The Atlas of Shared Learning

Case study

Adrenal insufficiency – Improving safety and experience at Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust

Leading change

Endocrine nurses worked with colleagues to implement a digital system at Royal Bournemouth and Christchurch Hospitals (RBCH) to identify and support all patients admitted with adrenal insufficiency (AI). This led to improved patient safety and associated outcomes and experience.

Where to look

Addison’s disease, also known as primary adrenal insufficiency or hypoadrenalism, is a rare disorder of the adrenal glands. About 8,400 people in the UK have Addison’s disease. It can affect people of any age, although it’s most common between the ages of 30 and 50. It’s also more common in women than men. Individuals with Addison’s disease must remain vigilant to the risk of a sudden worsening of symptoms, called an adrenal crisis. This can happen when the levels of cortisol in your body fall significantly (Endocrine Society, 2016).

Patients with AI, either primary or secondary are ‘steroid dependant’ and receive a replacement dose of steroids rather than a treatment dose. Failure to administer their oral steroid replacement on time can lead to worsening physical health and in the worst-case scenario, cardiac arrest and death. Following the news of a tragic death of an 18-year-old man with such a condition, the nursing team at RCBH began to consider carefully whether safeguards were in place to avoid this happening within their services.

What to change

The clinical team identified and reviewed Learning Event Report Notification (LERN) incidents involving patients with adrenal insufficiency following admission to RBCH. Two LERN incidents were further investigated. Here, the steroid doses were either given late or missed which had left the patient vulnerable and physically compromised.

The endocrine nurses and colleagues began to identify opportunities to make improvements to both patient safety and inpatient experience and how interventions could be implemented. An aim was to enhance nursing and medical staff awareness of AI and support them to administer appropriate treatment, as well as seek support where needed.

How to change

Following discussions with the wider Endocrine Team, the endocrine nurses decided to implement a system already successfully established – an alert for the Clinical Research team notifying them of any clinical trial patients admitted to RBCH. It was anticipated that this could highlight to the endocrine nurses any AI admissions, permitting them to visit a patient and offer reassurance. This would also increase a timely presentation of advice and education supporting the provision of high quality care during their stay.

The leads discussed their requirements with Informatics (IT) colleagues. This involved adapting the existing ‘steroid dependant’ critical patient incident (CPI) flag on the inpatient patient administration system, currently in use at Poole Hospital, to cover RBCH as well. A group email and alert system was set up, notifying the group when a patient with the CPI flag was admitted to RBCH.

Having developed and tested the system, it was launched in February 2018. Endocrine nurses receive an alert when a patient is admitted. The alert notifies them of the admission. This instant system means from the very beginning of their admission, the nurses can ensure the treatment plans are correct, that the care is tailored to their specific needs and AI support is available.

The next steps include the roll out of AI steroid alert cards, as produced by the Society for Endocrinology. This will continue to contribute to patient and staff understanding of the specific needs of this patient group. This will dovetail the development of a comprehensive education programme for staff at the Trust, for example a computer screen saver to raise awareness.

Adding value

Better outcomes – The new alert system has identified 64 patient admissions (to date), which is particularly advantageous as it means tailored treatment options from the outset. It has also enhanced collaborative working across the team with frequent telephone calls between the nursing leads and the acute medical unit (AMU) to discuss the admissions and care plans. Such increased awareness and joint working have been a positive outcome and the interventions and advice has become increasingly specialist and focused. It is anticipated that this will have long term benefit, including minimising any missed or late medication doses.

Better experience – Patient experience has improved in line with the streamlining of the admission and continued care process. Endocrine nurses and colleagues have been able to visit and reassure patients who have been admitted, whilst also offering education and advice to the staff looking after them. For example:

Patient: “Thank you for coming to see me, it feels much safer knowing you are aware of my admission”

Better use of resources – Staff are now better placed to ensure patients with AI receive timely support. This is optimising patient treatment early in their stay at the Trust. The clinical team anticipate this is impacting positively the length of stay for patients. Indeed, wrapping specialist services around the patient from Day 1 is expected to further contribute to best use of resources. There is also now heightened awareness of the availability and specialism of the endocrine nurse role.

Challenges and lessons learnt for implementation

Improvement is continuous, and the system continues to evolve and learn from experience. Simple interventions such as a patient ‘flag’ can have real-world implications on patient experience and outcomes and should not be underestimated.

Find out more

For more information contact:

  • Becci Watling, Endocrine Specialist Nurse, Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust,