Characteristics and Outcomes of Patients with Cancer Pain Placed in an Emergency Department Observation Unit.

Pain remains an undertreated complication of cancer, with poor pain control decreasing patients' quality of life. Traditionally, patients presenting to an emergency department with pain have only had two dispositions available to them: hospitalization or discharge. A third emerging healthcare environment, the emergency department observation unit (EDOU), affords patients access to a hospital's resources without hospitalization. To define the role of an EDOU in the management of cancer pain, we conducted a retrospective study analyzing patients placed in an EDOU with uncontrolled cancer pain for one year. Patient characteristics were summarized using descriptive statistics and predictors of disposition from the EDOU and were identified with univariate and multivariate analyses. Most patients were discharged home, and discharged patients had low 72-hour revisit and 30-day mortality rates. Significant predictors of hospitalization were initial EDOU pain score (odds ratio (OR) = 1.12; 95% CI 1.06−1.19; p < 0.001) and supportive care (OR = 2.04; 95% CI 1.37−3.04; p < 0.001) or pain service (OR = 2.67; 95% CI 1.63−4.40; p < 0.001) consultations. We concluded that an EDOU appears to be the appropriate venue to care for a subsegment of patients presenting to an emergency department with cancer pain, with patients receiving safe care as well as appropriate consultation and admission when indicated.

Heparin-Induced Thrombocytopenia at the Emergency Department Due to Intermittent Heparin Flush in a Patient Undergoing Stem Cell Transplant.

Heparin-induced thrombocytopenia (HIT) is an adverse reaction to heparin products, but not warfarin. HIT usually occurs 5‒10 days after exposure to heparin. Here, we report a case of HIT with multiple thrombotic events and severe thrombocytopenia resulting from intermittent intravenous heparin flushes for maintenance of a newly placed subclavian central venous catheter (CVC) for stem cell transplant. The patient is a woman in her forties with multiple myeloma who presented to the emergency department (ED) with dyspnea, pleuritic-type chest pain, hemoptysis, and worsening left-leg swelling. Heparin had been used to flush the CVC. Her platelet count began dropping approximately one week after insertion. The patient was receiving other medications known to cause thrombocytopenia. She had undergone multiple platelet transfusions. In the ED, her lab results showed thrombocytopenia), anemia; renal insufficiency; and elevated troponin, prothrombin time, and D-dimer levels. Because of the hemoptysis and thrombocytopenia, she initially received platelet transfusion and oxygen. She was found to have deep vein thrombosis of the lower extremity and started a referral to interventional radiology for inferior vena cava (IVC) filter placement. However, further review and consultation of the Benign Hematology service, discussion about the timing of decreased platelet count shortly after CVC placement and heparin administration, and the presence of thrombosis, suggested a high pre-test probability of HIT. Anticoagulation with argatroban was initiated, and IVC filter insertion was canceled. Further workup confirmed HIT diagnosis and saddle pulmonary embolism. During the patient's hospitalization, her platelets continued to improve and reached baseline upon discharge. She was transitioned to fondaparinux at the time of discharge. A few weeks later, she had successful stem cell transplantation. Emergency physicians treating patients with thrombocytopenia receiving heparin, even in small amounts, should consider the possibility of HIT and be familiar with its management.

"Triple Threat" Conditions Predict Mortality Among Patients With Advanced Cancer Who Present to the Emergency Department.

BACKGROUND: Delirium, poor performance status, and dyspnea predict short survival in the palliative care setting. OBJECTIVE: Our goal was to determine whether these three conditions, which we refer to as a "triple threat," also predict mortality among patients with advanced cancers in the emergency department (ED). METHODS: The study sample included 243 randomly selected, clinically stable patients with advanced cancer who presented to our ED. The analysis included patients who had delirium (Memorial Delirium Assessment Scale score ≥ 7), poor performance status (Eastern Cooperative Oncology Group performance status score of 3 or 4), or dyspnea as a presenting symptom. We obtained survival data from medical records. We calculated predicted probability of dying within 30 days and association with number of symptoms after the ED visit using logistic regression analysis. RESULTS: Twenty-eight patients died within 30 days after presenting to the ED. Death within 30 days occurred in 36% (16 of 44) of patients with delirium, 28% (17 of 61) of patients with poor performance status, and 14% (7 of 50) of patients with dyspnea, with a predicted probability of 30-day mortality of 0.38 (95% confidence interval [CI] 0.25-0.53), 0.28 (95% CI 0.18-0.40), and 0.15 (95% CI 0.07-0.29), respectively. The predicted probability of death within 30 days for patients with two or three of the conditions was 0.49 (95% CI 0.34-0.66) vs. 0.05 (95% CI 0.02-0.09) for patients with none or one of the conditions. CONCLUSIONS: Patients with advanced cancers who present to the ED and have at least two triple threat conditions have a high probability of death within 30 days.

The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain.

PURPOSE OF REVIEW: Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain. RECENT FINDINGS: Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.

Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature.

BACKGROUND: Carotid blowout syndrome (CBS) is an infrequent but dangerous oncologic emergency that must be recognized due to a mortality rate that approaches 40% and neurologic morbidity that approaches 60%. Patients present with a variety of symptoms ranging from asymptomatic to frank hemorrhage, and appropriate recognition and management may improve their outcomes. CASE REPORT: A man in his late 60s with squamous cell carcinoma of the oropharynx presented to the emergency department (ED) with hemoptysis and several episodes of post-tussive emesis with large clots. He had been cancer free for multiple years after treatment with chemotherapy and radiation to the neck. Evaluation revealed a necrotic tumor on the posterior pharynx on bedside laryngoscopy and an external carotid pseudoaneurysm that was stented by interventional radiology. The patient experienced recurrent hemorrhage several months later and opted for palliative measures and expired of massive hemorrhage in the ED on a subsequent visit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CBS can be fatal, and early suspicion and recognition are key to ensure that a threatened or impending carotid blowout are appropriately managed. Once carotid blowout is suspected, early resuscitation and consultation with interventional radiology and vascular surgery is warranted.

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.

Integration of palliative care into COVID-19 pandemic planning.

The COVID-19 pandemic is expected to surpass the healthcare system's capacity to provide intensive care to all patients who deteriorate as a result of the disease. This poses a unique challenge to healthcare teams of rationing care during pandemic when resources are scarce. Healthcare providers will need to acquire new skills in care decision making and effective symptom control for patients who do not receive life-saving measures. In this review, we describe some of the important palliative care considerations that need to be incorporated into COVID-19 pandemic planning. The main aspects to be considered include decision algorithms for rationing care, training on effective symptoms management, alternative delivery methods of palliative care services such as telemedicine and finally death and bereavement support for surviving family members who are likely to be isolated from their loved one at the moment of death.

High-Flow Oxygen and High-Flow Air for Dyspnea in Hospitalized Patients with Cancer: A Pilot Crossover Randomized Clinical Trial.

BACKGROUND: The effect of high-flow oxygen (HFOx) and high-flow air (HFAir) on dyspnea in nonhypoxemic patients is not known. We assessed the effect of HFOx, HFAir, low-flow oxygen (LFOx), and low-flow air (LFAir) on dyspnea. SUBJECTS, MATERIALS, AND METHODS: This double-blind, 4×4 crossover clinical trial enrolled hospitalized patients with cancer who were dyspneic at rest and nonhypoxemic (oxygen saturation >90% on room air). Patients were randomized to 10 minutes of HFOx, HFAir, LFOx, and LFAir in different orders. The flow rate was titrated between 20-60 L/minute in the high-flow interventions and 2 L/minute in the low-flow interventions. The primary outcome was dyspnea numeric rating scale (NRS) "now" where 0 = none and 10 = worst. RESULTS: Seventeen patients (mean age 51 years, 58% female) completed 55 interventions in a random order. The absolute change of dyspnea NRS between 0 and 10 minutes was -1.8 (SD 1.7) for HFOx, -1.8 (2.0) for HFAir, -0.5 (0.8) for LFOx, and - 0.6 (1.2) for LFAir. In mixed model analysis, HFOx provided greater dyspnea relief than LFOx (mean difference [95% confidence interval] -0.80 [-1.45, -0.15]; p = .02) and LFAir (-1.24 [-1.90, -0.57]; p < .001). HFAir also provided significantly greater dyspnea relief than LFOx (-0.95 [-1.61, -0.30]; p = .005) and LFAir (-1.39 [-2.05, -0.73]; p < .001). HFOx was well tolerated. Seven (54%) patients who tried all interventions blindly preferred HFOx and four (31%) preferred HFAir. CONCLUSION: We found that HFOx and HFAir provided a rapid and clinically significant reduction of dyspnea at rest in hospitalized nonhypoxemic patients with cancer. Larger studies are needed to confirm these findings (Clinicaltrials.gov: NCT02932332). IMPLICATIONS FOR PRACTICE: This double-blind, 4×4 crossover trial examined the effect of oxygen or air delivered at high- or low-flow rates on dyspnea in hospitalized nonhypoxemic patients with cancer. High-flow oxygen and high-flow air were significantly better at reducing dyspnea than low-flow oxygen/air, supporting a role for palliation beyond oxygenation.

Characteristics of cancer patients with COVID-19 in a cancer hospital.

BACKGROUND: Cancer patients are vulnerable to the coronavirus disease (COVID-19) given their compromised immune system. The purpose of this study was to describe the presenting symptoms, inpatient stay trajectory, and survival outcomes, for cancer patients infected with COVID-19; who presented to the emergency department (ED) of a single center during the early months of the pandemic. METHODS: We reviewed the electronic medical records of all cancer patients diagnosed with COVID-19 at our institution for demographic information, clinical presentation, laboratory findings, treatment intervention and outcomes. All patients had at least 14 days of follow-up. We determined their survival outcomes as of August 5, 2020. RESULTS: Twenty-eight cancer patients were diagnosed with COVID-19, and 16 (57%) presented to the ED during the study period. The median age of patients who presented to the ED was 61 years, 69% were women, and the median length of hospitalization was 11 days. There was no difference between the groups (ED vs. no ED visit) for demographics, treatment status or solid tumor versus hematologic malignancies or treatments. Dyspnea was a significant symptom with 67% of ED patients experiencing it versus only 17% of those that did not come to the ED (P=0.009). Do not resuscitate orders were initiated in eight patients, as early as two days from ED presentation and two of these patients died, while 88% of patients were discharged alive. CONCLUSIONS: Most cancer patients with COVID-19 infection admitted though the ED experienced dyspnea and were discharged from the hospital. We did not notice a statistically significant difference between cancer types or type of therapy. A broad differential is of utmost importance when caring for cancer patients with COVID-19 due to the complexity of this population. Early goals of care discussion should be initiated in the ED.

Diagnosis and management of immune-related adverse effects of immune checkpoint therapy in the emergency department.

Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first-line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune-related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune-related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment-related toxicities.

Management of altered mental status and delirium in cancer patients.

Delirium is a syndrome characterized by acute onset of changes in awareness and cognition, which fluctuate in severity during the episode. Altered mental status (AMS) and delirium have a high incidence rate among patients with cancer and this increases dramatically towards the end of life. Delirium is multifactorial, as cancer patients have an array of predisposing and precipitating factors: metabolic disturbances, structural lesions, in addition to medications and infection. The complex nature of delirium in cancer patients and the high variability of its presentation make its diagnosis and management challenging and frequently missed. Management of delirium requires identifying and correcting the precipitating cause if feasible. Diagnosis of delirium requires a high index of suspicion, and a systematic assessment to confirm the diagnosis and identify the possible cause. This includes detailed history and comprehensive physical examination together with the use of diagnostic tools, for example: Confusion Assessment Method (CAM) tool. Given the considerable distress cancer patients suffer from, clinicians must assure safety of patients with delirium and safety of the medical team caring for the patient. Family members should be provided with counseling and support.

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.

Advance Directives, Hospitalization, and Survival Among Advanced Cancer Patients with Delirium Presenting to the Emergency Department: A Prospective Study.

BACKGROUND: To improve the management of advanced cancer patients with delirium in an emergency department (ED) setting, we compared outcomes between patients with delirium positively diagnosed by both the Confusion Assessment Method (CAM) and Memorial Delirium Assessment Scale (MDAS), or group A (n = 22); by the MDAS only, or group B (n = 22); and by neither CAM nor MDAS, or group C (n = 199). MATERIALS AND METHODS: In an oncologic ED, we assessed 243 randomly selected advanced cancer patients for delirium using the CAM and the MDAS and for presence of advance directives. Outcomes extracted from patients' medical records included hospital and intensive care unit admission rate and overall survival (OS). RESULTS: Hospitalization rates were 82%, 77%, and 49% for groups A, B, and C, respectively (p = .0013). Intensive care unit rates were 18%, 14%, and 2% for groups A, B, and C, respectively (p = .0004). Percentages with advance directives were 52%, 27%, and 43% for groups A, B, and C, respectively (p = .2247). Median OS was 1.23 months (95% confidence interval [CI] 0.46-3.55) for group A, 4.70 months (95% CI 0.89-7.85) for group B, and 10.45 months (95% CI 7.46-14.82) for group C. Overall survival did not differ significantly between groups A and B (p = .6392), but OS in group C exceeded those of the other groups (p < .0001 each). CONCLUSION: Delirium assessed by either CAM or MDAS was associated with worse survival and more hospitalization in patients with advanced cancer in an oncologic ED. Many advanced cancer patients with delirium in ED lack advance directives. Delirium should be assessed regularly and should trigger discussion of goals of care and advance directives. IMPLICATIONS FOR PRACTICE: Delirium is a devastating condition among advanced cancer patients. Early diagnosis in the emergency department (ED) should improve management of this life-threatening condition. However, delirium is frequently missed by ED clinicians, and the outcome of patients with delirium is unknown. This study finds that delirium assessed by the Confusion Assessment Method or the Memorial Delirium Assessment Scale is associated with poor survival and more hospitalization among advanced cancer patients visiting the ED of a major cancer center, many of whom lack advance directives. Therefore, delirium in ED patients with cancer should trigger discussion about advance directives.

Delirium frequency among advanced cancer patients presenting to an emergency department: A prospective, randomized, observational study.

BACKGROUND: The frequency of delirium among patients with cancer presenting to the emergency department (ED) is unknown. The purpose of this study was to determine delirium frequency and recognition by ED physicians among patients with advanced cancer presenting to the ED of The University of Texas MD Anderson Cancer Center. METHODS: The study population was a random sample of English-speaking patients with advanced cancer who presented to the ED and met the study criteria. All patients were assessed with the Confusion Assessment Method (CAM) to screen for delirium and with the Memorial Delirium Assessment Scale (MDAS) to measure delirium severity (mild, ≤15; moderate, 16-22; and severe, ≥23). ED physicians were also asked whether their patients were delirious. RESULTS: Twenty-two of the 243 enrolled patients (9%) had CAM-positive delirium, and their median MDAS score was 14 (range, 9-21 [30-point scale]). The median age of the enrolled patients was 62 years (range, 19-89 years). Patients with delirium had a poorer performance status than patients without delirium (P < .001); however, the 2 groups did not differ in other characteristics. Ten of the 99 patients who were 65 years old or older (10%) had CAM-positive delirium, whereas 12 of the 144 patients younger than 65 years (8%) did (P = .6). According to the MDAS scores, delirium was mild in 18 patients (82%) and moderate in 4 patients (18%). Physicians correctly identified delirium in 13 of the CAM-positive delirious patients (59%). CONCLUSIONS: Delirium is relatively frequent and is underdiagnosed by physicians in patients with advanced cancer who are visiting the ED. Further research is needed to identify the optimal screening tool for delirium in ED. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2918-2924. © 2016 American Cancer Society.

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.

Integrating palliative care in oncologic emergency departments: Challenges and opportunities.

Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.