Impact of alert systems on glucocorticoid administration for adrenal insufficiency in the emergency department

CONTEXT: Inappropriate glucocorticoid management in adrenal insufficiency (AI) can lead to adrenal crises, particularly in an emergency setting. Clinical decision support (CDS) can be helpful, but its impact on AI management in emergency departments (EDs) remains limited. OBJECTIVE: To evaluate the efficacy of CDS on glucocorticoid administration time in known AI patients presenting to the ED. DESIGN: Quasi-experimental (pre- and post- intervention) design. SETTING: Tertiary academic hospital. PATIENTS: A total of 211 patients with AI; 145 had no ED visits, 66 patients had 187 ED encounters. MAIN OUTCOME MEASURES: Time from ED arrival to intravenous hydrocortisone administration pre- versus post-CDS implementation. RESULTS: The incidence of ED visits was 42 events per 100 patient-years, and the incidence of ED visits presenting with hypotension was 7 events per 100 patient-years. Among patients with ED visits, the number of visits was 73 before and 114 after CDS implementation. Events requiring intravenous hydrocortisone were 19 before and 24 after implementation, with treatment given in 89% vs. 92%, respectively (p=0.81). The median time from ED arrival to hydrocortisone administration decreased from 202 (IQR: 99-306) minutes to 77 (IQR: 45-153) minutes (p=0.01). The proportion of patients receiving hydrocortisone within 1 hour increased from 0% to 42% (p=0.002). New-onset hypotension occurred in 4 cases (21%) before implementation and in 1 case (4%) after implementation. CONCLUSIONS: Following CDS implementation, the time to hydrocortisone administration was significantly shorter among patients with known AI. These findings highlight the value of CDS in improving AI recognition and management in high-risk settings.