The Cancer Emergency Department-The Ohio State University James Cancer Center Experience

Arranging Hospice Care from the Emergency Department: A Single Center Retrospective Study

BACKGROUND

Arranging hospice services from the Emergency Department (ED) can be difficult due to physician discomfort, time constraints, and the intensity of care coordination needed. We report patient and visit characteristics associated with successful transition from the ED directly to hospice.

METHODS

Setting: Academic ED with 82,000 annual visits.

POPULATION

ED patients with a referral to hospice order placed during the ED visit from January 2014-December 2018. Charts were abstracted by trained, non-blinded personnel. Primary goal was to evaluate patient and visit factors associated with requiring admission for hospice transition.

RESULTS

Electronic Health Record inquiry yielded 113 patients, 93 of which met inclusion criteria. Patients were aged 65.8 years (range 32-92), 54% were female, and 78% were white, non-hispanic. The majority had cancer (78%, n = d72) and were on public insurance (60%, n = 56). Half (55%, n = 51) were full code upon arrival. Average ED length of stay was 4.6 ± 2.6 hours. Discharge from the ED to hospice was successful for 38% (n = 35), a few (n = 5) were dispositioned to an ED observation unit, and 57% (n = 53) were admitted. Only 10 (11%) required an inpatient length of stay longer than an observation visit (2 days). Case management and social work team arranged for transportation (54.8%, n = 51), hospital beds (16.1%, n = 16), respiratory equipment (18.3%, n = 17), facility placement (33.3%, n = 31), and home health aides (29.0%, n = 27).

CONCLUSION

Transitioning patients to hospice care from the ED is possible within a typical ED length of stay with assistance from a case manager/social work team.

Impact of underlying malignancy on emergency department utilization and outcomes

PURPOSE

Cancer patients frequently utilize the emergency department (ED) for a variety of diagnoses both related to and unrelated to their cancer, yet ED outcomes for cancer patients are not well documented. This study sought to define risks and identify predictors for inpatient admission and hospital mortality among cancer patients presenting to the ED.

PATIENTS AND METHODS

We utilized the National Emergency Department Sample to identify patients with and without a diagnosis of cancer presenting to the ED between January 2016 and December 2018. We used multivariable mixed-effects logistic regression models to assess the influence of cancer on outcomes of hospital admission after the ED visit and hospital mortality for the whole patient cohort and individual presenting diagnoses.

RESULTS

There were 340 million weighted ED visits, of which 8.3 million (2.3%) were associated with a cancer diagnosis. Compared to non-cancer patients, patients with cancer had an increased risk of inpatient admission (64.7% vs. 14.8%; p < 0.0001) and hospital mortality (4.6% vs. 0.5%; p < 0.0001). For each of the top 15 presenting diagnoses, cancer patients had increased risks of hospitalization (odds ratio [OR] range 2.0-13.2) or death (OR range 2.1-14.4). Although our dataset does not contain reliable estimation of stage, cancer site was the most robust individual predictor associated with the risk of hospitalization or death compared to other clinical or system-related factors.

CONCLUSIONS

Cancer patients in the ED have high risks for hospital admission and death when compared to patients without cancer. Cancer patients represent a distinct population and may benefit from cancer-specific risk stratification or focused interventions to improve outcomes.

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study

PURPOSE

Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC).

METHODS

A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods.

RESULTS

During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5).

CONCLUSIONS

This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.

Outpatient Interventions for Managing Acute Complications of Chronic Diseases: A Scoping Review and Implications for Patients With CKD

RATIONALE & OBJECTIVE

Patients with chronic kidney disease (CKD) have high rates of emergency department (ED) use and hospitalization. Outpatient care may provide an alternative to ED and inpatient care in this population. We aimed to explore the scope of outpatient interventions used to manage acute complications of chronic diseases and highlight opportunities to adapt and test interventions in the CKD population.

STUDY DESIGN

Scoping review of quantitative and qualitative studies.

SETTING & POPULATION

Outpatient interventions for adults experiencing acute complications related to 1 of 5 eligible chronic diseases (ie, CKD, chronic respiratory disease, cardiovascular disease, cancer, and diabetes).

SELECTION CRITERIA FOR STUDIES

MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, grey literature, and conference abstracts were searched to December 2019.

DATA EXTRACTION

Intervention and study characteristics were extracted using standardized tools.

ANALYTICAL APPROACH

Quantitative data were summarized descriptively; qualitative data were summarized thematically. Our approach observed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews.

RESULTS

77 studies (25 randomized controlled trials, 29 observational, 12 uncontrolled before-after, 5 quasi-experimental, 4 qualitative, and 2 mixed method) describing 57 unique interventions were included. Of identified intervention types (hospital at home [n = 16], observation unit [n = 9], ED-based specialist service [n = 4], ambulatory program [n = 18], and telemonitoring [n = 10]), most were studied in chronic respiratory and cardiovascular disease populations. None targeted the CKD population. Interventions were delivered in the home, ED, hospital, and ambulatory setting by a variety of health care providers. Cost savings were demonstrated for most interventions, although improvements in other outcome domains were not consistently observed.

LIMITATIONS

Heterogeneity of included studies; lack of data for outpatient interventions for acute complications related to CKD.

CONCLUSIONS

Several interventions for outpatient management of acute complications of chronic disease were identified. Although none was specific to the CKD population, features could be adapted and tested to address the complex acute-care needs of patients with CKD.