Cancer Patients in the ED…Sign of the Times?

Nick Mulcahy

July 11, 2011

July 11, 2011 — A rare study that characterizes the use of the emergency department (ED) by cancer patients provides insight into a situation in need of some remedial action by the oncology community, suggest both the authors of a new study and an expert not involved with the study.

The study of ED visits in North Carolina appears in July 1 issue of the Journal of Clinical Oncology.

The investigators from the University of North Carolina at Chapel Hill found that of about 4.1 million ED visits in the state in 2008, there were 37,760 visits by 27,644 patients with cancer. With an estimated 358,200 cancer survivors in North Carolina, the numbers mean that 7.7% of cancer patients visited EDs in that year.

The findings are, in part, a reflection of healthcare trends, said Marcia Grant, RN, DNSc, director and professor of nursing research and education at the City of Hope Medical Center in Duarte, California, who was not part of the study.

Care is shifting from the hospital and clinic to the home.

"Since the push to decrease hospitalization and move much of the care of patients to the home and the family caregivers, the preparation of patients, staff, and families for the care of challenging symptoms at home has not kept up with the resulting needs of cancer patients," Dr. Grant told Medscape Medical News.

"Care is shifting from the hospital and clinic to the home, where patients and families get into difficulty with poorly managed symptoms," she summarized.

Reasons for Visits

Dr. Deborah Mayer

Pain, respiratory distress, and gastrointestinal issues were the 3 top reasons that cancer patients visited EDs, according to the study authors, led by Deborah Mayer, PhD, associate professor of nursing at the University of North Carolina at Chapel Hill.

Educating patients and caregivers about pain cannot be left in the hands of nonprofessionals, warned Dr. Grant. "Pain management is still a challenge for staff, and education of the patient and family by uninformed staff will clearly result in emergency room visits," she said.

The study also showed that about half of all visits (44.9%) occurred during normal office hours.

Dr. Mayer was unsure of the reason for these daytime ED visits. "It is hard to know if the visits during office hours were related to geographic distance to the site of care, as we did not have that information. It may also be related to practices being so busy that they may not have the capacity to see unanticipated visits," she told Medscape Medical News.

Dr. Mayer emphasized another study finding: that a majority of the ED visits (62.3%) resulted in hospitalization. Nationally, only 12.5% of all patient visits to EDs result in hospital admissions, she and her coauthors point out.

"We were surprised by the high number of admissions, compared to other ED visits. We will be developing another study to explore this using claims data to better understand why these cancer patients are being admitted and what is happening to them," Dr. Mayer said.

The study by Dr. Mayer and colleagues is only the second to characterize a population-based sample of patients with cancer who use the ED. The first study looked at end-of-life visits to EDs in Ontario, Canada (CMAJ. 2010;182:563-568).

In their study, patients with lung cancer accounted for 26.9% of the ED visits; patients with breast, prostate, and colorectal cancers accounted for 6.3%, 6.0%, and 7.7% of visits, respectively. When controlling for sex, age, time of day, day of week, insurance, and diagnosis position, patients with lung cancer were more likely to be admitted than patients with other types of cancer.

Dr. Grant suggested that the lung cancer findings could be improved upon. "The respiratory distress experienced by lung cancer patients is to be expected; it is one of the most frequent symptoms. However, teaching staff and having staff teach patients and families how to manage this shortness of breath is not occurring," she said.

Ideas for Change

If some part of the problem of having cancer patients in the ED is due to oncology practices being unable to accommodate unanticipated visits, Dr. Mayer believes there are solutions. "I think we can get creative about that," she said. "Pediatricians have had sick child call in/visit times before normal office hours for a long time."

"Some cancer programs are also setting up urgent clinics to see patients for acute symptom management," she continued.

Patient education is another solution. "I wonder if patients know to call their oncology team when they start having problems. Some basic patient education may reinforce when and whom to call for symptoms like pain and nausea and vomiting," Dr. Mayer said.

Dr. Grant echoed some of Dr. Mayer's points and encouraged healthcare professionals to get trained in patient education.

"Clearly, what is needed is preparation of the professional staff that discharge patients and are responsible for teaching patients symptom management — pain control, dyspnea management, nausea, vomiting, diarrhea, and other symptoms," she said.

The practice of giving a cancer patient a printed handout at discharge is not sufficient education, said Dr. Grant. "Excellent discharge teaching is critical and requires a review with patients and families about symptom management, not simply handing them a booklet. One-to-one teaching and discussion with the patient and family is essential."

At the City of Hope, Dr. Grant has been part of a program to improve outcomes in discharged hematopoietic cell transplant patients.

"We tested an intervention to prepare these very sick (at discharge) patients to manage infections, nutritional problems, fatigue, pain, and other symptoms," she explained. "Teaching materials included specific aspects of symptom control and information on telephone access to a professional at the institution 24/7."

Efforts are needed to evaluate and expand discharge teaching for all cancer populations, said Dr. Grant. "Then, when symptoms become difficult to manage at home, patients and families know where to call, regardless of the time of day or the day of the week," she said about the benefits of discharge teaching.

When good education occurs and support is established, emergency visits will likely only be used "if no professional access by telephone occurs, or if the professional providing advice recommends that the patient go to the emergency room."

J Clin Oncol.2011;29:2683-2688. Abstract