Adrenal Insufficiency: Improving Paramedic Practice
By Andy Baines, Advanced Paramedic, North West Ambulance Service
Acute adrenal insufficiency can lead to severe morbidity and even death if ineffectively managed. Unfortunately, in the pre-hospital setting patients with acute adrenal insufficiency often receive sub-optimal care. The early administration of hydrocortisone in these cases is critical and significantly improves outcomes to the extent it can be life-saving. Such therapy is part of current paramedic practice, however, there is evidence that hydrocortisone is rarely used in the pre-hospital setting. Ultimately, patients with acute adrenal insufficiency may currently be sub-optimally managed by paramedics.
Adrenal emergencies in the pre-hospital field are rare, but when encountered, the outcome can be fatal if it is not recognised and treated rapidly (Shulman 2007). The greatest challenge for pre-hospital clinicians is to recognise this elusive condition; the signs and symptoms may be non-specific early in the presentation and the diagnosis may not be suspected or immediately clear. Coupled with the vague nature of the presentation, a gap in paramedic education means that the care provided to patients with acute adrenal insufficiency is not always optimal (McBride 2012). These factors combined, suggest that much can be done to improve the response to this group of patients. To improve practice, a project was undertaken to address this gap in paramedic education.
Defining the problem
Within the 17 years that I have been an operational paramedic in North West Ambulance Service (NWAS), I have encountered several patients who were adrenal insufficient. The occasions where I offered the optimal treatment package, as recommended by the Joint Royal Colleges Ambulance Liaison Committee 2013 (JRCALC), were after I had received higher level clinical learning and education. It would be impractical and negative, to the current cost improvement programme that NWAS is facing, to offer this education to each of its 2200 responding clinicians.
Consequently, this gap in skills and knowledge has been the driving factor to develop a package which incorporates e-learning and a film of a patient’s journey through an adrenal crisis. An oral presentation will also be delivered to the senior paramedics within NWAS. This blended learning approach is ultimately more effective as Ruiz (2006) makes the point that this approach combines technology and traditional instructor led training.
The package will be accessible on NWAS intranet e-learning zone and be available to all 5000 staff in NWAS. Once completed, the clinicians will be able to download a certificate stating that they have completed the module and be encouraged to self-reflect on the new education gained. Reflection in medicine is seen as vital, as this allows consideration of the wider context and the implications of the experience and the assimilation of the skills or knowledge into the existing knowledge base (Branch and Pranjape 2002). The introduction to the package is illustrated in figure 1:
Figure 1: Introduction to NWAS E-Learning Module
Within the United Kingdom, each ambulance service clinical quality is measured through ambulance quality indicators, these are benchmarked against other ambulance trusts NHS England (2013). The system analyses the clinical care delivered to patients with common pre-hospital conditions. Because the conditions reported on are relatively frequent in the pre-hospital arena it can be argued that clinicians largely now offer excellent care. This can be evidenced by NWAS achieving 97% stroke care bundle in 2012-2013 (NWAS stroke care bundle 2013).
As discussed earlier, the prevalence of adrenal insufficiency is a rare event with approximately 800 patients in NWAS area of responsibility. Hahner et al (2010) report that 42% of these patients will have at least one adrenal crisis per year. This would equate to approximately 336 possible pre-hospital presentations. Taking this into consideration, to arrange an audit system for adrenal insufficiency, would be extremely difficult because of the low expected numbers in comparison to the 1.4 million patient journeys made by NWAS annually.
This has led the project to explore other methods of evaluation, such as patient involvement and satisfaction, rather than using traditional ambulance methods. A patient representative was heavily involved in the development of the training package and this package will be delivered to the patient group at the monthly meeting in July 2014. Patient involvement is highlighted by the Royal College of General Practitioners statement on safety and quality of care. One of the key messages is that patients should be encouraged to be actively involved in planning their care and the development of services at practice level (RCGP curriculum 2013). The Health Foundation, which is an independent charity working to improve healthcare in the United Kingdom, emphasise the importance of this patient-centred approach by reporting that if health staff can engage patients and help them feel involved, patients are likely to hear the advice they are given and more importantly act on it (health.org.2013).
By direct patient involvement with the patient group and by continuous interaction with the patient group representative, a level of achievement can be claimed. This can be evidenced on production of the accompanying film of a patient’s journey through adrenal crisis, to be displayed on the package which is displayed in figure two. The patient states that she “finally feels like someone is listening and, more importantly, doing something about it”
2016 Spring Campaign
As mentioned briefly above, The Foundation ran a campaign after this article was written. The campaign was to raise awareness about emergency hydrocortisone to ambulance staff by publicising a free e-learning module.
North West England Ambulance Service developed this e-learning module for ambulance staff about adrenal insufficiency. Andy Baines, Advanced Paramedic in Cheshire & Merseyside Area and author of this article, produced the module.
Andy also sits on The Pituitary Foundation’s medical committee and we worked with him closely on this campaign. As a result of our campaign nine ambulance trust/training organisations are now utilising our training module!
Paramedics across the UK have also been contacting us to ask to take the module as part of their own personal development and 72 people contacted us via email asking for flyers. These included, paramedics, Heads of Patient Safety departments, Union Learning Reps, friends and family of ambulance staff, and our own volunteers and supporters offering to distribute flyers. The Pituitary Foundation contacted all UK ambulance trusts with information about the module.
The campaign has resulted in increased numbers of paramedics improving their knowledge of treating adrenal crisis and we are pleased with how many ambulance trusts and training organisations are now using the module.
Please note this campaign is no longer running but you can read more about what activities took place and the resources are still available if you want to spread awareness/ or use the e-module.
Also read about our 2015 Get Red Flagged campaign which encouraged patients with Adrenal Insufficiency to register with their Ambulance Trust so their condition is flagged on the Trust’s system automatically.
Branch W, Pranjape A (2002) Feedback and Reflection; Teaching Methods for Clinical Settings. Academic Medicine. 2002.77; 1185-1188
Hahner S, Allolio B, (2009) Therapeutic Management of adrenal insufficiency. Journal of Clinical Endocrinology and Metabolism. April 2009; 94(4); 1059-67.
Health.org Measuring Patient Views On Health Care Quality www.health.org.uk measuringpatientviews.
Assessed on 10/04/2014
Joint Royal Colleges Ambulance Liaison Committee (2013) Guidelines. UK Ambulance Services Clinical Practice Guidelines 2013. The University of Warwick. Class Professional Publishing. Bristol.
McBride P (2012) Hydrocortisone Emergency in Pituitary Patients. Journal of Paramedic Practice, Vol 4 Issue 500 May 2012
National Health Service Statistics (2013) www. (englandnhs)/ ukstatistics/stat/work-arear/ ambulance-quality-indicators. Assessed on 07/04/2014
North West Ambulance Service Quality Accounts (2013) www.nwas.nhs.uk/media/385086/ quality_account_2013Assessed on 07/04/2014
Royal Colleges of General Practitioners Curriculum (2010) Statement of Patient Safety and Quality of Care. RCGP 30 Euston Square London NW1 12 FB
Ruiz J, Mintzer M, Issenberg B (2006) Learning Objects In Medical Education. Medical Teacher. Vol 28 no 7 pp 599-605
Schulman DP (2007) Adrenal Insufficiency Still accused Of Morbidity In childhood Paediatrics. 2007 Feb; 119 (2):e484-94