SCHN Asthma Follow-up Project

Summary of project

Children over the age of two years, who re-present to Sydney Children’s Hospital, Randwick ED with asthma or Viral Induced Wheeze (VIW) and are then discharged home from ED, represent a vulnerable group who appear to have limited optimal support and care in the community.  By implementing an integrated model of asthma/VIW follow-up care using a bundle of change ideas we were able to significantly reduce the number of representations made by this group of children. These change ideas included;

  • Care coordination
  • Enhancing links between the hospital and community services
  • Improved communication with General Practitioners (GP)
  • Parental education
  • Emergency department flagging

The target patient group for this project was those with “non-complex asthma/VIW”, defined in this project as being patients aged between 2 and sixteen years and having 4 or more presentations to ED without admission. 


he project was analysed pre and post enrolment, with patient presentations before intervention, compared to presentations post intervention. The analysis revealed that between the 6 months prior to project implementation and the 6 months post implementation, there was a 57% reduction in representations of children with non-complex asthma/VIW (99 to 43 presentations in 46 children). When the 12 month pre and post data was analysed for children who were enrolled December 2016 to February 2017 there was a 68% reduction in representations (57 to 18 presentations in 12 children).

Who was involved?

The success of this project was owed to its collaborative and multidisciplinary approach. This included a commitment to engaging hospital clinical staff, local GPs and practice nurses, CESPHN representative, parents of children with asthma/VIW and representatives from Asthma Australia.

What can GPs expect from this initiative?

  • Care Coordinators send a pdf letter to the parent/guardian (536 KB)  that highlights the importance of viewing asthma/VIW educational resources such as those offered by SCHN and Asthma Australia. This parent/guardian letter also encourages;
  • attendance at Asthma/VIW education sessions at SCH
  • appropriate and regular use of their Asthma Action Plan
  • follow-up with the child’s GP within 2-3 days following discharge and regularly thereafter
  • Care Coordinators also send a pdf letter to the family’s nominated GP (515 KB)  that flags the child as having re-presented to SCH ED and encourages regular reviews of the child. This letter also includes recommendations for best practice management of the child’s asthma/VIW and summarises pdf asthma management tools. (670 KB)
  • All parents/guardians are given a medication weaning plan, and/or asthma action plan, standardised asthma/VIW resource pack upon discharge from ED and provided with asthma education.
  • GP, ED and parent asthma/VIW education sessions take place at SCH, as well as GP education via Webinar.

What next?

This integrated care initiative has now been sustained as usual practice for over 12 months. The project group will now commence Phase 2 of the project which will address the needs of children with asthma and VIW who repeatedly present to SCH and require admission. SCH is now asking for pdf Expressions of Interest (207 KB)  from GPs to join Phase 2 of the Asthma Follow-up Project.

Click here to view the EIS Health Representation Policy.