof method to the new, fixed-roof method right before they leave the hospital.

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How They Built the Toolkit (The 3-Step Recipe)

The researchers didn't just guess what would work. They used a "Person-Based Approach," which is like designing a video game by actually playing it with the users first to see what's fun and what's frustrating.

Phase 1: Listening to the Players

They interviewed patients and doctors to understand the "roadblocks."

• The Doctors' View: "I'm in a rush. I don't have time to explain complex new drugs. I'm worried I'll get it wrong."
• The Patients' View: "I'm scared of steroids. I don't understand why I need a new inhaler. I'll probably forget the instructions by the time I get home."

The Insight: They realized they needed to make the new method simple, fast, and reassuring.

Phase 2: Designing the Tools

They built a specific set of tools to tackle those roadblocks, using psychology theories to make sure the tools actually changed behavior.

1. For the Doctors (The "Cheat Sheet"):

   • A Decision Aid: A simple flowchart (like a "Choose Your Own Adventure" book) that helps the doctor quickly decide if a patient is ready for the new inhaler.
   • Training: Short, punchy videos and slides that explain why the change is happening, so doctors feel confident, not confused.
   • The "Auto-Pilot" Letter: A template for the discharge letter that automatically tells the patient's regular doctor (GP) what changed, so no one gets left out of the loop.

2. For the Patients (The "User Manual"):

   • An Animation Video: Instead of a boring pamphlet, they made a short, clear cartoon video explaining how the new inhaler works. It's like a "How-To" guide for your lungs.
   • Take-Home Leaflets: Simple papers with QR codes. If you scan the code, you can watch the video again on your phone later.
   • The "No-Quiz" Rule: Early drafts had a quiz to test patients. Patients hated it! They felt judged. The team removed the quiz and focused on just giving clear, friendly info.

Phase 3: The "Test Drive"

Before launching, they let doctors and patients "test drive" the materials.

• Doctors said, "Hey, if I'm prescribing this new inhaler, I need a warning box that says 'Don't also give the old quick-fix inhaler!'"
• Patients said, "I don't want to feel like I'm being tested. Just tell me what to do."
• The Fix: They added the warning box and removed the quiz. They also made sure the new inhalers were actually in stock in the hospital cupboards so doctors could hand them out immediately.

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The Final Toolkit: What's Inside?

The final AMEND package is a five-part kit designed to fit into the chaotic ER workflow without slowing anyone down:

1. The Animation: A friendly video for patients to watch on a tablet or phone.
2. The Leaflet: A simple paper guide to take home.
3. The Decision Aid: A digital flowchart for the doctor to click through.
4. The Training: Short videos for doctors to watch during their shifts.
5. The Discharge Template: A pre-written note to send to the patient's regular doctor.

Why This Matters

Think of the Emergency Department as a fire station. Usually, they just put out the fire (the asthma attack) and send you home. But if they don't teach you how to prevent the next fire, you'll be back.

AMEND is the fire safety kit they hand you before you leave. It ensures that:

• The doctor knows exactly what to prescribe.
• The patient understands why they are getting it.
• The patient's regular doctor knows what happened.

By making this switch happen right in the ER, the goal is to stop the cycle of repeat visits, keep people breathing easier, and fix the "leaky roof" for good.

The Bottom Line

This paper isn't about a new drug; it's about a new way of delivering the right drug at the right time. It proves that if you listen to patients and doctors, and design tools that fit their busy lives, you can change how healthcare works—even in the most chaotic places like the Emergency Room.

Technical Summary

1. Problem Statement

Clinical Context:

• Current Practice: Adults discharged from Emergency Departments (ED) with uncontrolled asthma are typically prescribed Salbutamol (Short-Acting Beta-Agonist, SABA) as a reliever.
• The Issue: This pattern leads to SABA overuse and preventer (Inhaled Corticosteroid, ICS) underuse, increasing the risk of hospital admission and poor outcomes.
• Guideline Shift: Recent national (NICE/BTS/SIGN) and international guidelines recommend Maintenance and Reliever Therapy (MART) using a low-dose ICS/formoterol inhaler. This ensures patients receive anti-inflammatory medication whenever they use a reliever.
• Implementation Gap: While guidelines exist, implementation in primary care is slow, and the ED setting remains underutilized for initiating this change. EDs are high-pressure, fast-paced environments where clinicians face time constraints, role ambiguity (viewing long-term management as a primary care responsibility), and a lack of confidence in prescribing new regimens. Furthermore, follow-up care for ED patients is often limited, particularly for ethnic minority groups.

2. Methodology

The study employed a systematic, multi-phase intervention development process guided by the Medical Research Council (MRC) framework, the Behaviour Change Wheel (BCW), and the Person-Based Approach (PBA).

Phase 1: Understanding the Problem & Guiding Principles

• Data Sources: Synthesized evidence from previous qualitative studies (in-depth interviews with 38 patients and HCPs) and an integrative literature review.
• Theoretical Frameworks:
  • Theoretical Domains Framework (TDF): Used to deductively analyze barriers and facilitators (e.g., knowledge, skills, beliefs about consequences, professional role).
  • Perceptions and Practicalities Approach (PAPA): Distinguished between perceptual barriers (beliefs about necessity vs. concerns) and practical barriers (resources, workflow).
• Outcome: Established "Guiding Principles" to ensure the intervention was acceptable, feasible, and addressed specific user contexts (e.g., minimizing cognitive load for HCPs, providing take-home resources for patients).

Phase 2: Identifying Content & Implementation Options

• Target Behaviors: Five specific clinician behaviors were identified: (1) Identify suitable patients, (2) Identify correct inhaler, (3) Communicate rationale/agree change, (4) Provide inhaler/resources, (5) Communicate change to primary care.
• Mapping: TDF domains were mapped to these behaviors to select appropriate Behaviour Change Techniques (BCTs) (e.g., prompts/cues, instruction on how to perform, modeling).
• Logic Model: Developed to visualize the hypothesized mechanism of change from inputs (training, decision aids) to outputs (increased MART prescription) and outcomes (improved asthma control).

Phase 3: User Testing & Refinement (Iterative)

• Stakeholder Engagement:
  • Patients: Two online workshops (13 participants total) and a structured survey (12 respondents) tested patient-facing materials (animation video, leaflets).
  • HCPs: Six "think-aloud" interviews with ED doctors (consultants and trainees) tested the clinical decision aid.
• Refinement Process: Feedback was prioritized using the MoSCoW method (Must have, Should have, Could have, Won't have).
  • Key Changes: Simplified video messaging (removed "quiz" elements to reduce anxiety), added spacer images to decision aids, added warning boxes against duplicate SABA prescribing, and created pre-populated discharge templates.

3. Key Contributions: The AMEND Implementation Package

The resulting package is a multi-component intervention designed for seamless integration into ED workflows:

1. Clinical Decision Aid: A hyperlinked flowchart for HCPs to identify eligible patients, select the correct inhaler, and navigate prescribing guidelines. Includes visual aids (spacer images) and warnings against concurrent SABA prescription.
2. HCP Training Package:
   • A 5-minute pre-recorded video for handovers.
   • 30-minute in-person teaching sessions.
   • Focuses on the rationale for MART, assessing patient suitability, and using the decision aid.
3. Patient-Facing Resources:
   • Animated Video: Explains well-controlled asthma, the role of MART, and addresses steroid concerns.
   • Written Leaflet: Take-home information with QR codes linking to digital resources.
4. System Integration Tools:
   • Template Discharge Summary: Pre-populated text for electronic health records to ensure clear communication of medication changes to General Practitioners (Primary Care).
   • Organizational Support: Strategies to ensure stock availability of MART inhalers in "To Take Away" (TTA) cupboards.

4. Results

• Feasibility: The iterative testing confirmed that the package is feasible within the time-constrained ED environment. HCPs found the decision aid clear and the training valuable for building confidence.
• Acceptability: Patients found the animation concise and non-threatening. The removal of "testing" elements (quizzes) significantly improved patient engagement.
• Barriers Addressed: The package specifically targets:
  • Knowledge: Through training and decision aids.
  • Skills: Through demonstration and rehearsal in training.
  • Beliefs: Addressing fears of steroids and clarifying the ED's role in long-term management.
  • Environment: Providing physical resources (inhalers, leaflets) and digital prompts (QR codes).

5. Significance and Implications

• Theoretical Advancement: Demonstrates the successful application of behavioral science frameworks (TDF, BCW, PBA) in a high-acuity, acute care setting to change prescribing behavior.
• Clinical Impact: Provides a pragmatic model to translate updated guidelines into practice, potentially reducing SABA overuse, improving long-term asthma control, and decreasing repeat ED attendances.
• Health Equity: By targeting the ED—a point of contact for underserved populations and those with limited follow-up—the intervention aims to reduce health inequalities in asthma management.
• Scalability: The package is designed to be low-burden and adaptable, with potential for expansion to Urgent Treatment Centres (UTCs) and other unscheduled care settings.
• Future Work: The authors propose a future evaluation to assess clinical outcomes, implementation fidelity, and equitable impact across diverse demographic groups.

Conclusion:
The AMEND package represents a theory-driven, evidence-based, and stakeholder-informed solution to a critical gap in asthma care. By shifting the focus from simple education to a comprehensive implementation strategy that addresses both clinician behavior and system constraints, it offers a viable pathway to optimize asthma medication at the point of ED discharge.