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Carvalho da Silva MA, Silva SC, Catarata MJ, Padrão ED, Ferreira L. Oncologic Emergencies in Lung Cancer Patients and the Effects of SARS-COV2 Pandemic. TANAFFOS 2023; 22:395-402. [PMID: 39176141 PMCID: PMC11338502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/09/2023] [Indexed: 08/24/2024]
Abstract
Background Lung cancer is one of the most frequent neoplasms and is associated with serious oncologic emergencies (OE). We performed a retrospective study to characterize OE in lung cancer patients admitted to the pulmonology department to determine the effects of the SARS-CoV2 pandemic. Materials and Methods A total number of 82 patients were admitted with an emergency, mostly brain metastasis (n=37; 45.1%), followed by superior vena cava syndrome (n=13; 15.9%), cardiac tamponade (n=7; 8.5%), large pleural effusion (n=7; 8.5%), severe pulmonary embolism (n=6; 7.3%), spinal cord syndrome (n=6; 7.3%), massive hemoptysis (n=3; 3.7%), stridor (n=2; 2.4%) and atelectasis (n=1; 1.2%). Clinical and pathological data were retrieved from clinical charts including demographic information, smoking status, cancer histology, clinical stage at diagnosis, anticancer treatment, time between LC diagnosis until the OE, outcomes of OE treatment, and overall survival after OE. Results The predominant histology was adenocarcinoma (n=59; 71.9%) and 86.8% of the patients (n=71) were in stage IV. OE was the disease presentation in 45.2% (n=37) and 6-month mortality was 75.6%. Neurologic emergencies were associated with a lower risk of 6-month mortality compared to cardiovascular and respiratory [OR 0.255 (CI 0.72-0.90), p=0.035)]. Younger patients (p=0.011), metastatic disease (p=0.02), no cancer treatment (p<0.001), and small cell carcinoma (SCLC) (p=0.016) had a shorter time between cancer diagnosis and the event. Conclusion OE occurred mostly in men with metastatic adenocarcinomas. Younger patients, SCLC, metastatic disease, and no cancer treatment were associated with a shorter time between lung cancer diagnosis until the occurrence of an OE and brain metastasis with a better prognosis. There were no differences between patients admitted in 2019 and 2020 that could be related to the access to healthcare services during the SARS-COV2 pandemic.
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Lee SY, Ro YS, Shin SD, Ko E, Kim SJ. Epidemiology of patients who died in the emergency departments and need of end-of-life care in Korea from 2016 to 2019. Sci Rep 2023; 13:686. [PMID: 36639721 PMCID: PMC9839758 DOI: 10.1038/s41598-023-27947-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/10/2023] [Indexed: 01/14/2023] Open
Abstract
The need of palliative care at the end-of-life in the emergency departments (ED) is growing. The study aims to investigate the epidemiology of patients who died during care in ED using nationwide database, and to estimate the need for palliative care in the ED. A retrospective observational study was conducted using the National Emergency Department Information System (NEDIS) database. Patients who died during ED care between 2016 and 2019 were included. Palliative care-eligible disease was defined as cancer (C00-C99 of ICD-10), chronic respiratory disease (CRD, J44-J46), chronic liver disease (CLD, K70-K77), and heart failure (HF, I50). Among the 36,538,486 ED visits during 4 years, 34,086 ED deaths were included. The crude incidence rate of ED deaths per 100,000 person-year was steady between 16.6 in 2016 and 16.3 in 2019 (p-for-trend = 0.067). Only 3370 (9.9%) ED deaths were injury, while 30,716 (90.1%) deaths were related to diseases. The most common ED diagnosis was cardiac arrest (22.1%), followed by pneumonia (8.6%) and myocardial infarction (4.7%). In cases of disease-related ED deaths, about 34.0% stayed longer than 8 h in the ED (median (interquartile range): 4.5 (1.9-11.7) h) and 44.2% received cardiopulmonary resuscitation (CPR) at end-of-life time. A quarter of the disease-related ED deaths were diagnosed with palliative care eligible disease: cancer (16.9%), CLD (3.8%), HF (3.5%), and CRD (1.4%). Cancer patients received less CPR (23.4%) and stayed longer in the ED (median (interquartile range): 7.3 (3.2-15.9) h). Over the past 4 years, more than 30,000 patients, including 5200 cancer patients, died during care in the ED. A quarter of disease-related ED death were patients with palliative care-eligible condition and more than 30% of them stayed longer than 8 h in the ED before death. It is time to discuss about need of palliative care in the ED.
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Affiliation(s)
- Sun Young Lee
- grid.412484.f0000 0001 0302 820XPublic Healthcare Center, Seoul National University Hospital, Seoul, Korea ,grid.412484.f0000 0001 0302 820XLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea ,grid.31501.360000 0004 0470 5905Department of Medicine, Seoul National University college of Medicine, Seoul, Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea. .,Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Korea. .,Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea. .,National Emergency Medical Center, National Medical Center, Seoul, Korea.
| | - Sang Do Shin
- grid.412484.f0000 0001 0302 820XLaboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea ,grid.412484.f0000 0001 0302 820XDepartment of Emergency Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080 Korea ,grid.31501.360000 0004 0470 5905Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Eunsil Ko
- grid.415619.e0000 0004 1773 6903National Emergency Medical Center, National Medical Center, Seoul, Korea
| | - Seong Jung Kim
- National Emergency Medical Center, National Medical Center, Seoul, Korea. .,Department of Emergency Medicine, Chosun University Hospital, 365 Pilmun-Daero, Dong-Gu, Gwangju, 61453, Korea.
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Workina A, Habtamu A, Zewdie W. Reasons for Emergency Department Visit, Outcomes, and Associated Factors of Oncologic Patients at Emergency Department of Jimma University Medical Centre. Open Access Emerg Med 2022; 14:581-590. [PMID: 36330170 PMCID: PMC9624217 DOI: 10.2147/oaem.s381816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 10/19/2022] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The number of oncologic patients visiting the emergency department (ED) is increasing and represent a challenge for the emergency team owing to they might have acute sign and symptoms of a still undiagnosed malignancy, management of treatment-related side effects, co-morbidities, and palliative care. Thus, this study was aimed to identify reasons for ED visits, management outcomes, and associated factors of oncologic patients. PATIENTS AND METHODS A prospective cross-sectional study was conducted from March 11, 2021 to August 25, 2021 at the ED of Jimma University Medical Center on a total of 338 oncologic patients. Data were collected from the patient and the patient's medical record using a questionnaire developed from up-to-date similar literatures. The questionnaire was started filled out upon diagnosis of cancer and completed during discharge from the ED. The outcomes of the patients were dichotomized into died and survived then, it was analyzed using frequency and bivariate logistic regression. RESULTS The most common reasons for oncologic patients ED visit were neutropenic fever 79 (23.4%) followed by vomiting 38 (11.2%) and electrolyte abnormality 37 (10.9%) respectively. Among oncologic patients visited ED, 137 (40.5%) of them were admitted to ward and 126 (37.3%) of them were discharged with improvement while 64 (18.9%) of them were died. Based on multivariate logistic regression, those patients who had distant metastasis cancer (AOR 1.85; 95% CI 1.03-7.21), comorbidity (AOR 2.56; 95% CI 1.20, 6.96), and ECOG >3 (AOR 2.40; 95% CI 1.25,13.43) were more likely to die than their counterparts. CONCLUSION Most of the oncologic patients visited ED due to neutropenic fever, nausea and or vomiting, and electrolyte disorder. Amongst oncologic patients who were visited ED, most of them were admitted to ward while around one-fifth of them were died. Having distant metastasis cancer, comorbidity and ECOG >3 were independent predictors of an oncologic patient's outcome at the ED.
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Affiliation(s)
- Abdata Workina
- Department of Nursing, Jimma University, Jimma, Oromia, Ethiopia,Correspondence: Abdata Workina, Department of Nursing, Jimma University, Jimma University, P.O. Box-378, Jimma, Oromia, Ethiopia, Tel +251923643857, Email
| | - Asaminew Habtamu
- Department of Nursing, Jimma University, Jimma, Oromia, Ethiopia
| | - Wondeson Zewdie
- Department of Emergency, Jimma University Medical Centre, Jimma, Oromia, Ethiopia
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Aaronson EL, Wright RJ, Ritchie CS, Grudzen CR, Ankuda CK, Bowman JK, Kuntz JG, Ouchi K, George N, Jubanyik K, Bright LE, Bickel K, Isaacs E, Petrillo LA, Carpenter C, Goett R, LaPointe L, Owens D, Manfredi R, Quest T. Mapping the future for research in emergency medicine palliative care: A research roadmap. Acad Emerg Med 2022; 29:963-973. [PMID: 35368129 PMCID: PMC11298868 DOI: 10.1111/acem.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/23/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation. OBJECTIVE The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research. METHODS Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics. RESULTS Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC. CONCLUSIONS There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.
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Affiliation(s)
- Emily L. Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Mongan Institute Center for Aging and Serious Illness, Boston, Massachusetts, USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NYU Langone Health/Bellevue Hospital Center, New York, New York, USA
| | - Claire K. Ankuda
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason K. Bowman
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joanne G. Kuntz
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Naomi George
- Department of Emergency Medicine and Division of Adult Critical Care, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Karen Jubanyik
- Emergency Department, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Leah E. Bright
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kathleen Bickel
- Hospice and Palliative Medicine in the Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Eric Isaacs
- Emergency Department, Zuckerberg San Francisco General Hospital, University of California at San Francisco, San Francisco, California, USA
| | - Laura A. Petrillo
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Rebecca Goett
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lauren LaPointe
- Department of Social Work, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Darrell Owens
- University of Washington Medical Center, UW School of Medicine, Seattle, Washington, USA
| | - Rita Manfredi
- Department of Emergency Medicine, The George Washington University School of Medicine, Washington, DC, USA
| | - Tammie Quest
- Department of Palliative and Supportive Care, Emory University Hospital Midtown, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Family and Preventive Medicine, Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Willert AC, Ploner CJ, Kowski AB. Causes for Emergency Hospitalization of Neurological Patients With Palliative Care Needs. Front Neurol 2021; 12:674114. [PMID: 34408720 PMCID: PMC8365085 DOI: 10.3389/fneur.2021.674114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/01/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Acute and unexpected hospitalization can cause serious distress, particularly in patients with palliative care needs. Nevertheless, the majority of neurological inpatients receiving palliative care are admitted via an emergency department. Objective: Identification of potentially avoidable causes leading to acute hospitalization of patients with neurological disorders or neurological symptoms requiring palliative care. Methods: Retrospective analysis of medical records of all patients who were admitted via the emergency department and received palliative care in a neurological ward later on (n = 130). Results: The main reasons for acute admission were epileptic seizures (22%), gait disorders (22%), disturbance of consciousness (20%), pain (17%), nutritional problems (17%), or paresis (14%). Possible therapy limitations, (non)existence of a patient decree, or healthcare proxy was documented in only 31%. Primary diagnoses were neoplastic (49%), neurodegenerative (30%), or cerebrovascular (18%) diseases. Fifty-nine percent were directly admitted to a neurological ward; 25% needed intensive care. On average, it took 24 h until the palliative care team was involved. In contrast to initially documented problems, key challenges identified by palliative care assessment were psychosocial problems. For 40% of all cases, a specialized palliative care could be organized. Conclusion: Admissions were mainly triggered by acute events. Documentation of the palliative situation and treatment limitations may help to prevent unnecessary hospitalization. Although patients present with a complex symptom burden, emergency department assessment is not able to fully address multidimensionality, especially concerning psychosocial problems. Prospective investigations should develop short screening tools to identify palliative care needs of neurological patients already in the emergency department.
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Affiliation(s)
| | - Christoph J Ploner
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander B Kowski
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Mostarac I, Barbera L, Sussman J, Dainty K, Wu L, Ratcliffe J, Atzema CL. I'm here because I was told to come: a study of cancer patients' reasons for attending the emergency department. Support Care Cancer 2021; 29:6565-6578. [PMID: 33913007 DOI: 10.1007/s00520-021-06215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 04/09/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Patients with cancer are seen frequently in emergency departments (EDs). It has been proposed that many of these visits are preventable, but the patient perspective has not been well-studied. METHODS We conducted structured interviews with a convenience sample of patients who presented to a single ED with a cancer-related complaint. We asked standardized questions regarding patient predisposing characteristics, enabling factors (e.g., access to support), and perceived need for care. We compared the reported perceived need with the evaluated need by ED healthcare providers. Themes were identified using descriptive content analysis. RESULTS Forty-five patients completed interviews, of whom 30 (67%) were admitted to hospital. The most frequent reasons for seeking ED care were pain (includes abdominal) (33%), fever (11%), and weakness (11%). The majority (77%) did not make the decision to go to the ED alone: healthcare providers (40%, most commonly oncologists) and caregivers (36%) were the reported decision-makers in these cases. The majority (73%) felt their ED visit was not preventable. Themes of an alternative oncological setting for tests, improved community services, and both earlier medication management and referral to specialist care were identified from patients who reported their visit was avoidable. Congruence between (patient) perceived need and evaluated need was high (96%). CONCLUSIONS The minority of patients made the decision to seek ED care by themselves. While the majority did not believe emergency care was avoidable, those who did had cogent suggestions to that end. Patient's assessments of their own need had high agreement with ED providers' evaluations.
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Affiliation(s)
- Ivona Mostarac
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Lisa Barbera
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,ICES, Toronto, ON, Canada.,Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan Sussman
- Department of Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Katie Dainty
- The Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,North York General Hospital, Toronto, ON, Canada
| | - Libo Wu
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Jenna Ratcliffe
- Department of Oncology, McMaster University, Juravinski Cancer Centre, Hamilton, ON, Canada
| | - Clare L Atzema
- Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,ICES, Toronto, ON, Canada.,The Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of Emergency Medicine, University of Toronto, Toronto, ON, Canada
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7
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Alsharawneh A, Hasan AAH. Cancer related emergencies with the chief complaint of pain: Incidence, ED recognition, and quality of care. Int Emerg Nurs 2021; 56:100981. [PMID: 33706045 DOI: 10.1016/j.ienj.2021.100981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/16/2021] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pain is the most common reason for cancer-related emergency department (ED) visits and a precursor of the urgency of oncological emergencies. PURPOSE To identify the incidence of oncological emergencies with the chief complaint of pain and evaluate ED recognition and quality of care in managing the associated emergency. METHODS This was a retrospective observational study of cancer patients presented to three EDs during the four-year study period. RESULTS The study's sample consisted of 252 patients admitted with oncological emergencies with a chief complaint of pain. Some oncological emergencies were more likely to be prioritized appropriately, such as febrile neutropenia and increased intracranial pressure. However, most patients with spinal cord compression and cardiac tamponade were more likely to be triaged to less urgent triage categories. Timeliness of ED care was suboptimal for most patients, particularly among those assigned to less urgent triage categories. Indicators for the low quality of care extended beyond ED with multiple adverse events in the hospital. CONCLUSION Triage nurses are expected to use the oncological emergencies' prevalent symptoms to allocate the patients to high triage urgency accurately. Patient waiting to be seen expected to be reassessed periodically to ensure waiting remain safe. Hospitals can adopt or establish pathways, protocols, or standardized order sets to fast-track patients with oncological emergencies. The health information system should be available to monitor and improve the delivered care continuously.
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Affiliation(s)
| | - Abd Al-Hadi Hasan
- Fakeeh College for Medical Sciences, P.O. box 2537, Jeddah 21461, Saudi Arabia
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8
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Torigoe T, Imanishi J, Yazawa Y, Koyama T, Kadono Y, Oda H, Saita K. Oncologic emergency in patients with skeletal metastasis of unknown primary. Acute Med Surg 2021; 8:e600. [PMID: 33552525 PMCID: PMC7860590 DOI: 10.1002/ams2.600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/15/2020] [Accepted: 10/16/2020] [Indexed: 11/17/2022] Open
Abstract
Aim Patients with skeletal metastasis from prediagnosed primary malignancy sometimes have concurrent oncologic emergency (OE) during the first visit. This study aims to investigate the types of OEs and treatment outcome in such patients. Methods We have experienced 359 patients with skeletal metastasis from unknown primary malignancy. Among them, 130 patients required immediate admission for OE treatment (OE group), 229 patients had no OE and did not required immediate admission (non‐OE group). Results The recognized types of OE were spinal cord compression in 60 patients, cancer pain in 30, hypercalcemia in 19, delirium in 16, deep vein thrombosis in 13, acute renal failure in 6, respiratory failure in 3, gastrointestinal hemorrhage in 3, and disseminated intravascular coagulation in 1. The overall 5‐year survival rates were 28% and 37% in the OE and non‐OE groups, respectively (P < 0.001). The multivariate analysis revealed that delirium (hazard ratio 4.2; 95% confidence interval, 1.6–12.5; P < 0.005) and respiratory failure (hazard ratio 22.6; 95% confidence interval, 4.5–92.8; P < 0.001) were significant prognostic factors in patients with OEs, whereas other OEs did not confer a significant risk for patient outcomes. Conclusion In this study, OE was observed in as many as 36% of patients with skeletal metastasis from unknown primary malignancy. Delirium and respiratory failure were only two significant prognostic risk factors, which suggest that many of the OEs in untreated advanced cancer patients have probable chance to resolve. Early detection followed by appropriate treatment of such OEs is recommended.
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Affiliation(s)
- Tomoaki Torigoe
- Department of Orthopedic Oncology and Surgery Saitama Medical University International Medical Center Hidaka Japan
| | - Jungo Imanishi
- Department of Orthopedic Oncology and Surgery Saitama Medical University International Medical Center Hidaka Japan
| | - Yasuo Yazawa
- Department of Orthopedic Oncology and Surgery Saitama Medical University International Medical Center Hidaka Japan
| | - Tadaaki Koyama
- Division of Orthopedic Oncology Shizuoka Cancer Center Hospital Nagaizumi Japan
| | - Yuho Kadono
- Department of Orthopedic Surgery Saitama Medical University Moroyama Japan
| | - Hiromi Oda
- Department of Orthopedic Surgery Saitama Medical University Moroyama Japan
| | - Kazuo Saita
- Department of Orthopedic Surgery Saitama Medical Center Saitama Medical University Kawagoe Japan
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Sadler K, Abudari G, Aljawi D, Snelling D. Deaths in the Emergency Department: An Assessment of Patient's End-of-Life Trajectory and Quality of Care. Indian J Palliat Care 2020; 26:352-357. [PMID: 33311879 PMCID: PMC7725167 DOI: 10.4103/ijpc.ijpc_206_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 11/24/2022] Open
Abstract
Background: A considerable proportion of deaths occur in the emergency department (ED), and yet a palliative care approach is not well integrated. End-of-life patients often either receive invasive care, or their care is neglected due to being perceived as not being “acutely” ill. While a small proportion of these deaths are of an unpredictable nature, most have identifiable dying trajectories: (a) advanced cancer, (b) organ failure, (c) chronic frailty, and (d) sudden death. Aims: This study aims (1) to determine the incidence, nature and illness trajectory of deaths in the ED; (2) to examine to which extent end of life discussions took place; (3) to analyze the aggressiveness of the care; and (4) to determine if palliative care services were being consulted. Methods: This retrospective study was conducted in a large tertiary hospital and cancer center in Saudi Arabia over a 1 year period. Data collection included demographics, clinical presentation, end-of-life care, and palliative care involvement. Results: Our study included 103 patients. Cancer was the main diagnosis (45.7%). Deaths were related to advanced cancer (45.6%), followed by organ failure (29.1%), sudden death (13.6%), and chronic frailty (11.7%,). 35.9% had a documented Do-Not-Attempt-Resuscitation (DNAR) status prior to admission. 51.5% received aggressive treatments. Palliative care was consulted for 19.4% of patients, among which 50% of referrals occurred 1 day prior to death. Conclusions: End-of-life care discussions tend to occur late in the disease trajectory; a number of patients are subjected to aggressive treatments, and palliative care services remain underutilized. An early, integrated and collaborative approach is warranted to address the challenges of end of life care.
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Affiliation(s)
- Kim Sadler
- Department of Oncology and Liver Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gassan Abudari
- Department of Oncology and Liver Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Deena Aljawi
- Department of Oncology and Liver Transplant, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - David Snelling
- Adult Emergency Department, Penn State Health Milton S Hershey Medical Center, Pennsylvania, USA
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Abstract
PurposeThe purpose of this article is to highlight the importance of the foundational construct of “connection” in linking design and service in performing vital functions in the healthcare sector. “Connection” facilitates patients receiving life-saving and life-improving care at the right time, in the right place, in the right way.Design/methodology/approachThis article discusses various design-improvement initiatives making clear that healthcare, like any labor-intensive service delivered to people, is a human endeavor whose systems and features can be materially and cleverly enhanced once their intricacies are analyzed, understood and then redesigned to move closer to excellence.FindingsBy designing connection into healthcare and thinking holistically about the needs and preferences of users (patients), the functionality and the appeal of healthcare services can be enhanced.Originality/valueThe gap between the service that healthcare aims to deliver – and what it actually delivers – is unacceptably large. This article calls for incorporating connection through design into healthcare as a way to bridge this gap.
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11
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Mills SEE, Geneen LJ, Buchanan D, Guthrie B, Smith BH. Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis. BMJ Support Palliat Care 2020:bmjspcare-2020-002410. [PMID: 33051311 DOI: 10.1136/bmjspcare-2020-002410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND People who die from cancer (cancer decedents) may experience unpleasant and distressing symptoms which cause them to present to unscheduled care. Unscheduled care is unplanned care delivered by general practitioner out-of-hours and emergency departments. Use of unscheduled care can disrupt treatment plans, leading to a disjointed patient care and suboptimal outcomes. OBJECTIVES This systematic review aimed to identify factors associated with unscheduled care use by cancer decedents. METHOD Systematic review with narrative synthesis of seven electronic databases (PubMed; Medline; Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; Web of Science; Cumulative Index to Nursing and Allied Health Literature) from inception until 01 January 2020. All observational and experimental studies were included, irrespective of their research design. RESULTS The search yielded 238 publications included at full-text, of which 47 were included in the final review and synthesis. Unscheduled care use by cancer decedents was influenced by multiple factors, synthesised into themes: demography, clinical and patient, temporal, prescribing and systems. Cancer decedents who were older, men, had comorbidities, or lung cancer, were most likely to use unscheduled care. Unscheduled care presentations were commonly due to pain, breathlessness and gastrointestinal symptoms. Low continuity of care, and oncology-led care were associated with greater unscheduled care use. Access to palliative care, having an up-to-date palliative care plan, and carer education were associated with less unscheduled care use. CONCLUSION The review identifies multiple factors associated with unscheduled care use by cancer decedents. Understanding these factors can inform future practice and policy developments, in order to appropriately target future interventions, optimise service delivery and improve the patient journey. PROSPERO REGISTRATION NUMBER CRD42016047231.
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Affiliation(s)
- Sarah E E Mills
- Division of Population Health and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Louise J Geneen
- Systematic Review Initiative, NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - Deans Buchanan
- Palliative Medicine & Supportive Care, NHS Tayside, Dundee, UK
| | - Bruce Guthrie
- College of Medicine and Veterinary Medicine, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Blair H Smith
- Division of Population Health and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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12
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Rajha E, Pillow MT, Brock PA, Jenks S. Oncologic emergencies in the emergency medicine residency curriculum: A national survey. Am J Emerg Med 2020; 38:2477-2481. [PMID: 32178896 DOI: 10.1016/j.ajem.2020.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/25/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- E Rajha
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - M T Pillow
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - P A Brock
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Jenks
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
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13
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Berry LL, Crane J, Deming KA, Barach P. Using Evidence to Design Cancer Care Facilities. Am J Med Qual 2020; 35:397-404. [DOI: 10.1177/1062860619897406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The nuts and bolts of planning and designing cancer care facilities—the physical space, the social systems, the clinical and nonclinical workflows, and all of the patient-facing services—directly influence the quality of clinical care and the overall patient experience. Cancer facilities should be conceived and constructed on the basis of evidence-based design thinking and implementation, complemented by input from key stakeholders such as patients, families, and clinicians. Specifically, facilities should be designed to improve the patient experience, offer options for urgent care, maximize infection control, support and streamline the work of multidisciplinary teams, integrate research and teaching, incorporate palliative care, and look beyond mere diagnosis and treatment to patient wellness—all tailored to each cancer center’s patient population and logistical and financial constraints. From conception to completion to iterative reevaluation, motivated institutions can learn to make their own facilities reflect the excellence in cancer care that they aim to deliver to patients.
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Affiliation(s)
- Leonard L. Berry
- Texas A&M University, College Station, TX
- Institute for Healthcare Improvement, Boston, MA
| | | | | | - Paul Barach
- Wayne State University, Detroit, MI
- Jefferson College of Population Health, Philadelphia, PA
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Deckert K, Walter J, Schwarzkopf L. Factors related to and economic implications of inhospital death in German lung cancer patients - results of a Nationwide health insurance claims data based study. BMC Health Serv Res 2018; 18:793. [PMID: 30340487 PMCID: PMC6194570 DOI: 10.1186/s12913-018-3599-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/02/2018] [Indexed: 12/04/2022] Open
Abstract
Background When patients die in a hospital their quality of life is lower than when they die at home or in a hospice. Despite efforts to improve palliative care supply structures, still about 60% of lung cancer patients die in a hospital. Studies have examined factors related to inhospital death in lung cancer patients, yet none used data of a representative German population, additionally including economic aspects. This study aimed to identify factors related to inhospital death in German lung cancer patients and analysed resulting costs. Methods We analysed a dataset of health insurance claims of 17,478 lung cancer patients (incident 2009) with 3 year individual follow-up. We grouped patients into inhospital death and death elsewhere. Studied factors were indicators of healthcare utilization, palliative care, comorbidities and disease spread. We used logistic regression models with LASSO selection method to identify relevant factors. We compared all-cause healthcare expenditures for the last 30 days of life between both groups using generalized linear models with gamma distribution. Results Twelve thousand four hundred fifty-seven patients died in the observation period, thereof 6965 (55.9%) in a hospital. The key factors for increased likelihood of inhospital death were receipt of inpatient palliative care (OR = 1.85), chemotherapeutic treatments in the last 30 days of life (OR = 1.61) and comorbid Congestive Heart Failure (OR = 1.21), and Renal Disease (OR = 1.19). In contrast, higher care level (OR = 0.16), nursing home residency (OR = 0.25) and receipt of outpatient palliative care (OR = 0.25) were associated with a reduced likelihood. All OR were significant (p-values< 0.05). Expenditures in the last 30 days of life were significantly higher for patients with inhospital death (€ 6852 vs. € 33,254, p-value< 0.0001). Conclusion Findings suggest that factors associated with inhospital death often relate to previous contact with hospitals like prior hospitalizations, and treatment of the tumour or comorbidities. Additionally, factors associated with dying elsewhere relate to access to care settings which are more focused on palliation than hospitals. From these results, we can derive that implementing tools like palliative care into tumour-directed therapy might help patients make self-determined decisions about their place of death. This can possibly be achieved at reduced economic burden for SHIs. Electronic supplementary material The online version of this article (10.1186/s12913-018-3599-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karina Deckert
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-University (LMU), Marchioninistr. 15, 81377, Munich, Germany. .,Helmholtz Zentrum München GmbH, German Center for Environmental Health, Institute of Health Economics and Health Care Management, Member of Comprehensive Pneumology Center Munich (CPC-M), Member of German Center for Lung Research (DZL), Ingolstaedter Landstrasse 1, 85764, Neuherberg, Germany.
| | - Julia Walter
- Helmholtz Zentrum München GmbH, German Center for Environmental Health, Institute of Health Economics and Health Care Management, Member of Comprehensive Pneumology Center Munich (CPC-M), Member of German Center for Lung Research (DZL), Ingolstaedter Landstrasse 1, 85764, Neuherberg, Germany
| | - Larissa Schwarzkopf
- Helmholtz Zentrum München GmbH, German Center for Environmental Health, Institute of Health Economics and Health Care Management, Member of Comprehensive Pneumology Center Munich (CPC-M), Member of German Center for Lung Research (DZL), Ingolstaedter Landstrasse 1, 85764, Neuherberg, Germany
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15
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Wong TH, Lau ZY, Ong WS, Tan KB, Wong YJ, Farid M, Teo MCC, Yee ACP, Nguyen HV, Ong MEH, Iyer NG. Cancer patients as frequent attenders in emergency departments: A national cohort study. Cancer Med 2018; 7:4434-4446. [PMID: 30117313 PMCID: PMC6144141 DOI: 10.1002/cam4.1728] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/17/2018] [Accepted: 07/21/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cancer patients contribute significantly to emergency department (ED) utilization. The objective of this study was to identify factors associated with patients becoming ED frequent attenders (FA) after a cancer-related hospitalization. METHODS A retrospective cohort study was conducted using national administrative, billing, and death records of Singapore residents discharged alive from Singapore public hospitals from January 2012 to December 2015, with a primary discharge diagnosis of cancer. Patients with four or more ED visits within any 12-month period after discharge from their index hospitalization were classified as FA. Time to FA distribution was estimated using the Kaplan-Meier method, and factors associated with risk of FA were identified using multivariate Cox regression analyses. RESULTS Records for 47 235 patients were analyzed, of whom 2980 patients were FA within the study period. Age (<17 years, hazard ratio [HR] 2.92, 95% CI 2.28-3.74; 75-84 years, HR 1.29, 95% CI 1.16-1.45; and ≥85 years, HR 1.71, 95% CI 1.45-2.02, relative to age 55-64), male gender (HR 1.26, 95% CI 1.16-1.37), Charlson comorbidity index (HR 1.21, 95% CI 1.19-1.23), and socioeconomic factors (Medifund use, HR 1.40, 95% CI 1.23-1.59; housing subsidy type, HR 2.12, 95% CI 1.77-2.54) were associated with increased risk of FA. Primary malignancies associated with FA included brain and spine (HR 2.51, 95% CI 1.67-3.75), head and neck cancers (tongue, HR 2.05, 95% CI 1.27-3.31; hypopharynx, HR 2.72, 95% CI 1.56-4.74), lung (trachea and lung, HR 1.57, 95% CI 1.13-2.18; pleural, HR 3.69, 95% CI 2.12-6.34), upper gastrointestinal (stomach, HR 1.93, 95% CI 1.26-2.74; esophagus, HR 4.13, 95% CI 2.78-6.13), hepato-pancreato-biliary (liver, HR 1.42, 95% CI 1.01-2.00, pancreas, HR 2.48, 95% CI 1.72-3.59), and certain hematological malignancies (diffuse non-Hodgkin's lymphoma, HR1.59, 95% CI 1.08-2.33, lymphoid leukemia, HR 1.86, 95% CI 1.21-2.86). Brain (HR 1.69, 95% CI 1.27-2.26), lung (HR 1.31, 95% CI 1.01-1.71), liver (HR 1.46, 95% CI 1.14-1.89), and bone (HR 1.35, 95% CI 1.04-1.76) metastases were also associated with FA. CONCLUSION There are cancer-specific factors contributing to ED frequent attendance. Additional resources should be allocated to support high-risk groups and prevent unnecessary ED use.
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Affiliation(s)
- Ting Hway Wong
- Singapore General HospitalSingaporeSingapore
- Duke‐National University of Singapore Medical SchoolSingaporeSingapore
| | - Zheng Yi Lau
- Policy Research and Evaluation DivisionMinistry of HealthSingaporeSingapore
| | | | - Kelvin Bryan Tan
- Policy Research and Evaluation DivisionMinistry of HealthSingaporeSingapore
- Saw Swee Hock School of Public HealthSingaporeSingapore
| | - Yu Jie Wong
- Policy Research and Evaluation DivisionMinistry of HealthSingaporeSingapore
| | - Mohamad Farid
- Duke‐National University of Singapore Medical SchoolSingaporeSingapore
- National Cancer CentreSingaporeSingapore
| | - Melissa Ching Ching Teo
- Duke‐National University of Singapore Medical SchoolSingaporeSingapore
- National Cancer CentreSingaporeSingapore
| | - Alethea Chung Pheng Yee
- Duke‐National University of Singapore Medical SchoolSingaporeSingapore
- National Cancer CentreSingaporeSingapore
| | - Hai V. Nguyen
- School of PharmacyMemorial University of NewfoundlandSt John'sNewfoundlandCanada
| | - Marcus Eng Hock Ong
- Singapore General HospitalSingaporeSingapore
- Duke‐National University of Singapore Medical SchoolSingaporeSingapore
| | - N. Gopalakrishna Iyer
- Duke‐National University of Singapore Medical SchoolSingaporeSingapore
- National Cancer CentreSingaporeSingapore
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Batalini F, Gomes M, I F, Kuwae F, Macanhan G, Pereira JL. Cancer complaints: The profile of patients from the emergency department of a Brazilian oncology teaching hospital. F1000Res 2017; 6:1919. [PMID: 30410725 PMCID: PMC6198257 DOI: 10.12688/f1000research.12632.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/20/2018] [Indexed: 11/21/2022] Open
Abstract
Background: With the increase in prevalence of cancer in our society, we aim to clarify through primary data use what drives emergency department (ED) utilization among patients with cancer. Methods: This is a cross-sectional study. A direct survey was applied to cancer patients over 277 visits in 2015. Variables including chief complaint for current and last visit, frequency of visits, primary tumor site, and demographics were collected. Results: Pain was the most common complaint, responsible for 40% of visits, followed by constitutional symptoms (17%), and gastrointestinal complaints (11%). Abdominal pain was the single most noted pain type, with 18.4%, and had the highest rate of recurrence. It was followed by back pain, dyspnea, asthenia and fever, accounting for 8.5%, 8.5%, 8.1% and 7%, respectively. Cervical cancer represented 14.8% of patients, followed by breast (11.6%) and lung (7.6%) cancers. The majority of patients visited the emergency department less than once a month. Conclusion: The drivers of emergency department utilization among patients with cancer found through primary use data mostly confirm findings from larger studies with secondary use data. Our research underscores the burden of pain to patients with cancer, as it is the most common complaint leading to ED visits, and generally requires multiple visits. Abdominal pain was more likely to recur than other complaints. Patients could benefit from focused outpatient pain management, and from more research and education targeting cancer-related pain.
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Affiliation(s)
- Felipe Batalini
- Department of Medicine, Boston University Medical Center, Boston, MA, USA
- Hospital Araújo Jorge, Goiânia, GO, Brazil
| | - Millena Gomes
- Department of Medicine, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Fábio I
- Department of Medicine, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Flávio Kuwae
- Department of Medicine, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Giselle Macanhan
- Department of Medicine, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Julio L.B. Pereira
- Department of Surgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, SP, Brazil
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Wong J, Gott M, Frey R, McLay J, Jull A. Palliative care presentations to emergency departments in a secondary and a sub-acute hospital: A one year incidence study. PROGRESS IN PALLIATIVE CARE 2017. [DOI: 10.1080/09699260.2017.1365407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Joanne Wong
- Auckland District Health Board, Private Bag 92024, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Rosemary Frey
- School of Nursing, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Jessica McLay
- Department of Statistics, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Andrew Jull
- School of Nursing, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
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18
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Berry LL, Dalwadi SM, Jacobson JO. Supporting the Supporters: What Family Caregivers Need to Care for a Loved One With Cancer. J Oncol Pract 2017; 13:35-41. [DOI: 10.1200/jop.2016.017913] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Patients with cancer who live at home often require help with activities of daily living, basic medical care (eg, injections), social needs, and patient advocacy. Most of that support comes from intimate caregivers, typically members of the patient’s family. These family caregivers themselves require support so that they can be effective and maintain their own well-being while caring for the patient with cancer. Research shows that support for caregivers contributes to achieving these goals. We propose a four-part framework for supporting family caregivers: (1) assess caregivers’ needs using formal measures, just as the cancer patient’s own needs are assessed, (2) educate caregivers for their caregiving roles, most notably, with training in the low-level medical support that cancer patients require at home, (3) empower caregivers to become full-fledged members of the patient’s cancer team, all working toward common goals, and (4) assist caregivers proactively in their duties, so that they retain a sense of control and self-efficacy rather than having to react to imminent medical crises without sufficient resources at their disposal. Funding support for family caregivers requires refocusing on the overall well-being of the patient-caregiver dyad rather than just on the patient. It will necessitate a paradigm shift in reimbursement that recognizes the need for holistic cancer care.
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Affiliation(s)
- Leonard L. Berry
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge; and Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Shraddha Mahesh Dalwadi
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge; and Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Joseph O. Jacobson
- Texas A&M University, College Station, TX; Institute for Healthcare Improvement, Cambridge; and Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
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19
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Retrospective study of unplanned hospital admission for metastatic cancer patients visiting the emergency department. Support Care Cancer 2016; 25:1409-1415. [PMID: 27966026 DOI: 10.1007/s00520-016-3535-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of the study was to identify factors that predict unplanned admission for metastatic cancer patients visiting the emergency department (ED). METHODS Patients visiting the ED of a general hospital from April 2012 to March 2013 were investigated retrospectively. Data including demographics, vital signs, and laboratory measurements were collected from a chart review for each patient. Factors related to emergency admission were identified by univariate and multivariate analyses. RESULTS A total of 15,716 individuals visiting the ED during the study period included 1244 (7.9%) patients with cancer. Among the 491 cancer patients with metastasis, univariate analysis revealed that emergency admission was significantly associated with an age of ≥76 years; an altered mental status; fever (≥38 °C); a blood oxygen saturation of <90%; a white blood cell (WBC) count of ≤2000 or ≥10,000/μL; hypoalbuminemia (≤2.5 g/dL); and elevated levels of aspartate aminotransferase (≥100 IU/L), blood urea nitrogen (≥25 mg/dL), and C-reactive protein (CRP, ≥10 mg/dL). Multivariate analysis identified age, an altered mental status, hypoxemia, an abnormal WBC count, and elevated CRP as putative independent predictive factors for emergency admission. The number of these five factors present was also correlated with 30-day mortality (c-statistic = 0.72). CONCLUSIONS Age, unconsciousness, hypoxemia, an abnormal WBC count, and elevated CRP were found to be associated with emergency admission and 30-day mortality for metastatic cancer patients. Prospective validation of a predictive scoring system based on these findings is warranted.
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20
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Berry LL, Mate KS. Essentials for improving service quality in cancer care. Healthcare (Basel) 2016; 4:312-316. [DOI: 10.1016/j.hjdsi.2016.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 01/26/2016] [Accepted: 01/26/2016] [Indexed: 11/28/2022] Open
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Tamang S, Patel MI, Blayney DW, Kuznetsov J, Finlayson SG, Vetteth Y, Shah N. Detecting unplanned care from clinician notes in electronic health records. J Oncol Pract 2016; 11:e313-9. [PMID: 25980019 DOI: 10.1200/jop.2014.002741] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Reduction in unplanned episodes of care, such as emergency department visits and unplanned hospitalizations, are important quality outcome measures. However, many events are only documented in free-text clinician notes and are labor intensive to detect by manual medical record review. METHODS We studied 308,096 free-text machine-readable documents linked to individual entries in our electronic health records, representing care for patients with breast, GI, or thoracic cancer, whose treatment was initiated at one academic medical center, Stanford Health Care (SHC). Using a clinical text-mining tool, we detected unplanned episodes documented in clinician notes (for non-SHC visits) or in coded encounter data for SHC-delivered care and the most frequent symptoms documented in emergency department (ED) notes. RESULTS Combined reporting increased the identification of patients with one or more unplanned care visits by 32% (15% using coded data; 20% using all the data) among patients with 3 months of follow-up and by 21% (23% using coded data; 28% using all the data) among those with 1 year of follow-up. Based on the textual analysis of SHC ED notes, pain (75%), followed by nausea (54%), vomiting (47%), infection (36%), fever (28%), and anemia (27%), were the most frequent symptoms mentioned. Pain, nausea, and vomiting co-occur in 35% of all ED encounter notes. CONCLUSION The text-mining methods we describe can be applied to automatically review free-text clinician notes to detect unplanned episodes of care mentioned in these notes. These methods have broad application for quality improvement efforts in which events of interest occur outside of a network that allows for patient data sharing.
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Affiliation(s)
- Suzanne Tamang
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Manali I Patel
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Douglas W Blayney
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Julie Kuznetsov
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Samuel G Finlayson
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Yohan Vetteth
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
| | - Nigam Shah
- Stanford University School of Medicine; Stanford Health Care, Stanford, CA; and Harvard Medical School, Boston, MA
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22
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Elsayem AF, Merriman KW, Gonzalez CE, Yeung SCJ, Chaftari PS, Reyes-Gibby C, Todd KH. Presenting Symptoms in the Emergency Department as Predictors of Intensive Care Unit Admissions and Hospital Mortality in a Comprehensive Cancer Center. J Oncol Pract 2016; 12:e554-63. [PMID: 27072570 DOI: 10.1200/jop.2015.009019] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The identification of patients at high risk for poor outcomes may allow for earlier palliative care and prevent futile interventions. We examined the association of presenting symptoms on risk of intensive care unit (ICU) admission and hospital death among patients with cancer admitted through an emergency department (ED). METHODS We queried MD Anderson Cancer Center databases for all patients who visited the ED in 2010. Presenting symptoms, ICU admissions, and hospital deaths were reviewed; patient data analyzed; and risk factors for ICU admission and hospital mortality identified. RESULTS The main presenting symptoms were pain, fever, and respiratory distress. Of the patients with cancer who visited the ED, 5,362 (58%) were admitted to the hospital at least once (range, 1 to 13 admissions), 697 (13%) were admitted to the ICU at least once, and 587 (11%) died during hospitalization (31% of 233 patients with hematologic malignancies and 27% of 354 patients with solid tumors died in the ICU; P < .001). In multivariable logistic regression, presenting symptoms of respiratory distress or altered mental status; lung cancer, leukemia, or lymphoma; and nonwhite race were independent predictors of hospital death. Patients who died had a longer median length of hospital stay than patients discharged alive (14 v 6 days for hematologic malignancies and 7 v 5 days for solid tumors; P < .001). CONCLUSION Patients with cancer admitted through an ED experience high ICU admission and hospital mortality rates. Patients with advanced cancer and respiratory distress or altered mental status may benefit from palliative care that avoids unnecessary interventions.
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Affiliation(s)
- Ahmed F Elsayem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly W Merriman
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Carmen E Gonzalez
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Patrick S Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cielito Reyes-Gibby
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Knox H Todd
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Elsayem AF, Elzubeir HE, Brock PA, Todd KH. Integrating palliative care in oncologic emergency departments: Challenges and opportunities. World J Clin Oncol 2016; 7:227-33. [PMID: 27081645 PMCID: PMC4826968 DOI: 10.5306/wjco.v7.i2.227] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 12/01/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.
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van der Meer DM, Weiland TJ, Philip J, Jelinek GA, Boughey M, Knott J, Marck CH, Weil JL, Lane HP, Dowling AJ, Kelly AM. Presentation patterns and outcomes of patients with cancer accessing care in emergency departments in Victoria, Australia. Support Care Cancer 2015; 24:1251-60. [PMID: 26306522 DOI: 10.1007/s00520-015-2921-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 08/18/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE People with cancer attend emergency departments (EDs) for many reasons. Improved understanding of the specific needs of these patients may assist in optimizing health service delivery. ED presentation and hospital utilization characteristics were explored for people with cancer and compared with those patients without cancer. METHODS This descriptive, retrospective, multicentre cohort study used hospital administrative data. Descriptive and inferential statistics were used to summarise and compare ED presentation characteristics amongst cancer and non-cancer groups. Predictive analyses were used to identify ED presentation features predictive of hospital admission for cancer patients. Outcomes of interest were level of acuity, ED and inpatient length of stay, re-presentation rates and admission rates amongst cancer patients and non-cancer patients. RESULTS ED (529,377) presentations occurred over the 36 months, of which 2.4% (n = 12,489) were cancer-related. Compared with all other attendances, cancer-related attendances had a higher level of acuity, requiring longer management time and length of stay in ED. Re-presentation rates for people with cancer were nearly double those of others (64 vs 33%, p < 0.001), with twice the rate of hospital admission (90 vs 46%, p < 0.001), longer inpatient length of stay (5.6 vs 2.8 days, p < 0.001) and had higher inpatient mortality (7.9 vs 1.0%, p < 0.001). Acuity and arriving by ambulance were significant predictors of hospital admission, with cancer-related attendances having ten times the odds of admission compared to other attendances (OR = 10.4, 95% CI 9.8-11.1). CONCLUSIONS ED presentations by people with cancer represent a more urgent, complex caseload frequently requiring hospital admission when compared to other presentations, suggesting that for optimal cancer care, close collaboration and integration of oncology, palliative care and emergency medicine providers are needed to improve pathways of care.
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Affiliation(s)
- Dania M van der Meer
- Emergency Practice Innovation Centre, St. Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, VIC, 3065, Australia
| | - Tracey J Weiland
- Emergency Practice Innovation Centre, St. Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, VIC, 3065, Australia.,Department of Medicine, The University of Melbourne (St. Vincent's Hospital), Melbourne, Victoria, Australia
| | - Jennifer Philip
- Palliative Medicine, St. Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Palliative Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - George A Jelinek
- Emergency Practice Innovation Centre, St. Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, VIC, 3065, Australia. .,Department of Medicine, The University of Melbourne (St. Vincent's Hospital), Melbourne, Victoria, Australia. .,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Mark Boughey
- Palliative Medicine, St. Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Palliative Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Knott
- Emergency Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Claudia H Marck
- Emergency Practice Innovation Centre, St. Vincent's Hospital, PO Box 2900, Fitzroy, Melbourne, VIC, 3065, Australia
| | - Jennifer L Weil
- Palliative Medicine, St. Vincent's Hospital, Melbourne, Victoria, Australia.,Centre for Palliative Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Heather P Lane
- Palliative Medicine, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Anthony J Dowling
- Department of Oncology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - Anne-Maree Kelly
- Joseph Epstein Centre for Emergency Medicine Research at Western Health, Sunshine Hospital, Victoria, Australia
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25
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Oatley M, Fry M, Mullen L. A cross-sectional study of the clinical characteristics of cancer patients presenting to one tertiary referral emergency department. Int Emerg Nurs 2015; 24:35-8. [PMID: 26120049 DOI: 10.1016/j.ienj.2015.05.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/18/2015] [Accepted: 05/26/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION There is increasing evidence of cancer patients presenting to emergency departments (ED). The study aim was to analyse the characteristics of adult cancer patients presenting to one ED. Understanding cancer patient presentations could assist in the development of new models of care. METHODS A 12 month retrospective audit was conducted of a random sample of cancer patients. Demographics and characteristic variables were analysed using descriptive, comparative and correlational statistics. RESULTS The presentation rate for adult cancer patients was 1110 (2.4%) with 290 sampled. The common symptoms were fever (n = 54: 18.6%), abdominal pain (n = 34: 11.7%), and shortness of breath (n = 32: 11%). The majority of patients were allocated a Triage Category 2 (n = 94: 32.4%) or Triage Category 3 (n = 131: 45.2%). The majority of patients presented between 2 and 15 times. For patients administered antibiotics the average time was 119.8 minutes (SD ± 85.5). The average ED length of stay was mean 8.08 hours with 271 patients (93.4%) admitted to the hospital. Of the 290 patients, 105 (36.2%) had died within 12 months of ED presentation. CONCLUSION The study has shown that while cancer patients are only a small percentage of ED presentations the vast majority are allocated high triage codes, have high admission rates and high mortality rates.
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Affiliation(s)
- Meredith Oatley
- Clinical Nurse Consultant Oncology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia.
| | - Margaret Fry
- Research and Practice Development NSLHD, University of Technology, Sydney, NSW, Australia
| | - Lesley Mullen
- Emergency Department, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia
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26
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Patel MI, Moore D, Milstein A. Redesigning Advanced Cancer Care Delivery: Three Ways to Create Higher Value Cancer Care. J Oncol Pract 2015; 11:280-4. [PMID: 25991638 DOI: 10.1200/jop.2014.001065] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors believe their cancer care model constructed from quality-improving strategies has potential to help US clinicians respond effectively to an urgent policy imperative.
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27
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Lee YH, Chu D, Yang NP, Chan CL, Cheng SP, Pai JT, Chang NT. Emergency visits among end-of-life cancer patients in Taiwan: a nationwide population-based study. BMC Palliat Care 2015; 14:25. [PMID: 25956135 PMCID: PMC4436097 DOI: 10.1186/s12904-015-0016-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 03/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An increased number of emergency visits at the end of life may indicate poor-quality cancer care. The study aimed to investigate the prevalence and utilization of emergency visits and to explore the reasons for emergency department (ED) visits among cancer patients at the end of life. METHODS A retrospective cohort study was performed by tracking one year of ambulatory medical service records before death. Data were collected from the cancer dataset of Taiwan's National Health Insurance Research Database (NHIRD). RESULTS A total of 32,772 (19.2%) patients with malignant cancer visited EDs, and 23,883 patients died during the study period. Of these, the prevalence of emergency visits in the mortality group was 81.5%, and their ED utilization was significantly increased monthly to the end of life. The most frequent types of cancer were digestive and peritoneum cancers (34.8%), followed by breast cancer (17.7%) and head and neck cancers (13.3%). Older patients, males, and those diagnosed with metastases, respiratory or digestive cancer were more likely to use ED services at the end of life. Use of an ED service in the nearest community hospital to replace medical centers for dying cancer patients would be more acceptable in emergency situations. CONCLUSIONS Our study provided population-based evidence related to ED utilization. An understanding of the reasons for such visits could be useful in preventing overuse of ED visits to improve the quality of end-of-life care.
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Affiliation(s)
- Yi-Hui Lee
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan. .,Department of Nursing, School of Nursing, College of Medicine, Chang-Gang University, Taoyuan, Taiwan.
| | - Dachen Chu
- Institute of Public Health, College of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Neurosurgery, Taipei City Hospital, Taipei, Taiwan.
| | - Nan-Ping Yang
- Institute of Public Health, College of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Medical Research, Keelung General Hospital, Ministry of Health & Welfare, Keelung, Taiwan.
| | - Chien-Lung Chan
- Department of Information Management, Yuan-Ze University, Taoyuan, Taiwan.
| | - Shun-Ping Cheng
- Institute of Public Health, College of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Rehabilitation, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan.
| | - Jih-Tung Pai
- Institute of Public Health, College of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Oncology & Internal Medicine, Taoyuan General Hospital, Ministry of Health & Welfare, Taoyuan, Taiwan.
| | - Nien-Tzu Chang
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan.
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28
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Alsirafy SA, Raheem AA, Al-Zahrani AS, Mohammed AA, Sherisher MA, El-Kashif AT, Ghanem HM. Emergency Department Visits at the End of Life of Patients With Terminal Cancer. Am J Hosp Palliat Care 2015; 33:658-62. [DOI: 10.1177/1049909115581819] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Frequent emergency department visits (EDVs) by patients with terminal cancer indicates aggressive care. The pattern and causes of EDVs in 154 patients with terminal cancer were investigated. The EDVs that started during working hours and ended by home discharge were considered avoidable. During the last 3 months of life, 77% of patients had at least 1 EDV. In total, 309 EDVs were analyzed. The EDVs occurred out of hour in 67%, extended for an average of 3.6 hours, and ended by hospitalization in 52%. The most common chief complaints were pain (46%), dyspnea (13%), and vomiting (12%). The EDVs were considered avoidable in 19% of the visits. The majority of patients with terminal cancer visit the ED before death, mainly because of uncontrolled symptoms. A significant proportion of EDVs at the end of life is potentially avoidable.
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Affiliation(s)
- Samy A. Alsirafy
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
- Palliative Medicine Unit, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Ahmad A. Raheem
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
- Department of Medical Oncology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
| | | | - Amrallah A. Mohammed
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
- Department of Medical Oncology, Faculty of Medicine, Zagazig University, Sharkia, Egypt
| | - Mohamed A. Sherisher
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Amr T. El-Kashif
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
- Department of Clinical Oncology, Kasr Al-Ainy Center of Clinical Oncology & Nuclear Medicine (NEMROCK), Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Hafez M. Ghanem
- Oncology Center, King Abdullah Medical City-Holy Capital, Makkah, Saudi Arabia
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Bryant AL, Deal AM, Walton A, Wood WA, Muss H, Mayer DK. Use of ED and hospital services for patients with acute leukemia after induction therapy: one year follow-up. Leuk Res 2015; 39:406-10. [PMID: 25711944 PMCID: PMC4879586 DOI: 10.1016/j.leukres.2015.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/07/2015] [Accepted: 01/15/2015] [Indexed: 12/21/2022]
Abstract
Previous studies have documented use of health care services by oncology patients in the Emergency Department (ED), but little is known about the utilization of health services of patients with acute leukemia after induction therapy. The aim of this study was to examine chief reasons for ED and hospital use by patients newly diagnosed with acute leukemia patients after induction therapy up to one year after discharge. A retrospective, longitudinal study of all visits to the ED or unplanned hospital admissions at a single institution for patients with acute leukemia was conducted. Inclusion criteria were patients ≥18 years of age at time of diagnosis, a confirmed diagnosis of AML or ALL, and received and discharged from induction treatment between 2007 and 2010. Donabedian's structure-process-outcome framework guided this study examining health services utilization and assessing patient outcomes. 80 patients met the inclusion criteria; 52 had AML and 28 had ALL; median age was 48 (range: 18-76) and 29% (n=23) were non-Caucasian. 70% (n=56) were discharged from induction in remission. 81% (n=65) had at least 1 ED or hospitalization event, and 44% (n=35) had 2 or more events. Of 137 events in 65 patients, the most common reason was neutropenic fever/infection (55%), bleeding (12%), and GI problems (11%). Mean number of events for ALL was 2.43 compared to 1.33 for AML patients (p=0.02), and 2.23 for <50 years of age compared to 1.20 for those older (p=0.002). 20 patients died within one year of diagnosis. Findings from this study can help inform health services delivery and utilization among patients with acute leukemia after induction therapy. Oncology providers can anticipate discharge needs and enhance follow-up care for those at higher risk for problems needing hospitalization.
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Affiliation(s)
- Ashley Leak Bryant
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core, The University of North Carolina at Chapel Hill, United States.
| | - AnnMarie Walton
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States; Lineberger Comprehensive Cancer Center Biostatistics Core, The University of North Carolina at Chapel Hill, United States; University of Utah College of Nursing, United States.
| | - William A Wood
- Division of Hematology/Oncology, The University of North Carolina at Chapel Hill, United States.
| | - Hyman Muss
- Division of Hematology/Oncology, The University of North Carolina at Chapel Hill, United States.
| | - Deborah K Mayer
- School of Nursing, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.
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30
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Miller AH, Sandoval M, Wattana M, Page VD, Todd KH. Cardiopulmonary resuscitation outcomes in a cancer center emergency department. SPRINGERPLUS 2015; 4:106. [PMID: 25793149 PMCID: PMC4359188 DOI: 10.1186/s40064-015-0884-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 02/12/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cardiopulmonary resuscitation (CPR) after cardiac arrest is utilized indiscriminately among unselected populations. Cancer patients have particularly low rates of return of spontaneous circulation (ROSC) and survival to hospital discharge after CPR. Our study determines rates of ROSC and survival to hospital discharge among cancer patients undergoing CPR in our cancer center. We examined whether these rates have changed over the past decade. METHODS This IRB-approved retrospective observational study was conducted in our cancer center. The ED and cancer center provide medical care for ≥ 115,000 patients annually. Cases of CPR presenting to the cancer center for years 2003-2012 were identified using Institutional CPR and Administrative Data for Resuscitation and Billing databases. Age, gender, ethnicity, ROSC and Discharge Alive using a modified Utsein template was used to compare proportions achieving ROSC and survival to hospital discharge for two time periods: 2003-2007 (Group 1) and 2008-2012 (Group 2), using traditional Pearson chi-square statistics. RESULTS One hundred twenty-six cancer center patients received CPR from 2003-2012. Group 1 (N = 64) and Group 2 (N = 62) were similar; age (60 vs. 60 years), gender (63% vs. 58% male), and race/ethnicity (67% vs. 56% White). Proportions achieving ROSC were similar in the two time periods (36% Group 1 vs. 45% Group 2, OR = 1.47, 95% CI 0.72 - 3.00) as was survival to hospital discharge (11% Group 1 vs. 10% Group 2, OR 0.87, 95% CI 0.28 - 2.76). CONCLUSIONS ROSC after CPR in cancer patients and survival to hospital discharge did not change over time.
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Affiliation(s)
- Adam H Miller
- Department of Emergency Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1468, Houston, Texas 77030 USA
| | - Marcelo Sandoval
- Department of Emergency Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1468, Houston, Texas 77030 USA
| | - Monica Wattana
- Department of Emergency Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1468, Houston, Texas 77030 USA
| | - Valda D Page
- Department of Emergency Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1468, Houston, Texas 77030 USA
| | - Knox H Todd
- Department of Emergency Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd Unit 1468, Houston, Texas 77030 USA
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31
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Henson LA, Gao W, Higginson IJ, Smith M, Davies JM, Ellis-Smith C, Daveson BA. Emergency department attendance by patients with cancer in their last month of life: a systematic review and meta-analysis. J Clin Oncol 2014; 33:370-6. [PMID: 25534384 DOI: 10.1200/jco.2014.57.3568] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To explore factors associated with emergency department (ED) attendance by patients with cancer in their last month of life. METHODS Five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Library) were searched through February 2014 for studies investigating ED attendance toward the end of life by adult patients (age 18 years or older) with cancer. No time or language limitations were applied. We performed meta-analysis of factors using a random-effects model, with results expressed as odds ratios (OR) for ED attendance. Sensitivity analyses explored heterogeneity. RESULTS Thirty studies were identified, reporting three demographic, five clinical, and 13 environmental factors, combining data from five countries and 1,181,842 patients. An increased likelihood of ED attendance was found for men (OR, 1.24; 95% CI, 1.19 to 1.29; I(2), 58.2%), black race (OR, 1.45; 95% CI, 1.40 to 1.50; I(2), 0.0%; reference, white race), patients with lung cancer (OR, 1.17; 95% CI, 1.10 to 1.23; I(2), 59.5%; reference, other cancers), and those patients of the lowest socioeconomic status (SES; OR, 1.15; 95% CI, 1.10 to 1.19; I(2), 0.0%; reference, highest SES). Patients receiving palliative care were less likely to attend the ED in their last month of life (OR, 0.43; 95% CI, 0.36 to 0.51; I(2), 59.4%). CONCLUSION We identified demographic (men; black race), clinical (lung cancer), and environmental (low SES; no palliative care) factors associated with an increased risk of ED attendance by patients with cancer in their last month of life. Our findings may be used to develop screening interventions and assist policy-makers to direct resources. Future studies should also investigate previously neglected areas of research, including psychosocial factors, and patients' and caregivers' emergency care preferences.
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Affiliation(s)
- Lesley A Henson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom.
| | - Wei Gao
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Irene J Higginson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Melinda Smith
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Joanna M Davies
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Clare Ellis-Smith
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
| | - Barbara A Daveson
- All authors: King's College London, Cicely Saunders Institute, London, United Kingdom
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32
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Lafond P, Chalayer E, Roussier M, Weber E, Lacoin-Reynaud Q, Tardy B. A Hospice and Palliative Care Bed Dedicated to Patients Admitted to the Emergency Department for End-of-Life Care. Am J Hosp Palliat Care 2014; 33:403-6. [DOI: 10.1177/1049909114562947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A hospice and palliative care (PC) bed was created in 2006, located within a quiet area of our intensive care unit, in order to admit terminally ill patients sent to the emergency department (ED) for end-of-life care. We retrospectively analyze the records of the 342 terminally ill patients sent to the ED from 2007 to 2011. Among them, 176 (51.5%) were admitted to our hospice and PC bed, where 114 died. Besides, 99 (28.9%) of them died on stretchers in the ED. Our intervention led to a significant decrease in the number of terminally ill patients dying on stretchers in the ED. It also allowed both patients and families to have access to a more suitable environment.
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Affiliation(s)
- Pierre Lafond
- Intensive Care Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne Cedex 2, France
| | - E. Chalayer
- Intensive Care Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne Cedex 2, France
| | - M. Roussier
- Palliative Care Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne Cedex 2, France
| | - E. Weber
- Intensive Care Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne Cedex 2, France
- Interne
| | - Q. Lacoin-Reynaud
- Intensive Care Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne Cedex 2, France
| | - B. Tardy
- Intensive Care Unit, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne Cedex 2, France
- Inserm CIE3, Centre Hospitalier Universitaire de Saint-Etienne, France, Saint-Etienne Cedex 2, France
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Carron PN, Dami F, Diawara F, Hurst S, Hugli O. Palliative care and prehospital emergency medicine: analysis of a case series. Medicine (Baltimore) 2014; 93:e128. [PMID: 25437023 PMCID: PMC4616376 DOI: 10.1097/md.0000000000000128] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 08/26/2014] [Accepted: 08/26/2014] [Indexed: 11/24/2022] Open
Abstract
Palliative care, which is intended to keep patients at home as long as possible, is increasingly proposed for patients who live at home, with their family, or in retirement homes. Although their condition is expected to have a lethal evolution, the patients-or more often their families or entourages-are sometimes confronted with sudden situations of respiratory distress, convulsions, hemorrhage, coma, anxiety, or pain. Prehospital emergency services are therefore often confronted with palliative care situations, situations in which medical teams are not skilled and therefore frequently feel awkward.We conducted a retrospective study about cases of palliative care situations that were managed by prehospital emergency physicians (EPs) over a period of 8 months in 2012, in the urban region of Lausanne in the State of Vaud, Switzerland.The prehospital EPs managed 1586 prehospital emergencies during the study period. We report 4 situations of respiratory distress or neurological disorders in advanced cancer patients, highlighting end-of-life and palliative care situations that may be encountered by prehospital emergency services.The similarity of the cases, the reasons leading to the involvement of prehospital EPs, and the ethical dilemma illustrated by these situations are discussed. These situations highlight the need for more formal education in palliative care for EPs and prehospital emergency teams, and the need to fully communicate the planning and implementation of palliative care with patients and patients' family members.
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Affiliation(s)
- Pierre-Nicolas Carron
- From the Emergency Service (P-NC, FDa, OH); Palliative Care Unit, Lausanne University Hospital, Lausanne (FDi); and Institute of Biomedical Ethics, University of Geneva, Geneva, Switzerland (SH)
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Bryant AL, Walton A, Albrecht TA. Management of febrile neutropenia in a patient with acute leukemia. J Emerg Nurs 2014; 40:377-81. [PMID: 24054730 PMCID: PMC3956732 DOI: 10.1016/j.jen.2013.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/26/2013] [Accepted: 07/29/2013] [Indexed: 12/29/2022]
Abstract
Hematologic cancers comprise an aggregate of several different cancers, such as leukemia, lymphoma, and multiple myeloma. There are more than 100,000 new cases of these hematologic cancers in the United States annually, and more than 50,000 children and adults die from these cancers.1 ,2 Hematologic cancers affect the body’s blood, bone marrow, and lymphatic system, leaving these patients more susceptible to infections.1 A newly diagnosed patient with acute leukemia receives aggressive chemotherapy treatment and is closely monitored in the hospital for at least 3 to 4 weeks. Treatment-related signs and symptoms including fever, pain, nausea and vomiting, and respiratory distress may bring the patient to the emergency department before his or her next scheduled clinic appointment.3 ,4 In this article a case study of a patient with acute lymphoblastic leukemia who enters the emergency department will be used to illustrate a common clinical scenario and provide clinical implications for emergency nurses who care for patients with hematologic cancers.
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35
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Lung cancer patients frequently visit the emergency room for cancer-related and -unrelated issues. Mol Clin Oncol 2014; 2:322-326. [PMID: 24649355 DOI: 10.3892/mco.2014.241] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 01/09/2014] [Indexed: 11/05/2022] Open
Abstract
Lung cancer patients visit the emergency room (ER) for cancer-related and -unrelated reasons more often compared to patients with other types of cancer. This results in increased admissions and deaths in the ER. In this study, we retrospectively reviewed the characteristics of lung cancer patients visiting the ER in order to optimize the utilization of emergency medical services and improve the patients' quality of life. Lung cancer patients visiting the ER of a single institution over a 2-year period (2010-2011) were analyzed. The patients' chief complaints and diagnoses at presentation in the ER were classified as cancer-related and -unrelated. Hospital admission, discharge from the ER, hospital mortality and survival of advanced lung cancer patients hospitalized through admission to the ER was surveyed. A total of 113 patients visited the ER 143 times. Seventy visits (49.0%) were cancer-related and 73 (51.0%) were cancer-unrelated. Respiratory symptoms, pain, gastrointestinal and neurological events and fever were the most common cancer-related issues recorded. With the progression of cancer stage, the number of ER visits, admissions, ambulance use and hospital mortalities increased. In visits due to cancer-unrelated issues, including infection, cardiovascular and gastrointestinal diseases, fever was the most common complaint. Emergency admissions of advanced-stage patients for cancer-related issues revealed a significantly shorter median survival time compared to that for patients admitted for cancer-unrelated issues (61 vs. 406 days, respectively; P<0.05). It was observed that outpatients with lung cancer visited the ER for cancer-related and -unrelated reasons with a similar frequency. Therefore, accurate differential diagnosis in the ER is crucial for patients with lung cancer.
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