Outcomes of Patients Placed in an Emergency Department Observation Unit of a Comprehensive Cancer Center.

PURPOSE: Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. METHODS: We performed a retrospective observational study that included all patients age 18 years and older who presented to our emergency department (ED) and were placed in the EDOU between March 1, 2019, and February 29, 2020. The patients' electronic medical records were queried for demographics, comorbidities, diagnosis at the time of placement in the EDOU, length of stay, disposition from the EDOU, ED return within 72 hours after discharge from the EDOU, and mortality outcomes at 14 and 30 days. RESULTS: A total of 2,461 visits were eligible for analysis. Cancer-related pain was the main reason for observation in more than one quarter of the visits. The median length of stay in the EDOU was approximately 23 hours, and 69.6% of the patients were discharged. The ED return rate for unscheduled visits at 72 hours was 1.9%. The 14- and 30-day mortality rates were significantly higher for patients who were admitted than for those who were discharged (14 days: 1.7% v 0.3%, P < .001; 30 days: 5.9% v 1.8%, P < .001). CONCLUSION: Our data suggest that placing patients with cancer in EDOUs is safe, reduces admissions, and reserves hospital resources for patients who can receive the most benefit without compromising care.

Association of emergency department admission and early inpatient palliative care consultation with hospital mortality in a comprehensive cancer center.

PURPOSE: Consultation to palliative care (PC) services in hospitalized patients is frequently late after admission to a hospital. The purpose of this study is to examine the association of in-hospital mortality and timing of palliative care consultation in cancer patients admitted through the emergency department (ED) of MD Anderson Cancer Center. METHODS: Institutional databases were queried for unique medical admissions over a period of 1 year. Primary cancer type, ED versus direct admission, length of stay (LOS), presenting symptoms, and in-hospital mortality were reviewed; patient data were analyzed, and risk factors for in-hospital mortality were identified. The association of early palliative care consultation (within 3 days of admission) with these outcomes was studied. Descriptive statistics and multivariate logistic regression model were used. RESULTS: Equal numbers of patients were admitted directly versus through the ED (7598 and 7538 respectively). However, of all patients who died in the hospital, 990 (88%) were admitted through the ED, compared with 137 admitted directly (P < 0.001). Patients who died in the hospital had longer median LOS compared with patients who were discharged alive (11 vs. 4 days, respectively, P < 0.001). Early palliative care consultation was associated with decreased mortality, compared with late consultation (P < 0.001). Chief complaints of respiratory problems, neurologic issues, or fatigue/weakness were significantly associated with in-hospital mortality. CONCLUSION: We found an association between ED admission and hospital mortality. Decedent cancer patients had a prolonged LOS, and early palliative care consultation for terminally ill symptomatic patients may prevent in-hospital mortality and improve quality of cancer care.

Presenting Symptoms in the Emergency Department as Predictors of Intensive Care Unit Admissions and Hospital Mortality in a Comprehensive Cancer Center.

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.

Changes in symptoms and inpatient mortality: a study in advanced cancer patients admitted to an acute palliative care unit in a comprehensive cancer center.

CONTEXT: Although several symptoms have been shown to predict survival, little is known of the roles of symptom changes in predicting inpatient death. OBJECTIVES: To determine the association between changes in symptoms and inpatient mortality among advanced cancer patients in an acute palliative care unit (APCU). METHODS: We retrospectively reviewed the medical records of 166 consecutive cancer patients admitted to our APCU from the emergency center (EC) or clinic from June 2006 to December 2007. We recorded symptom severity and presence of delirium on admission (baseline) and on the third, fourth, or fifthth day, whichever appeared first (follow-up). The primary endpoint was the vital status at discharge. Univariate (UVA) and multivariate analyses (MVA) were used to estimate the odds of inpatient death. RESULTS: One hundred and thirty-four patients (80.7%) were discharged alive and 32 (19.3%) died in the APCU. All symptoms significantly improved at follow-up. In UVA, persistent delirium was significantly associated with inpatient mortality (odds ratio [OR] 2.59, 95% confidence interval [CI 1] 0.09-6.17, p = 0.031), although presence of baseline delirium was not. MVA revealed that greater risk of dying was jointly correlated with a high level of baseline dyspnea (OR 1.35, 95% CI 1.13-1.61, p = 0.001) and drowsiness (OR 1.25, 95% CI 1.04-1.50, p = 0.02), low level of baseline anxiety (OR 0.83, 95% CI 0.70-0.99, p = 0.038), and transfer from EC (OR 6.78, 95% CI 1.99-23.14, p = 0.002). Worsened depression was significantly related with death in UVA (OR 1.30, 95% CI 1.08-1.56, p < 0.001), but not in MVA. CONCLUSION: Changes in certain symptoms, such as worsened depression and persistent delirium, might be important predictors of inpatient death.

Availability and integration of palliative care at US cancer centers.

CONTEXT: The current state of palliative care in cancer centers is not known. OBJECTIVES: To determine the availability and degree of integration of palliative care services and to compare between National Cancer Institute (NCI) and non-NCI cancer centers in the United States. DESIGN, SETTING, AND PARTICIPANTS: A survey of 71 NCI-designated cancer centers and a random sample of 71 non-NCI cancer centers of both executives and palliative care clinical program leaders, where applicable, regarding their palliative care services between June and October 2009. Survey questions were generated after a comprehensive literature search, review of guidelines from the National Quality Forum, and discussions among 7 physicians with research interest in palliative oncology. Executives were also asked about their attitudes toward palliative care. MAIN OUTCOME MEASURE: Availability of palliative care services in the cancer center, defined as the presence of at least 1 palliative care physician. RESULTS: A total of 142 and 120 surveys were sent to executives and program leaders, with response rates of 71% and 82%, respectively. National Cancer Institute cancer centers were significantly more likely to have a palliative care program (50/51 [98%] vs 39/50 [78%]; P = .002), at least 1 palliative care physician (46/50 [92%] vs 28/38 [74%]; P = .04), an inpatient palliative care consultation team (47/51 [92%] vs 28/50 [56%]; P < .001), and an outpatient palliative care clinic (30/51 [59%] vs 11/50 [22%]; P < .001). Few centers had dedicated palliative care beds (23/101 [23%]) or an institution-operated hospice (37/101 [37%]). The median (interquartile range) reported durations from referral to death were 7 (4-16), 7 (5-10), and 90 (30-120) days for inpatient consultation teams, inpatient units, and outpatient clinics, respectively. Research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon. Executives were supportive of stronger integration and increasing palliative care resources. CONCLUSION: Most cancer centers reported a palliative care program, although the scope of services and the degree of integration varied widely.

Antineoplastic therapy use in patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center: a simultaneous care model.

BACKGROUND: Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of antineoplastic therapy (ANT) in these patients remains controversial. In the current study, the authors examined the frequency and predictors associated with ANT use in hospitalized patients who required admission to an acute palliative care unit (APCU). METHODS: Included in the study were all 2604 patients admitted over a 5-year period to a 12-bed APCU located within a National Cancer Institute comprehensive cancer center, in which patients had access to both palliative care and ANT. Institutional databases were used to retrospectively retrieve data regarding patient demographics, cancer diagnosis, ANT use, length of hospital stay, and survival from time of admission. RESULTS: The median hospital stay was 11 days, and the median survival was 22 days. During hospitalization, 435 patients (17%) received ANT, including chemotherapy (N = 297; 11%), hormonal agents (N = 54; 2%), and targeted therapy (N = 155; 6%). No significant change in the frequency of ANT use was detected over the 5-year period. Multivariate logistic regression analysis revealed that younger age, specific cancer diagnoses, and longer admissions were independently associated with ANT use. CONCLUSIONS: The use of ANT during hospitalization that included an APCU stay was limited to a small percentage of patients and did not increase over time. ANT use was associated with younger age, specific cancer diagnoses, and longer admissions. The APCU facilitates simultaneous care for patients receiving ANT.

Discharge outcomes and survival of patients with advanced cancer admitted to an acute palliative care unit at a comprehensive cancer center.

BACKGROUND: Acute palliative care units (APCUs) are new programs aimed at integrating palliative and oncology care. Few outcome studies from APCUs are available. OBJECTIVES: We examined the frequency, survival, and predictors associated with home discharge and death in our APCU. METHODS: All patients discharged from the APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis, discharge outcomes, and overall survival from discharge were retrieved retrospectively. RESULTS: The 2568 patients admitted to APCU had the following characteristics: median age, 59 years (range, 18-101); male, 51%; median hospital stay, 11 days; median APCU stay, 7 days; and median survival 21 days (95% confidence interval [CI] 19-23 days). Five hundred ninety-two (20%), 89 (3%), and 1259 (43%) patients were discharged to home, health care facilities, and hospice, respectively, with a median survival of 60, 29, and 14 days, respectively (p < 0.001). Nine hundred fifty-eight (33%) patients died during admission (median stay, 11 days). Compared to hospice transfers, home discharge (hazard ratio = 0.35, 95% CI 0.30-0.41, p < 0.001) was associated with longer survival in multivariate analysis, with a 6-month survival of 22%. Multivariate logistic regression revealed that male gender, specific cancer primaries, and admissions from oncology units were associated with death in the APCU, while younger age and direct admissions to the APCU were associated with home discharge. CONCLUSIONS: Our APCU serves patients with advanced cancer with diverse clinical characteristics and survival, and discharged home a significant proportion with survival greater than 6 months. RESULTS from this simultaneous care program suggest a pattern of care different from that of traditional hospice and palliative care services.

Predictors of inpatient mortality in an acute palliative care unit at a comprehensive cancer center.

GOALS OF WORK: Predicting inpatient mortality has clinical and financial implications and helps improve the care of patients with advanced cancer and their families. Models with excellent validity and reliability are available for mortality prediction in intensive care units. The purpose of the current study was to determine factors associated with increased likelihood of mortality in an acute palliative care unit (APCU). PATIENTS AND METHODS: We retrospectively reviewed the medical records of 500 patients admitted to the APCU. Basic characteristics and information on symptom intensity, vital signs, relevant laboratory tests, and the presence or absence of delirium were obtained from the records of the consultation that preceded the APCU admission. Univariate and multivariate analyses were conducted to compare characteristics of patients who died in the APCU with characteristics of those who were discharged alive. MAIN RESULTS: Of the 500 patients admitted to the APCU, 124 (25%) died. Factors that were jointly prognostic for death, using multivariate analysis were younger age (odds ratio [OR] for older patients [>/=65] 0.43, 95% confidence interval [CI], 0.25-0.73, p < 0.001), admission from another oncology floor (OR 5.64, 95% CI, 1.82-17.44, p = 0.003), hyponatremia (OR 3.02, 95% CI, 1.76-5.17, p < 0.001), hypernatremia (OR 4.14, 95% CI, 1.25-13.75, p = 0.020), high blood urea nitrogen (BUN) (OR 1.95, 95% CI, 1.15-3.30, p = 0.013), high heart rate (>/=101 bpm) (OR 1.72, 95% CI, 1.01-2.93, p = 0.047), high respiration rate (>/=21/min) (OR 1.67, 95% CI, 1.00-2.79, p = 0.048), and supplemental oxygen use (OR 2.69, 95% CI, 1.60-4.52, p < 0.001). CONCLUSIONS: We observed a significant association of certain factors with increased likelihood of APCU death in patients with advanced cancer. These findings need to be validated in a larger prospective study to develop a model for predicting APCU mortality for patients with advanced cancer.

Supportive versus palliative care: what's in a name?: a survey of medical oncologists and midlevel providers at a comprehensive cancer center.

BACKGROUND: : Palliative care has been progressively adopted by American cancer centers; however, referrals to palliative care continue to occur late in the trajectory of illness. It was hypothesized that the perceived association between the name palliative care and hospice was a barrier to early patients' referral. The objectives of this study were to determine the perception of the impact of the name palliative care compared with supportive care on patient referral and to determine whether there was an association between demographic factors and the perceptions of the 2 names by medical oncologists and their midlevel providers (advance practice nurses and physician assistants) at a comprehensive cancer center. METHODS: : A survey was conducted among a random sample of 100 medical oncologists and 100 midlevel providers from The University of Texas M. D. Anderson Cancer Center. Information was collected on demographics, previous experience in palliative care, and attitudes and beliefs toward the impact of the name palliative care compared with supportive care on patient referral. RESULTS: : A total of 140 of 200 (70%) participants responded (74 midlevel providers and 66 medical oncologists). Median age was 43 years (range, 34.5-50 years), and there were 83 (60%) women. Midlevel providers and medical oncologists generally agreed in their responses to most of the items. More participants preferred the name supportive care (80, 57%) compared with palliative care (27, 19% P < .0001). Medical oncologists and midlevel providers stated increased likelihood to refer patients on active primary (79 vs 45%, P < .0001) and advanced cancer (89 vs 69%, P < .0001) treatments to a service named supportive care. The name palliative care compared with supportive care was perceived more frequently by medical oncologists and midlevel providers as a barrier to referral (23 vs 6% P < .0001), decreasing hope (44 vs 11% P < .0001), and causing distress (33 vs 3% P < .0001) in patients and families. There were no significant associations among the perception of the 2 names and age (P = .82), sex (P = .35), or prior training in palliative care (P > .99). CONCLUSIONS: : The name palliative care was perceived by medical oncologists and midlevel providers as more distressing and reducing hope to patients and families. Medical oncologists and midlevel providers significantly prefer the name supportive care and stated more likelihood to refer patients on active primary and advanced cancer treatments to a service named supportive care. Cancer 2009. (c) 2009 American Cancer Society.

Use of palliative sedation for intractable symptoms in the palliative care unit of a comprehensive cancer center.

BACKGROUND: There is wide variation in the frequency of reported use of palliative sedation (PS) to control intractable and refractory symptoms in terminally ill patients. The aim of this study was to determine the frequency and outcomes of PS use and examine patterns of practice after establishment of a policy for the administration of midazolam for PS in our palliative care unit (PCU). MATERIALS AND METHODS: This retrospective study reviewed PCU admissions for 2004 and 2005 and pharmacy records to identify patients who received chlorpromazine, lorazepam, or midazolam for PS in the PCU. Data on indication for PS, drug used, and discharge outcome were assessed for each patient. RESULTS: During the period studied, there were 1,207 PCU admissions. Of these patients, 186 (15%) received PS; and 143 (41%) of the 352 patients who died in the PCU received PS. The median age of PS patients was 58 (range, 20-84) years, and 106 (57%) were male. The most common indications for PS were delirium, 153 cases (82%); dyspnea, 11 (6%); and multiple indications, 12 (6%). Midazolam was used in 18 PS cases (10%). Six (55%) of 11 patients with dyspnea received midazolam for PS, compared with 12 (7%) of 175 patients with other indications for PS (p < 0.001). Forty-three (23%) of 186 PS patients were discharged alive, compared with 812 (80%) of 1,021 patients who did not receive PS (p < 0.001). CONCLUSIONS: PS was required in 15% of PCU admissions, and 23% of PS patients were discharged alive. Our findings suggest a potential for significant underreporting of overall PS. If our institution's policy on midazolam use for PS were less restrictive, midazolam use might increase. More research is needed to define the optimal agent for inducing rapid, effective, and easily reversible PS.

Predictors of access to palliative care services among patients who died at a Comprehensive Cancer Center.

PURPOSE: Palliative care services can decrease physical and psychosocial distress in patients with advanced cancer. However, most patients with cancer die without access to palliative care services (APCS), and patterns of referral are not well understood. The purpose of this study was to determine predictors of patients' access to palliative care. PATIENTS AND METHODS: We reviewed patient records from the computerized database at UT M. D. Anderson Cancer Center over 2 (2003 and 2004) to determine differences in characteristics and outcomes between patients with and without APCS. APCS was defined as a palliative care consultation and follow-up or transfer to the palliative care unit. RESULTS: A total of 499 of 1453 (34%) inpatients who died at our cancer center had APCS. There were no significant differences in race, age, or insurance status between the APCS groups. The two major predictors of a low rate of APCS were hematologic malignancies (20% rate of APCS versus 44% for solid tumors, p < 0.0001) and intensive care unit (ICU) admission (15% versus 52% for non-ICU admission, p < 0.0001). Patients with hematologic malignancies who were admitted to the ICU had the lowest APCS rate (10%, p < 0.0001). The median relative cost of care per patient for decedents with APCS was 0.62 compared to non-referred patients (p < 0.0001). CONCLUSION: APCS was lower among patients with hematologic malignancies and those admitted to the ICU. APCS resulted in a lower cost of care. Mortality in comprehensive cancer centers is quite variable among different primary malignancies. More research is needed to better define patterns of referral.

Impact of a palliative care service on in-hospital mortality in a comprehensive cancer center.

BACKGROUND: Palliative care services provide symptom control and psychosocial support for dying patients and their families. These services are not available in many cancer centers and tertiary hospitals. The purpose of this study was to review the impact of a palliative care program, established in 1999, on overall in-hospital mortality. METHODS: We reviewed the M. D. Anderson Cancer Center computerized database to determine the total number of deaths and discharges and the place of death for each fiscal year from 1999 to 2004. The median length of stay for patients who died in different locations within the hospital was calculated. Annual palliative care consultations for patients who subsequently died in the hospital were retrieved. The annual mortality rate for the cancer center was calculated. RESULTS: The overall in-hospital mortality rates were 3.6, 3.7, 3.6, 3.5, 3.6, and 3.7% of all discharges for the period 1999-2004 respectively (p > 0.2). The number of deaths in the medical intensive care unit (MICU) dropped from 252 in 671 (38%) in 1999 to 213 in 764 (28%) in 2004 (p < 0.0001). Involvement of the palliative care service in the care of patients dying in the hospital grew from 8 in 583 (1%) in 1999 to 264 in 764 (35%) in 2004 (p < 0.0001). The median length of hospital stay (MLOS) for patients who subsequently died in-hospital was significantly longer than that for patients who were discharged alive. CONCLUSIONS: Increased involvement by the palliative care service in the care of decedent patients was associated with a decreased MICU mortality and no change in overall hospital mortality rate or inpatient length of hospital stay.

Palliative care inpatient service in a comprehensive cancer center: clinical and financial outcomes.

PURPOSE: Inpatient palliative care units are unavailable in most cancer centers and tertiary hospitals. The purpose of this article is to review the outcomes of the first 344 admissions to the Palliative Care Inpatient Service (PCIS) at our comprehensive cancer center. PATIENTS AND METHODS: We retrospectively reviewed our computerized database for clinical and demographic information, length of stay, and hospital billing during the first year of the service's operation. RESULTS: Three hundred twenty patients were admitted during the study period. Their median age was 57 years. The main cancer diagnoses were thoracic or head and neck (44%), gastrointestinal (25%), and hematologic malignancy (8%). The main referral symptoms were pain (44%), nausea (41%), fatigue (39%), and dyspnea (38%). The median length of stay in the PCIS was 7 days (range, 1 to 58 days). Fifty-nine patients died while in the PCIS. However, the overall hospital mortality rate was not increased compared with that in the year before the establishment of the PCIS (3.58% v 3.59%). The mean reimbursement rate for all palliative care charges was approximately 57%, and the mean daily charges in the PCIS were 38% lower than the mean daily charges for the rest of the hospital. Symptom intensity data showed severe distress on admission and significant improvement in the main target symptoms. Most patients were discharged to a hospice. CONCLUSION: The PCIS has been accepted in our tertiary cancer center on the basis of its clinical utility and financial viability.