Saving lives of in‐patients with adrenal insufficiency: implementation of an alert scheme within the Newcastle‐upon‐Tyne Hospitals e‐Prescribing platform

Mitchell, Anna L.; Napier, Catherine; Asam, Muhammad; Siddaramaiah, Naveen; Heed, Andrew; Morris, Margaret; Miller, Margaret; Perros, Petros; James, R; Ball, Stephen G.; Pearce, Simon H. S.; Quinton, Richard

doi:10.1111/cen.12457

Cited by 6 publications

(9 citation statements)

References 2 publications

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“…This should not be taken for granted, given the considerable resourcing pressures faced by most units. Recent initiatives at some teaching hospitals to introduce pop-up alerts on adrenal patient hospital records about the time-critical nature of emergency medical treatment and administration of glucocorticoid doses will undoubtedly assist in this respect [38]. A further promising safety initiative has been for direct ambulance registration of steroid-dependent patients by home address, with registration being arranged by their treating hospital [39].…”

Section: Discussionmentioning

confidence: 99%

A retrospective analysis of adrenal crisis in steroid-dependent patients: causes, frequency and outcomes

White

2019

BMC Endocr Disord

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Background: Adrenal patients have a lifelong dependency on steroid replacement therapy and are vulnerable to sudden death from undertreated adrenal crisis. Urgent treatment with parenteral steroids is needed, often with IV saline for volume repletion. Episodes of adrenal crisis are, for most patients, relatively infrequent and they may not be well prepared to respond. This study explores how patients recall previous episodes of adrenal crisis and their satisfaction with UK emergency medical treatment. Methods: We invited members of the main UK support groups representing steroid-dependent adrenal patients to complete an online questionnaire identifying the number, causes and location of previous adrenal crises (episodes needing injected steroids and/or IV fluids). Respondents were asked to rate the adequacy of their medical treatment in 2 successive questionnaires, conducted 2013 and 2017-18. Results: Vomiting was the major factor identified as a cause of adrenal crisis, indicated by 80% of respondents. The most common location, at 70%, was the home. Of the 30% away from home, 1 in 3 were overseas or travelling long-distance. Self-treatment played an increasing role in emergency response: in the 5 year interval between questionnaires an increasing number of patients self-injected. By the time of the 2017-18 survey self-injection was the most common method of initial treatment, with less than two-thirds travelling to hospital for follow-up medical treatment. This finding help to explain the higher rate of adrenal crisis identified in patient surveys than in hospital records. Satisfaction with medical care received stayed constant between the 2 surveys despite growing resourcing pressures across the NHS. Two-thirds were happy with the quality of the medical treatment they received for their most recent adrenal emergency; timeliness was the main factor influencing satisfaction. Conclusions: Around one-third of adrenal patients report sub-optimal treatment at emergency medical departments. Medical staff have a low probability of encountering adrenal crisis and may be unfamiliar with either the urgency of adrenal crisis or the specific treatment response it requires. Comprehensive protocols for emergency medical staff with detailed patient education and training are needed in how to respond to this infrequently encounteredbut acutely life-threateningscenario.

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Section: Discussionmentioning

confidence: 99%

A retrospective analysis of adrenal crisis in steroid-dependent patients: causes, frequency and outcomes

White

2019

BMC Endocr Disord

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“…Following the diagnosis of AI, comprehensive educational outreach should include the family and caregivers, the primary care physician, and the local emergency care providers regarding the signs, symptoms and treatment of cortisol deficiency to prevent adrenal crises. Electronic medical records (EMR) may be used to flag patients with known or at high risk for AI to increase provider attention 32 33…”

Section: Outpatient Prevention Of Acute Aimentioning

confidence: 99%

Emergency Management of Adrenal Insufficiency in Children: Advocating for Treatment Options in Outpatient and Field Settings

Miller

Spencer

Geffner

et al. 2020

Journal of Investigative Medicine

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Adrenal insufficiency (AI) remains a significant cause of morbidity and mortality in children with 1 in 200 episodes of adrenal crisis resulting in death. The goal of this working group of the Pediatric Endocrine Society Drug and Therapeutics Committee was to raise awareness on the importance of early recognition of AI, to advocate for the availability of hydrocortisone sodium succinate (HSS) on emergency medical service (EMS) ambulances or allow EMS personnel to administer patient’s HSS home supply to avoid delay in administration of life-saving stress dosing, and to provide guidance on the emergency management of children in adrenal crisis. Currently, hydrocortisone, or an equivalent synthetic glucocorticoid, is not available on most ambulances for emergency stress dose administration by EMS personnel to a child in adrenal crisis. At the same time, many States have regulations preventing the use of patient’s home HSS supply to be used to treat acute adrenal crisis. In children with known AI, parents and care providers must be made familiar with the administration of maintenance and stress dose glucocorticoid therapy to prevent adrenal crises. Patients with known AI and their families should be provided an Adrenal Insufficiency Action Plan, including stress hydrocortisone dose (both oral and intramuscular/intravenous) to be provided immediately to EMS providers and triage personnel in urgent care and emergency departments. Advocacy efforts to increase the availability of stress dose HSS during EMS transport care and add HSS to weight-based dosing tapes are highly encouraged.

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“…3 At a local level, we have developed an electronic record-based steroid alert system for Newcastle-upon-Tyne hospitals. 4 Nevertheless, steroid-dependent individuals remain a vulnerable patient group. The potential for damaging delays in "prehospital" emergency treatment is a concerning gap in the interlocking safety measures being developed to prevent serious clinical incidents.…”

Section: Improving the Prehospital Safety Of Steroid-dependent Patienmentioning

confidence: 99%

“…We have established a hospital-initiated ambulance registration pathway for steroid-dependent patients attending endocrinology clinics in Newcastle-upon-Tyne NHS Hospitals Foundation Trust. Using a patient database established when we set up electronic record alerts for this same group of patients, 4 we have identified patients attending endocrinology clinics with primary and secondary adrenal insufficiency. We received local Caldicott approval to share patient demographic information securely and directly (using nhs.net email) with the North East or the North West Ambulance Services, depending on the patient's postcode, to register them at their home addresses as being steroid-dependent.…”

Section: A National Survey Of Adrenal Patients Conducted By the Addismentioning

confidence: 99%

Improving the prehospital safety of steroid‐dependent patients in northern England: A hospital‐initiated ambulance service registration pathway

Mitchell

Devine

Lal

et al. 2017

Clinical Endocrinology

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Saving lives of in‐patients with adrenal insufficiency: implementation of an alert scheme within the Newcastle‐upon‐Tyne Hospitals e‐Prescribing platform

Cited by 6 publications

References 2 publications

A retrospective analysis of adrenal crisis in steroid-dependent patients: causes, frequency and outcomes

A retrospective analysis of adrenal crisis in steroid-dependent patients: causes, frequency and outcomes

Emergency Management of Adrenal Insufficiency in Children: Advocating for Treatment Options in Outpatient and Field Settings

Improving the prehospital safety of steroid‐dependent patients in northern England: A hospital‐initiated ambulance service registration pathway

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