MON-476 A Quality Improvement Project to Optimize Inpatient Diagnosis of Adrenal Insufficiency

Abstract Disclosure: H. Han: None. F. Noor: None. K. Hazen: None. C. Gleber: None. Y. Zhang: None. I. Harbuz-Miller: None. Background: The total cortisol assay is used to diagnose adrenal insufficiency. The Endocrine Society recommends holding glucocorticoids for 24 hours prior to measuring blood cortisol. Testing cortisol while on glucocorticoid leads to inaccurate results due to assay interference. Objective: We aim to 1) evaluate the status of inappropriate testing of cortisol for hospitalized patients across our academic medical center and affiliated hospitals; 2) identify a sustainable approach to guide inpatient providers on proper ordering of blood cortisol and improve diagnosis of adrenal insufficiency; and 3) reduce inappropriate testing of the total cortisol in hospitalized patients across institution by half within 6 months. Methods: Epic’s Slicer Dicer tool identified patients who had a total cortisol assay during March 1-31, 2024, at our academic medical center and affiliated hospitals. Data collected included the time and value of cortisol collection, the name, dosage and administration time of any glucocorticoid given within 24 hours of the assay collection. Results: A total of 106 hospitalized patients across the medical system had blood cortisol tested. The primary outcomes included percentage of patients tested while on glucocorticoid within 24 hours and the percentage of patients on supraphysiological doses of glucocorticoids within 24 hours of blood cortisol testing. The secondary outcome identified a percentage of patients with blood cortisol <10 ug/dL and lost to follow up. We noted 14.1% of patients (N=15 patients) received glucocorticoid within 24 hours of cortisol testing. Of these, 80% were on supraphysiological doses of glucocorticoids. To our surprise, 16% of patients (N=17 patients) had random cortisol <10 ug/dL and were lost to follow up. Proposed Intervention: Our first intervention aims to educate the inpatient providers on optimal blood cortisol testing. We added clinical decision support within the order set of total cortisol in the electronic medical record to reinforce ordering best practices. We continue to analyze the primary and secondary outcomes at three-month interval after the intervention. Conclusion: The diagnosis of adrenal insufficiency relies on appropriate testing of cortisol. Our data suggests a high prevalence of suboptimal blood cortisol testing. Our QI will close the gap in knowledge and educate on cortisol testing pitfalls, leading to an accurate diagnosis of adrenal insufficiency. Presentation: Monday, July 14, 2025