December 13, 2017

New clinical guidelines for pre-hospital emergency care were published in September 2017 by the national ambulance regulator, the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).

We are delighted to announce the new guidelines for adrenal crisis within the JRCALC incorporate extensive input from ADSHG and The Pituitary Foundation; our shared input was steered by the Chair of the ADSHG’s clinical advisory panel, Prof John Wass. 

Importantly, the new guidelines bring ambulance practice into line with a key recommendation in the ADSHG’s GP Diagnosis leaflet, that patients in adrenal crisis should be stabilised with injected hydrocortisone and IV fluids before being moved. Where a patient with severely low blood pressure cannot be transported flat on a stretcher (e.g. domestic stairs) they must not be moved until circulatory volume has been restored with IV fluids and they have received injected hydrocortisone.

Steven Irving, AACE director, with Lorna Dowling from Class Publishing at the launch of the 2017 JRCALC supplementary guidelines.

Cathryn James, clinical support manager for JRCALC and the Association of Ambulance Chief Executives, writes: 

“The guidelines have been updated to put more emphasis on recognising and managing anyone that may be in adrenal crisis or/and be steroid dependant. Additional wording has been added to the medical emergencies section and to the section around the use of hydrocortisone." 

“We are really pleased to have worked with both the Addison’s Disease Self-Help Group and The Pituitary Foundation to update our guidance for these important groups of patients. The groups have assisted us with ensuring we get the right emphasis and clarity and we thank them for their input."

“We anticipate these changes will improve clinical practice and ensure that all ambulance clinicians consider adrenal crisis when assessing and managing patients. Ambulance clinicians respond to a very wide range of types of emergency calls, and the pre-hospital guidelines need to reflect the best and current evidence based practice so that we can treat all patients appropriately and give the best possible care whatever is wrong with them.”

Julie Watson, ADSHG’s ambulance awareness co-ordinator, commented: 

“This is very encouraging news. We have been delighted to help in the improvement of the national guidelines for ambulance clinicians. We are especially grateful to Prof Wass for his time and commitment on this important aspect of adrenal patient safety.”

 “The ADSHG’s submission particularly emphasized the need for immediate treatment of anyone showing signs of adrenal crisis PRIOR to transportation to hospital. This has been acknowledged in the revised guidelines in several ways. Addison’s disease is now explicitly named in the guidelines for patients presenting with altered levels of consciousness. Another new inclusion is the very important advice that it is always better to give injected hydrocortisone than to wait."

“We look forward to these guidelines being rolled out to all ambulance services across the UK. The guidelines take us a step closer towards having a network of national ambulance services all operating in the same way and with the same emergency response procedures towards patients with specific conditions such as ourselves.”

Who is JRCALC and what is in the JRCALC guidelines?

The Joint Royal Colleges Ambulance Liaison Committee (JCALC) is the national regulator of clinical standards across the UK’s independent ambulance trusts. The JRCALC guidelines are an essential resource for paramedics and combine expert advice with practical guidance to support clinicians in providing patient care. They form the basis for UK paramedic training and education.

The 2006 JRCALC guidelines were a watershed for adrenal patients; these allowed paramedics to give injected hydrocortisone for adrenal crisis for the first time, where previously it had only been authorised for asthma and anaphylaxis.

Today, it’s hard to imagine that barely 11 years ago, paramedics received no training in adrenal crisis and were unable to treat it even if they recognised it.

This important safety advance reflected the joint ADSHG and Pituitary Foundation submission of 2005, co-signed by Prof John Wass, explaining the risks of adrenal crisis and the need for ambulance training in adrenal crisis. The ADSHG’s 2005 initiative, engaging the Pituitary Foundation on a joint submission to JRCALC, was the first big medical awareness project ADSHG took on after gaining charitable accreditation in late 2004. It achieved its success thanks to a working party spearheaded by former trustee Sue Thompson, and assisted by the Deputy Clinical Director at London Ambulance, David Whitmore.

In many countries ambulance crew are still not authorised to treat adrenal crisis. Within the UK, paramedic shortages mean it is recommended family members learn how to give an intramuscular injection, and to do so before phoning 999 for help in the event of adrenal crisis.

The JRCALC clinical guidelines are available to purchase via the AACE website and can be obtained in both electronic and print formats.

This article was first published in the December 2017 edition of the ADSHG newsletter.

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