Doctors at Great Ormond Street are being encouraged to consider air pollution levels at their patients’ home addresses when assessing the causes of their illnesses, under an innovative pilot scheme.
Data showing the average annual air pollution rates at patients’ postcodes has been embedded in patients’ electronic files, so that clinicians can help families understand whether their child has been exposed to elevated risk.
The initiative comes in response to criticisms made by the coroner during the inquest of Ella Adoo-Kissi-Debrah, who was nine when she died from asthma 10 years ago, and who in 2020 became the first person in the UK to have air pollution listed on her death certificate as a cause of death.
The coroner, Philip Barlow, noted that Ella’s mother, Rosamund Adoo-Kissi-Debrah, “was not given information about the health risks of air pollution and its potential to exacerbate asthma”. In his prevention of future deaths report, Barlow warned that the adverse effects of air pollution on health were not being sufficiently communicated to patients and their carers by medical and nursing professionals, and called on medical staff to do more to inform families about the dangers of air pollution.
Ella’s mother has said the family “would have moved straight away” if she had been told that her daughter was being killed by the air she was breathing.
The Great Ormond Street hospital initiative was conceived by Mark Hayden, who works in the intensive care unit, with colleagues Nicola Wilson and Johanna Andersson. Hayden said there had previously been a “significant knowledge gap” at the hospital regarding air pollution and its effects.
Data added to patients’ electronic records provides information on fine particulate matter (PM2.5) and nitrogen dioxide, and indicates whether they exceed World Health Organization safe levels. The information will encourage clinicians to think about whether air pollution is a factor in the patient’s illness. The pilot model has recently also been adopted by the Evelina children’s hospital, Guy’s and St Thomas’ and King’s College hospitals in London, so that air pollution is now visible on more than 2.5 million patients’ files.
In a report on air pollution and health, the chief medical officer for England, Chris Whitty, last year said doctors should be doing more to educate patients about the risks of air pollution, and noted that healthcare staff needed training in helping discuss with patients how they can minimise the effects of air pollution. Ella’s coroner also called for better training of medical staff in the effects of air pollution.
At Great Ormond Street the air pollution data only flashes up if the levels at the child’s postcode are higher than the WHO 2021 safe limit guidelines. Aware that older doctors will have received almost no teaching on the health risks of air pollution, Hayden has added links to background briefing pages to the files of patients who have had excess exposure. These pages cite WHO guidance explaining that air pollution is the “single biggest environmental threat to human health”, responsible for 7 million global deaths a year; the link that flashes up notes that 40% of all premature births (6 million) are attributable to PM2.5 annually worldwide.
There is also an option to create a letter to parents setting out the steps they can take to minimise their child’s exposure to the air pollution and providing them with a prototype letter they can send to their MP highlighting that they have been warned by doctors that air pollution in their area is exacerbating their child’s ill heath.
The Royal College of Physicians, in its formal response to Ella’s inquest, acknowledged that clinicians often shied away from discussing the issue, noting: “Many patients and their families will not be able to make the changes that will have the most benefit – that is, change where they live, work and play – so doctors and other clinicians may be uncertain of the benefits of such a conversation.”
Hayden agreed that staff have historically been uncomfortable about talking about the health risks posed by air pollution. “Obviously, air quality is a bit harder to fix than an infection. You can’t just give some antibiotics,” he said.
The consultant respiratory paediatrician Andrew Turnbull said staff were beginning to talk to patients with severe asthma about outdoor air pollution alongside conversations about tobacco and e-cigarette vapours, mould and damp exposure, dust and pet allergies.
“We’ve had a long understanding of the robust links between poor air quality and adverse outcomes, but getting data at this level is new,” he said. Given that most families do not have the option to move to less polluted areas, conversations are limited to strategies to reduce an individual’s air pollution exposure, perhaps around modifying a patient’s route to school.
Because most respiratory illnesses have complex, multifactorial causes, linking an individual’s disease to one cause remains challenging but the addition of air pollution data also had important research potential, helping staff to “understand how adverse pollution links to individual patient outcomes”, Turnbull added.
Hayden hopes the initiative will be introduced more widely, particularly at GP practices. “It does bring up dilemmas, because it would feel wrong to place that problem on a family that can’t do anything about it, but we’re trying give clinicians the resources they need to have that conversation with families who can then use that information to try to protect their children from further harm,” he said.