Non-scheduled consultation in oncologic patients. How many of them are true emergencies? An observational prospective study

Emergency Department Utilization of Adult Cancer Patient in Korea: A Nationwide Population-Based Study, 2017-2019

Purpose

The current study aimed to identify the overall characteristics of cancer-related emergency department (ED) visits by adult in Korea, including analyses of factors associated with ED stay time and outcomes nationwide.

Materials and Methods

We collected data on cancer-related ED visits from the National Emergency Department Information System (NEDIS) database between 2017 and 2019.

Results

ED visits by cancer patients comprised 5.5% (667,935 visits) of total ED visits from 2017 to 2019, which was slightly higher than in other counties. Patients with cancer who visited the ED were over 50 years old, the majority being males, and patients with cancer visited EDs in certified tertiary hospitals more frequently than patients without cancer. In multivariate analyses, the adjusted odds ratio for a length of stay more than 8 hours in the ED of certified tertiary hospitals was 126.34 (95% confidence interval, 1.422 to 1.460) when compared to hospitals. Nevertheless, the longer the patients stayed in the ED, the more likely they were to be admitted.

Conclusion

The longer ED stay and higher proportion of cancer patient hospitalizations suggest that cancer patients visit ED to be admitted as well as to receive acute care. The frequency of ED visits and admission may be adjusted to some extent depending on outpatient education, such as self-management of symptoms and situations. Improving cancer care in local communities should be met though provisions such as linking treatment between hospitals or supplying appropriate medical personnel, even for the efficient use of ED resources in hospitals.

Prospective cohort study of an Australian cancer care services-led model of emergent care

Objective Many cancer care services (CCS) provide pragmatic models of emergent care for their patients as part of 'business as usual' without understanding the scope of this work. We aimed to describe an Australian CCS-led model of emergent care and quantify and profile emergent care provided over a 6-month period to understand scope and demand. Methods This prospective cohort study was performed at a large tertiary hospital on the eastern coast of Australia in 2016. The study explored emergent care provided during business hour and after-hours, including telephone advice, unplanned care and unplanned admissions. Data were collected via electronic hospital records and clinical nurses regarding who accessed care, why care was accessed, what care was provided and how the episode of care ended. Results Between March and September 2016, 1412 episodes of unplanned care were provided in the CCS-led model of care, including 307 episodes of telephone advice (237 patients; min max 1-4 episodes per patient; 825 episodes of unplanned care (484 patients; min max 1-9 episodes per patient) and 280 unplanned admissions (233 patients; min max 1-6 episodes per patient). During the same time, an additional 459 unplanned admissions (361 patients) occurred via the emergency department (ED), of which 125 (27.2%) occurred during business hours which could have been managed by the CCS. Most people who received care experienced issues associated with disease or treatment and had received systemic anticancer therapy in the past 30 days. Conclusions The data demonstrate that a significant volume of emergent care was provided within the CCS over the study period, in addition to planned cancer treatment. Due to the ever-increasing demands on EDs and the significant need for emergent care for people with cancer, there is need for CCS-led models of care to provide specialist emergent care specifically for people who are receiving systemic anticancer therapy. Such models must be adequately resourced to meet the needs of patients, carers and healthcare professionals. What is known about the topic? There is increasing focus on innovative models of emergent care for people with cancer in the out-patient setting to relieve pressure on EDs and improve patient experiences. Limited literature has focused on such models in the Australian context. What does this paper add? This paper describes, quantifies and profiles care provided in a pragmatic CCS-led model of emergent care in a large tertiary hospital in Australia over 6 months. The data demonstrate significant demand for emergent care within business hours, as well as out of hours, predominantly for people undergoing systemic anticancer therapy. What are the implications for practitioners? The findings of this study highlight the need for CCS to develop pragmatic models of emergent care. Appropriate resources, infrastructure, policies and procedures are required to adequate meet the needs of patients and carers.

Causes of Hospital Admissions in Domus: A Randomized Controlled Trial of Specialized Palliative Cancer Care at Home

CONTEXT

Avoidable hospital admissions are important negative indicators of quality of end-of-life care. Specialized palliative care (SPC) may support patients remaining at home.

OBJECTIVES

Therefore, the purpose of this study was to investigate if SPC at home could prevent hospital admissions in patients with incurable cancer.

METHODS

These are secondary results of Domus: a randomized controlled trial of accelerated transition to SPC with psychological intervention at home (Clinicaltrials.gov: NCT01885637). Participants were patients with incurable cancer and limited antineoplastic treatment options and their caregivers. They were included from the Department of Oncology, Rigshospitalet, Denmark, between 2013 and 2016. The control group received usual care. Outcomes were hospital admissions, causes thereof, and patient and caregiver perceptions of place of care (home, hospital, etc.) at baseline, four weeks, eight weeks, and six months.

RESULTS

During the study, 340 patients were randomized and 322 were included in modified intention-to-treat analyses. Overall, there were no significant differences in hospital admissions between the groups. The intervention group had more admissions triggered by worsened general health (22% vs. 16%, P = 0.0436) or unmanageable home situation (8% vs. 4%, P = 0.0119). After diagnostics, admissions were more often caused by clinical symptoms of cancer without progression in the intervention group (11% vs. 7%, P = 0.0493). The two groups did not differ significantly in overall potentially avoidable admissions. Both groups felt mostly safe about their place of care.

CONCLUSION

The intervention did not prevent hospital admissions. Likely, any intervention effects were outweighed by increased identification of problems in the intervention group leading to hospital admissions. Overall, patients and caregivers felt safe in their current place of care.

Why do patients with cancer access out-of-hours primary care? A retrospective study

BACKGROUND

Identifying why patients with cancer seek out-of-hours (OOH) primary medical care could highlight potential gaps in anticipatory cancer care.

AIM

To explore the reasons for contact and the range and prevalence of presenting symptoms in patients with established cancer who presented to a primary care OOH department.

DESIGN AND SETTING

A retrospective review of 950 anonymous case records for patients with cancer who contacted the OOH general practice service in Grampian, Scotland between 1 January 2010 and 31 December 2011.

METHOD

Subjects were identified by filtering the OOH computer database using the Read Codes 'neoplasm', 'terminal care', and 'terminal illness'. Consultations by patients without cancer and repeated consultations by the same patient were excluded. Data were anonymised. Case records were read independently by two authors who determined the presenting symptom(s).

RESULTS

Anonymous case records were reviewed for 950 individuals. Eight hundred and fifty-two patients made contact because of a symptom. The remaining 97 were mostly administrative and data were missing for one patient. The most frequent symptoms were pain (n = 262/852, 30.8%); nausea/vomiting (n = 102/852, 12.0%); agitation (n = 53/852, 6.2%); breathlessness (n = 51/852, 6.0%); and fatigue (n = 48/852, 5.6%). Of the 262 patients who presented with pain, at least 127 (48.5%) had metastatic disease and 141 (53.8%) were already prescribed strong opiate medication.

CONCLUSION

Almost one-third of patients with cancer seeking OOH primary medical care did so because of poorly controlled pain. Pain management should specifically be addressed during routine anticipatory care planning.

Risk of unplanned visits for colorectal cancer outpatients receiving chemotherapy: a case-crossover study

AIM

This study was conducted to evaluate the impact of chemotherapy on the risk of unplanned visit in a cohort of colorectal cancer outpatients. Chief complaints for unplanned visits and risk factors for hospital admission were also analyzed.

PATIENTS AND METHODS

Clinical data of 229 consecutive colorectal cancer patients who were unexpectedly presented to our acute oncology clinic between 2006 and 2009 were reviewed. A case-crossover statistical analysis was applied to study the association between exposure to chemotherapy (trigger event) and the occurrence of unplanned visit (acute outcome) in three time windows (7, 15, and 21 days from the closest previous chemotherapy treatment). Cox model was used to assess the risk factors for hospitalization.

RESULTS

There were 469 unplanned visits registered. Most of the patients had Eastern Cooperative Oncology Group performance status (ECOG PS) 0-1 (80 %) and advanced cancer stage (78 %). The majority of unplanned visits (72 %) occurred within 30 days since last chemotherapy. The most frequent presenting complaints were pain, fatigue, and anorexia. The two time windows associated with higher risk of visit were 15 and 21 days from last treatment, both for early (odds ratio [OR] 3.8, CI 1.4-10.2 and OR 3.8, CI 1.4-10.2) and advanced disease stage (OR 1.71, CI 1-2.9 and OR 3, CI 1.5-5.9). Of the unplanned visits, 10 % resulted in hospital admission. Presenting with multiple symptoms and with deteriorated PS were both predictors for hospitalization.

CONCLUSION

Chemotherapy exposition triggers the need for unplanned visits over the second and third week after treatment. The prompt and effective management of unexpected events may be cost- and time-saving and reduce pressure on oncology services.

Unplanned presentations of cancer outpatients: a retrospective cohort study

PURPOSE

As a result of the growing cancer incidence and the increasing trend towards chemotherapy treatment, a higher number of cancer outpatients ask for unplanned visits. This study aimed to describe the nature and magnitude of this phenomenon and to identify risk factors for repeated unplanned presentations and hospital admission.

METHODS

Unplanned consultations (2,811) of 1,431 cancer patients who accessed our acute oncology clinic over a 2-year period were reviewed. Demographics, clinical variables and reason(s) for presentation were all recorded. Recurrent event survival analysis was used to evaluate the relation of potential predictors to the two outcome events repeated presentations and hospitalization. A stratified Cox proportional hazard model was used.

RESULTS

Of 1,431 patients, 625 (43 %) received chemotherapy during the 90 days before the unplanned visit. Pain (27.7 %), fatigue (17.6 %), dyspnoea (13.8 %), fever (11.5 %) and gastrointestinal problems (31 %) were reported frequently. The time interval since the last chemotherapy was significantly related to the rate of repeated presentation. Two hundred and nine patients (7 %) were hospitalized after an unplanned presentation. Number of symptoms and selected toxicities, along with distance from the hospital, were all predictors for hospitalization.

CONCLUSIONS

The management of unscheduled presentations of cancer outpatients is becoming crucial to avoid inappropriate selection for hospital admission and interferences with the ordinary work plan, improving quality of oncology services.

Emergency department visits for symptoms experienced by oncology patients: a systematic review

PURPOSE

The aim of this review was to explore the range and prevalence of cancer treatment or disease-related symptoms in the emergency department and their associated outcomes.

METHODS

A systematic review examined studies cited in Medline, Embase, PsycINFO, and CINAHL published from 1980 to July 2011. Eligible studies measured emergency department visits for symptom assessment in adult oncology patients. Two reviewers independently screened citations and double data extraction was used. Descriptive analysis was conducted.

RESULTS

Of 1,298 citations, six prospective and 12 retrospective descriptive studies were included. Of these, eight focused on multiple symptoms and 10 targeted specific symptoms. The studies were published between 1995 and 2011, conducted in seven countries, and had a median sample size of 143 (range 9-27,644). Of the 28 symptoms reported, the most common were febrile neutropenia, infection, pain, fever, and dyspnea. Definitions provided for individual symptoms were inconsistent. Of 16 studies reporting admission rates, emergency visits resulted in hospital admissions 58 % (median) of the time in multi-symptom studies (range 31 % to 100 %) and 100 % (median) of the time in targeted symptoms studies (range 39 % to 100 %). Of 11 studies reporting mortality rates, 13 % (median) of emergency visits captured in multi-symptom studies (range 1 % to 56 %) and 20 % (median) of visits in targeted symptoms studies (range 4 % to 67 %) resulted in death.

CONCLUSIONS

Individuals with cancer present to emergency departments with a myriad of symptoms. Over half of emergency department visits resulted in hospital admissions. Few symptoms were defined adequately to compare data across studies, thereby revealing an important gap in cancer symptom reporting.

A review of the role of emergency nurses in management of chemotherapy-related complications

AIMS AND OBJECTIVES

To examine the role of emergency nurses in caring for patients who receive chemotherapy in ambulatory oncology settings. Reasons for emergency department presentations are examined, specific sources of clinical risk for patients receiving chemotherapy who require emergency care are discussed and cost implications of emergency department presentations related to chemotherapy are analysed.

BACKGROUND

Given the increased administration of chemotherapy in ambulatory settings, emergency nurses play an important role in the management of patients undergoing adjuvant chemotherapy. Emergency departments are the major entry point for acute inpatient hospital care of complications arising from chemotherapy.

DESIGN

Systematic review.

RESULTS

Chemotherapy-related emergency department presentations have considerable clinical and cost implications for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications and reduction in preventable emergency department presentations has significant implications for improving cancer patients' quality of life and reducing the cost of cancer care.

CONCLUSIONS

Nurses are well placed to play a pivotal role in chemotherapy management and lead interventions such as a specialist oncology nursing roles that provide information and support to guide patients through their chemotherapy cycles. These interventions may prevent emergency department presentations for patients receiving chemotherapy in ambulatory settings.

RELEVANCE TO CLINICAL PRACTICE

Patients receiving chemotherapy require access to specialised care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach both within and across nursing specialities may improve care for patients receiving chemotherapy and increase effective use of healthcare resources.

Cancer pain as the presenting problem in emergency departments: incidence and related factors

GOALS OF WORK

Since emergency departments (ED) are designed to manage people with urgent and life-threatening conditions, cancer patients presenting with pain may not receive the appropriate care in the ED. The purpose of this study was to identify the incidence and factors related to ED visits by cancer patients with pain complaints.

MATERIALS AND METHODS

Medical charts selected by stratified random sampling were retrospectively reviewed to obtain information about ED visits by cancer patients during a 1-year period. The sample included 1,179 ED visits by 1,026 cancer patients.

MAIN RESULTS

Pain was the most common reason for ED visits by cancer patients. The incidence of ED visits for pain as a presenting problem was 27.8%. The 72-h ED return-visit rate was 8.2% for cancer patients who visited the ED with pain complaints. Patients with gastrointestinal and genitourinary cancers were more likely to visit the ED for pain. Patients who had received radiation therapy were less likely to visit the ED for pain.

CONCLUSION

Effective cancer pain management programs need to be developed and tested to reduce ED visits by cancer patients with pain. More research is needed to explore why cancer patients with pain visit the ED.

[Improving organization of care could reduce referrals of cancer patients to the emergency department. Prospective analysis of 123 patients]

OBJECTIVES

The objective of this prospective study was to analyze the profile of cancer patients admitted to an emergency department.

METHODS

The study included all cancer patients admitted to the emergency department of our tertiary care hospital during a 47-day period in 2004 and analyzed their demographic and medical data.

RESULTS

Patients were predominantly male (65%) with an average age of 62 years: 90% already knew their diagnosis. Most presented with immunodepression and severe deterioration of their general condition, in an advanced palliative stage (67%). They were referred mainly by their general practitioners (55%) and came from home (92%). In all, 81.3% were hospitalized. Follow-up at 3 months found 68.5% had died.

DISCUSSION

Reasons for admissions were varied. The primary reasons were the unavailability of beds in specialized cancer units and limited home care due to poor hospital-community coordination and to a lack of social and psychological assistance. Management through the emergency care system proved satisfactory but earlier preadmission care could be improved by developing supportive care and providing education for general practitioners about pain control and palliative care.