Using the Electronic Medical Record to Improve Education in Patients at Risk for Adrenal Insufficiency

Primary and secondary adrenal insufficiency can be associated with life-threatening events during acute illness or underlying stress if prompt glucocorticoid replacement is not provided. However, despite formal patient education being included in routine endocrine care of these patients, adrenal crisis continues to occur in the pediatric population because of failure to increase glucocorticoid dosage appropriately [1]. In a retrospective review of 526 patients with adrenal insufficiency, 42% of patients had documentation of at least one crisis [2]. Common aliments such as gastrointestinal infection and fever [2] have been found to precipitate adrenal crisis, often leading to overnight hospitalization. In fact, 8% of diagnosed cases of Addison's disease will need hospital treatment for adrenal crisis annually [3]. In the pediatric population, inappropriate management of adrenal insufficiency during crisis is associated with excess mortality [4–7].It is recommended that patients with known adrenal insufficiency and their families receive careful and repeated education on sick-day glucocorticoid management [8], including review of emergency injection of hydrocortisone [9]. They are also encouraged to purchase and wear an identification bracelet to ensure notification of the need for steroid replacement in case of incapacitation [10]. However, given the persistent occurrence of adrenal crisis due to inadequate management of stress dosing by families, traditional methods of stress dose education are clearly inadequate.Review of the literature reveals that the combination of an automatic electronic provider alert, to bring awareness of patient specific issues, along with patient education is more effective than either alone in improving patient care. Coté et al. examined the impact of physician education, a computer alert, or both on the targeted use of GI prophylaxis for NSAID-related upper GI tract complications in high-risk patients discharged from hospital and found t