Evaluation of a new emergency department avoidance model of care, the Cancer Urgent Assessment Clinic, in response to the COVID-19 pandemic

Introduction

The Cancer Urgent Assessment Clinic (CUAC) was an emergency department (ED) avoidance/unscheduled model of care implemented in response to the COVID-19 pandemic. The aim was to reduce the risk of COVID-19 exposure and infection by providing an alternative to ED for cancer patients while undergoing anticancer treatments.

Methods

The clinic incorporated a telephone triage process and face-to-face appointments 8am to 8pm, 7 days per week. CUAC operated between 23 March '20 and 31 July '20, led by a nurse practitioner candidate, oncology registrars, cancer nurse specialists, and overseen by oncology consultants. Evaluation followed a mixed-methods approach through (1) analysis of CUAC patient data, (2) comparison of ED cancer patient presentation data from a previous period (23 March 2019-31 July 2019), and (3) a patient survey.

Results

In total, 400 patients were telephone triaged via CUAC, with 166 recorded as having avoided ED. There was a reduction in the number of cancer patient admissions to the ED short stay unit during the clinic period compared with the same time-period in 2019: 130 vs. 234, associated with 615 fewer hours. Patient satisfaction was positive particularly regarding ease of access, time to treatment, confidence in assessment and treatment of cancer-related concerns, and likelihood of presenting to hospital when unwell during the pandemic.

Discussion

While initially being implemented to reduce the risk of COVID-19 exposure, this evaluation demonstrated the CUAC model was an efficient and potentially cost-saving model of care for the management of cancer patients with mild to moderate severity of disease and treatment-related concerns.

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.

Emergency ambulatory outpatient management of immune-mediated hypophysitis

PURPOSE

Immune-mediated hypophysitis is an important toxicity related to immune checkpoint inhibitors (ICI). Optimal management is associated with improved outcomes. It represents a wide spectrum of clinical presentations, and a proportion may be suitable for emergency ambulatory management.

METHODS

Emergency ambulatory management of patients presenting with clinical features and findings consistent with ICI-induced hypophysitis was considered at a tertiary cancer/endocrinology hospital. Suitable patients were initially investigated and treated in accordance with the UK emergency management guidelines for ICI induced hypophysitis. After an initial observation period of 4 h, patients were discharged with oral hydrocortisone (20, 10, 10 mg).

RESULTS

An initial cohort of 4 patients with emergency presentations of ICI-induced hypophysitis has been managed in an ambulatory fashion in the first 3 months. There were no 30-day readmissions.

CONCLUSION

Carefully selected emergency presentations with immune-mediated hypophysitis may be suitable for ambulatory management.

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

In 2015, The James Cancer Hospital's Emergency Department (ED) opened at The Ohio State University Wexner Medical Center's ED. Careful planning was undertaken to assure that the needs of patients with cancer would be addressed. Strong relationships between experts in hematology, oncology, and emergency medicine were built to maximize the positive impact. Ongoing reevaluation of operational needs facilitates optimal patient flow, resource use, and opportunities to build and develop new resources. The results are evident in improved patient satisfaction in the cancer ED and a much smoother flow of patients into the system.

Emergency oncology: development, current position and future direction in the USA and UK

The need for supportive and palliative care services in patients with cancer is well established. However, the emerging unique challenges of acutely unwell patients with cancer necessitate the need for research into the optimal strategies and pathways for their management. The clinical challenges of emergency oncology alongside its increasing financial burden have led to an interest as to the best strategies for delivering this care. In the USA and UK, varying models of emergency and acute care are developing. There is a clear need for non-oncology physicians with an interest in the management of oncological emergencies to be at the heart of this work. This paper considers the current situation in the USA and UK and the future directions for the delivery of this care.