Challenge of immune-mediated adverse reactions in the emergency department.

Multiple drugs of a new class of cancer treatments called immune checkpoint inhibitors, which work by enabling the immune system to attack tumour cells, have been approved for a variety of indications in recent years. Immune checkpoints, such as cytotoxic T-lymphocyte antigen-4 and programmed death-1, are part of the normal immune system and regulate immune activation. Treatment with inhibitors of these checkpoints can significantly improve response rates, progression-free survival and overall survival of patients with cancer; it can also result in adverse reactions that present similarly to other conditions. These immune-mediated adverse reactions (IMARs) are most commonly gastrointestinal, respiratory, endocrine or dermatologic. Although patients' presentations may appear similar to other types of cancer therapy, the underlying causes, and consequently their management, may differ. Prompt recognition is critical because, with appropriate management, most IMARs resolve and patients can continue receiving immune checkpoint inhibitor treatment. Rarely, these IMARs may be life-threatening and escape detection from the usual evaluations in the emergency environment. Given the unusual spectrum and mechanism of IMARs arising from immune checkpoint inhibitors, emergency departmentED staff require a clear understanding of the evaluation of IMARs to enable them to appropriately assess and treat these patients. Treatment of IMARs, most often with high-dose steroids, differs from chemotherapy-related adverse events and when possible should be coordinated with the treating oncologist. This review summarises the ED presentation and management of IMARs arising from immune checkpoint inhibitors and includes recommendations for tools and resources for ED healthcare professionals.

Impact of an electronic medical record system on emergency department discharge instructions for patients with hypertension.

BACKGROUND: Uncontrolled hypertension is associated with significant patient morbidity and health care costs. Many patients evaluated in the emergency department (ED) do not regularly consult health care providers and have socioeconomic barriers to receiving primary care. Hypertension screening and counseling has been advocated as a routine part of ED care. Previous work has shown poor referral rates and education for ED patients presenting with elevated blood pressure (BP). We sought to determine whether implementation of an electronic medical record (EMR) would improve these rates. METHODS: We performed a retrospective study conducted in 2 urban academic EDs, comparing pre-EMR (handwritten discharge) to post-EMR discharge instructions for patient referral for BP management and education on lifestyle modification. Medical records of patients aged ≥ 18 years with a systolic BP rate ≥ 140 or diastolic BP rate ≥ 90 mm Hg were included. Patient data included demographics, BP rate, presenting symptoms, and administration of antihypertensive medication while in the ED. Discharge instructions were reviewed for a directed referral for outpatient BP management, prescriptions for antihypertensive medication, and lifestyle modifications. RESULTS: Of the 1000 medical records reviewed, 500 were pre- and 500 were post-EMR, including a total of 389 patients who had persistently elevated BP on reassessment. At discharge, acknowledgment of elevated BP occurred in 45% of patients in the pre-EMR phase and only 26% in the post-EMR phase (P < 0.0001). Provision of all 5 lifestyle modifications occurred in none of the pre-EMR patients and in 15% of the post-EMR patients (P < 0.0001). Factors associated with a directed referral for the patient included increasing BP rate, pharmacologic treatment of hypertension in the ED, or provision of a prescription for an antihypertensive medication at discharge. The post-EMR phase was negatively associated with a directed referral for outpatient BP management. CONCLUSION: Overall, the initiation of EMR led to a decrease in outpatient referrals and acknowledgment of elevated BP rates in discharge instructions. The provision of more complete lifestyle modifications improved in the post-EMR phase.