Discussions are underway with the Department of Health, to introduce a universal, European-wide steroid-dependence emergency card. However, in Newcastle-upon-Tyne, we know that less than half of the steroid-dependent patients we look after at present carry a steroid alert card. Therefore we anticipated that this new development would be unable to make a profound impact upon patient safety, on its own. From a healthcare professional’s point of view, steroid-dependence is difficult to manage during emergency care – especially for emergency admissions to hospital. On arrival, we need to have immediate identification for people who are dependent on steroids, to give them the care that they need.
In our endocrinology department, improving the care of steroid-dependent people became a priority when a local audit, led by Simon Pearce, highlighted some areas for improvement. The results of this audit were presented at a quarterly Quality Improvement (QI) meeting, and as a department, we set about looking at ways of quickly identifying steroid-dependent patients “at the front door”, with a view to improving their care from the outset. Dr Richard Quinton suggested that we might be able to use the hospital’s electronic patient record and prescribing system (eRecord) to create a “pop-up” alert that would flag up steroid-dependent patients as soon as they are admitted. He started by confirming the feasibility of the project with Andrew Heed, the pharmacy eRecord lead, and then took the proposal to a Directorate of Medicine meeting. All parties were extremely supportive of the project from the outset: any initiative that aims to improve patient safety is generally well received! At the next quarterly endocrinology QI meeting, the wording of the alert was agreed and then Richard Quinton took this back to Andrew Heed who had the alert ready and functioning within a week.
To get the project off the ground, we then had to add an alert to every steroid-dependent patient’s individual eRecord. I got in touch with our clinical coding department to get a list of patient record numbers, for every patient coded as having adrenal insufficiency who had been admitted to hospital or who had attended outpatient appointments. Coding generated these lists the same day by extracting data from their coding database. Then Richard Quinton, Muhammad Asam (a trainee in the department) and I looked individually at each listed patient’s last electronic letter, to double check that they were prescribed long-term steroids. Once we had checked that the list was correct, we began logging each patient on eRecord as being steroid-dependent. This task was probably the most time-consuming part of the project. Shared between three people, it was not too painful to complete! From the outset, to completion of this first phase of electronic logging, took just under a year.
Now that the initial phase of electronic logging is complete, the endocrinology department continues to set up alerts for new patients to the hospital, both transfers and new diagnoses. We also check that our regular patients are logged as being steroid-dependent, when we see them for their follow-up appointments.
This project has not been financially expensive to set up, as we had an existing electronic record platform that we could use. However, it has been time-consuming for many hospital staff and heavily dependent upon the input and goodwill of the endocrine team, the eRecord and coding departments. Nevertheless, everyone involved gave their time willingly as we all felt that it was worth investing our personal time and effort in this important safety initiative.
We hope that this will improve the care of our steroid-dependent patients when they come to hospital, and that it will give them confidence that their care is one of our departmental and hospital trust priorities. We also hope that seeing the alert for patients will keep the care of steroid-dependent patients in the minds of front-line medical staff and improve the visibility of this rare, potentially life-threatening condition. The endocrinology unit plans to assess the impact of this safety initiative in the future by re-auditing. In this way, we can compare to the previous audit results to see if the eRecord alert has improved inpatient care for our steroid-dependent patients.
All patients who have ever attended a Newcastle-upon-Tyne trust hospital, even if just for Accident and Emergency or day case investigations, will have a hospital number. If you believe you have acquired a Newcastle hospital number in the past – and don’t regularly attend our endocrine clinics – please get in touch so we can log you in our Steroid Alert system. If you find yourself referred here for investigations or surgery at some future date, this may be useful!
Dr Anna Mitchell
Specialist registrar in the department of endocrinology, Newcastle-upon-Tyne NHS Trust
If you have a Newcastle hospital number, please contact firstname.lastname@example.org to get registered for the Newcastle Steroid Alert system
This article was first published in the September 2014 edition of the ADSHG newsletter.