Introduction: Children with adrenal insufficiency require emergency hydrocortisone for serious illness in addition to any regular requirements. Individualised emergency plans for patients during sick days, detailing their oral and intramuscular hydrocortisone requirements, should be maintained, alongside appropriate alerts on hospital and pre-hospital systems to ensure health professionals are aware of their requirements promptly if they present acutely unwell. Following a child death review, we audited whether patients had appropriate plans and corresponding alerts in place.
Methods: Data was collected from two local paediatric endocrinology databases. Patients on these databases who were seen in outreach, had transitioned to adults, died or whose adrenal deficiency had resolved, were excluded. The digital health records and local alert systems were reviewed to identify the presence of a steroid plan, the presence of a steroid deficiency alert and whether the steroid plan was current (defined as <12 months old or with appropriate emergency doses based on auxology from the last clinic attendance).
Results: 79 patients were identified. Reasons for steroid deficiency included: multiple pituitary hormone deficiency (46%), congenital adrenal hyperplasia (35%), congenital adrenal hypoplasia (1%), Addisons disease/APECED (5%) and exogenous steroid use (13%). 68 patients (86%) had an alert and plan. Of the 11 patients without an alert, 4 also did not have a steroid plan (omission: n=3; lost to follow-up: n=1). Of 7 patients with a plan but no alert, 2 were outreach patients (and may have had alerts at their local hospitals) with oncology follow-up at our hospital, and 5 were omissions. The plan was up to date in 66/75 patients (88%): 9 recommended a suboptimal intramuscular hydrocortisone dose and 4 recommended a suboptimal oral hydrocortisone stress dose.
Conclusion: The majority of patients have both a steroid plan and alert. However an important minority are missing either an alert or both. In addition, there is a possibility that the databases are incomplete. Imminent implementation of SNOMED CT should reduce this risk in the future. At times of serious illness, alerts and steroid plans can be lifesaving. The omissions identified have been rectified. Annual re-audit will allow omissions to be promptly identified.
27 - 29 Nov 2019
British Society for Paediatric Endocrinology and Diabetes