Masters Degree in Endocrinology: A two part story of research.
Abstract
The funding received was to enable further study into research with an endocrine viewpoint. The course comprised two modules that led to a Masters Degree in Endocrinology. The first module was based on research and statistics, the second module was a dissertation in which skills learnt through module one would be employed.
Module one: Statistics and research techniques
This module provided me with the understanding of how to critically appraise publications, particularly from medical journals, along with the different types of studies, statistical analysis interpretation, various ways of displaying data, levels of evidence, audit and clinical governance. This was an invaluable lesson and one that I was able to implement into conducting my own retrospective analysis of adrenal insufficiency and its management which formed the basis of my dissertation. It has also had far reaching benefit to my clinic practice, in that I am able to analyse medical journal articles now and draw my own conclusions as to whether the evidence being presented is valid or reliable, and therefore make an informed judgement about whether it has enough merit to be incorporated into my clinic practice, or whether it is based on tenuous results in which case the waiting for further research into that particular area would be the most sensible and patient safety conscious move to make.
Module two: Professional project
The subject I chose to base the research dissertation project upon was adrenal insufficiency.
Background
Adrenal insufficiency is a life-long condition that has the potential to be fatal if not managed correctly, it is also linked with an increased mortality risk ratio approximately two-fold that of the background population (Bergthorsdottir et al 2006, Burman et al 2013). The biggest risk of mortality to those with adrenal insufficiency is adrenal crisis, this occurs when levels of exogenous steroids are not adequate to match the body’s actual steroid demand (Bergthordottir et al 2006, White and Artl 2010). To prevent adrenal crisis, patients should be aware of when and how to take their steroid replacement including steroid dose adjustments during periods of increased stress, both physiological and at times, psychological (Chakera and Vaidya 2010).
Prevention of adrenal crisis and optimal management when it does occur is key to prevent associated mortality in those with both primary, or secondary, adrenal insufficiency (Hahner et al 2015). Adrenal crisis is still a cause of premature death today (Husebye et al 2014). Mills et al (2004) estimated that of those patients found dead or comatose, 86% could be attributed to adrenal crisis being overlooked or mismanaged. This highlights the necessity for this patient group to be better educated with regards to emergency hydrocortisone (parenteral) self-injection usage.
Aim
To capture a picture of the adrenal insufficient patient experience, a retrospective analysis on care provision to both inpatients and outpatients was undertaken. This was to establish if current patient management standards for adult patients with either primary or secondary adrenal insufficiency, was adequate and provided in accordance with guidelines and best practice recommendations. To investigatethis, two retrospective audits were completed.
- Outpatient: a retrospective analysis audit completed, it focused upon whether adrenal insufficient patients were provided with appropriate steroid sick day management education during endocrine outpatient clinic appointments.
- Inpatient: a retrospective analysis audit undertaken into the timing of hydrocortisone prescription and administration to those patients with adrenal insufficiency admitted to hospital.
Results:
- Outpatients: steroid sick day management advice was most documented as being discussed, however, there was no documentation of travel abroad being discussed.
- Inpatients: Just over half the hydrocortisone (oral and intravenous) analysed were prescribed late, while 88% were administered late. The longest time in minutes over criteria guidelines was 540 and 660 minutes respectively for prescription and administration.
Recommendations:
- Set up of multi-professionally runsteroid education sessions for patients and their relatives/carers. These are to run once quarterly. To offer individual sessions through the endocrine nurse specialist clinics on steroid sick day management for those patients that would prefer this, or for those it is more appropriate for, than the group sessions.
- For inpatient prescribers and medication administrators to be educated in correct usage of hydrocortisone in adrenal insufficient patients, also for robust systems to be introduced to alert prescribers and administrators to the importance of hydrocortisone dose timings.