Korea’s ‘Cancer ER’ Improves Care While Lowering Costs

Published on January 31, 2013
In 2009, Asan Medical Center in Seoul, Korea, set up a multi-disciplinary emergency department specifically for cancer patients. This retrospective study was conducted to compare the care provided before and after the Cancer ER (CER) was established.

With increasing incidence of cancer in the general population, com- bined with improved survival and widespread use of cancer thera- peutic agents relying on the outpatient treatments, emergency physicians are increasingly encounter- ing patients who present with symptoms related to underlying cancer and diverse toxicities that are direct effects of its treatments [1]. However, there is minimal reference to the published literature re- garding the percent of cancer patients who usually present with oncologic emergencies and their sub- sequent managements.

In May 2009, Korea’s Asan Medical Center set up an ED cancer unit, named Cancer Emergency Room (CER), designed for focused and specialized management of oncologic emergencies. This paper will clarify the operating characteristics of the CER and provide support for its administrative benefits, as well as discuss relationships between the patients’ diagnosis and their subsequent managements, in- cluding dispositions in ED.

Methods

The Asan medical center ED is a 97,000 visits- per-year ED in Seoul, Korea, and serves as a tertiary referral center. In May 2009, the CER was opened. In this year, it had monthly census of 360 patients with 18 beds allocated, and since January 2010, beds were increased to 22. This unit is staffed by one board certified emergency physician and one emer- gency medicine and one internal medicine resident work in turn. Patient managements are supervised by the board certified emergency physician, and on- cology and hematology staffs are invited in making further decisions during their daily rounds. Adult patients 15 years and older with cancer and who were managed in Asan medical center oncology and hematology department are eligible for the CER, so the new visitors or those who were managed in other departments are not allocated, and trauma related visits were also not indicated. Owing to its sixth floor location, the CER was not suitable for patients with profound shock, or requiring immediate resuscita- tion including airway management or cardiopulmo- nary resuscitation. When a patient enters the normal ED, he or she is triaged by triage nurse, and if the patient fulfills the criteria, he or she is assigned to the CER. Since this unit has fixed number of treatment beds (it was increased again to 30 beds in January, 2012), once the beds are full, all patients are sent to the normal ED.

We performed a retrospective electronic medi- cal record review of all patients admitted to the CER during the 12-month period between January 2010 to December 2010, and data of patients man- aged in the preexisting ED during January 2008 to December 2008 were collected to compare the care before and after the introduction of the CER.

We recorded baseline characteristics, including age, gender, and underlying malignancies. Main di- agnosis and treatments considered the most impor- tant were selected. Disposition of the patient, and their length of stay in the CER and inpatient unit for those admitted were calculated. Cost of ED and in- patient care were collected and calculated in United States dollars. Demographic data, chief complaints, cancer diagnosis, length of stay, and disposition were gathered electronically from the electronic medical record database. Diagnosis and main treatments were reviewed by two nurse practitioners who were blinded to the goals of this study, and data entry was reviewed on 30% of patients by one of the study’s lead investigators to ensure the consistency on the data acquisition. The study protocol was approved by the ethics committee of University of Ulsan.

Results

During the year 2010, 7,288 adult patients with cancer visited our ED. Excluding 212 patients with newly diagnosed cancer who were transferred from other hospitals, 455 patients whose cancer not being managed in the oncology and hematology depart- ment, 108 trauma related visits, and 114 patients requiring immediate resuscitation, 6,399 were indi- cated for management in the CER. However, due to fixed number of treatment beds, a total 5,502 pa- tients were managed in this area.

The mean age was 57.4 years (range 17 – 89), and 55.8% were men; 88.8% of underlying malignancies were solid tumors and 11.2% had hematologic ma- lignancies. Lung (20%), stomach (17.5%), colorectal (12.9%) and breast cancers (10.5%) were the most prevalent in terms of emergency visits among solid tumors, as lymphoma (5.7%) and multiple myeloma (3.2%) among hematologic malignancies (Table 1).

Of the 5,022 patients, 90.8% were under ac- tive treatment with chemotherapeutic agents, and among them, 53.9% received anticancer treatment within one month (37.2% within 15 days, and 16.7% between 15 – 30 days), and 12.0% had treat- ments between one and two months. In 24.8%, more than 2 months were passed since their last treatment. And 4.8 % were under radiation therapy and 6.2% were receiving supportive care without treatment.

Emergency visit related diagnoses

Diagnoses varied but were grouped into four main categories: disease progression (55.5%), in- fection (22.8%), treatment related complications (14.7%), and non-cancer related problems (7%). Bowel obstruction (10.9%) caused by peritoneal car- cinomatosis, cancer invasion, or paralytic ileus was the most common diagnosis related to disease pro- gression, and effusions (9.3%) including peritoneal, pleural and pericardial space, and cancer pain (7.7%) followed. Central nervous system metastases (7.0%) including brain parenchyme, spinal cord, and lep- tomeningeal seeding were also common diagnosis. Pulmonary system (10.7%) was the most common site for infections, and biliary tract (2.0%) followed. Although rare, catheter-related infection was impor- tant problem for those with port implanted in the subcutaneous space. Febrile neutropenia (8.0%) was the most frequent treatment related problems, and oral mucositis, chemotherapy induced colitis, and radiation pneumonitis, were all unique problems associated with cancer treatments.

Main treatments

Parenteral antibiotics administration (28.9%) and pain control with opioid (22.9%) were the most common treatments. Tapping for effusions, stent insertion for obstructed bowel, drainage for biliary or urinary tract obstructions, repositioning of previ- ously existing catheters, et al., were treatments clas- sified as drainage procedures (17.5%). Supportive care with parenteral hydration and nutritional sup- ply (10.7%), and colony stimulating factor adminis- tration for neutropenia (8.3%) were also common. Whole brain radiotherapy or gamma knife radiosur- gery depending on the extent of metastases, pallia- tive radiotherapy for metastatic bone pain or spinal cord compression, et al., were classified as radiother- apy (6.4%). Anticoagulation for newly diagnosed ve- nous thromboembolism and vascular interventions including inferior vena caval filter or superior vena caval stent were rare but important treatments, and classified as “other treatments.”

Difference in main treatments according to main diagnoses was analyzed. In patients with infection, parenteral antibiotics were given in 92.8%, and 46.5% of treatment related problems received par- enteral antibiotics. Pain control was done in 37.1% of disease progression, compared with 8.8% of non- cancer related problems. Supportive care only was provided most commonly to patients with disease progression (16.2%), however 1.5% of infection and 6.7% of treatment related problems received such treatment (Table 2).

Disposition of the patients

Of the 5,502 patients, 42% were admitted to the inpatient unit, 52.7% were discharged for outpatient follow-up, 0.2% died during the stay in the CER. Home service was supplied to 0.6% patients for palliative care including home nutritional support, catheter care, parenteral opioid administration et al., and 4.5% were transferred to other hospitals includ- ing hospice care center.

Regarding disposition of patients, the largest proportion of patients with infections (64.3%) were admitted to inpatient unit, compared with relatively small portion of treatment related prob- lems (26.4%), (P < 0.05). Although statistically not significant, half of patients with disease progression were discharged for outpatient follow up, while 7.7% were transferred to other hospitals including hospice care center. Death during stay in the CER took place in 10 patients, whose main diagnosis was all disease progression. Majority of patients with non-cancer re- lated problems (89.9%) and treatment related prob- lems (73.1) were discharged (P < 0.05) (Table 3).

Difference between 2008 and 2010

In 2008, 5,023 patients with cancer visited the ED, and when the criteria for the CER management were applied, 4,981 fulfilled these criteria. Of these 4981 patients, 4258 (85.5%) were admitted to the inpatient unit. Mean length of stay in ED was 31.6 ± 25.7 hours, and 13.8 ± 10.4 days in inpatient unit for those admitted. In 2010, 2310 (42.0%) patients were admitted to inpatient unit, which was significantly lower than that of 2008 (P < 0.001). However length of stay in ED (33.7 ± 23.7 hours), and inpatient unit (14.4 ± 10.7 days) were not significantly different. Median (range) cost of care in ED [2008: 725 (90 – 7,372) $ vs. 2010: 646 (40 – 5,005) $, P <0.001] and inpatient unit [2008: 3,530 (10 – 154,490) $ vs. 2010: 2,721 (11 – 104,998) $, P <0.001] were lower in 2010 than 2008 (Table 4).

Discussion

With an aging population and improving out- comes of treatments, cancer has been an impor- tant public health concern globally[2], and in- creased incidence and prevalence will lead to more cancer-related emergencies, which will present as a challenge for emergency physicians. In May 2009, for the purpose of prompt and pertinent manage- ment of increasing patients with oncologic emer- gencies, our institute established an ED unit for cancer, separated from the preexisting crowded ED treatment area. It is designed to segregate the cancer patients from the heterogeneous patient groups in ED, owing to their susceptibility to infections and their unique problems regarding malignancy and its treatment related complications. While ED oversees various units for the care of patients with different illnesses [3-5], to the best of our knowledge, ED units separated and specialized for oncologic emer- gency has not been reported elsewhere. An institute in Spain runs the oncology acute toxicity unit for improving the management of chemotherapy toxic- ity, but it is an outpatient facility, which is different from ours based on ED[6].

Definitive managements of various oncologic emergencies are usually performed in inpatient unit. However, our data shows that ED unit for cancer could deal with oncologic emergencies while patient staying in ED. This was possible because we have in- corporated multidisciplinary team approach includ- ing emergency medicine, medical oncology, radia- tion oncology, interventional diagnostic radiology, and hospice and palliative care members. Using al- gorithm-driven cares allowing for standardized and rapid treatments, and policy of transfer to hospice center for the patients with low benefits of further palliative management also helped. Traditionally hospice care is defined as support and care for per- sons in the last phase of incurable disease, with a prognosis of 6 months or less[7]. Our department has a consultation program with a team consisting of hospice and palliative care nurse, home service nurse, and social workers, and incorporation of this team with medical practice for those who would unlikely benefit from further treatments, discharge with home service or transfer to hospice center is well es- tablished as a common practice.

The fact that medical units dedicated to special subject can improve quality of care is well known [8], and in this respect, the ED unit for cancer is distinct from the general ED or inpatient beds, because we use algorithm-driven care allowing for standardized and rapid treatments and evaluation of the patients with oncologic emergencies, and further link to hos- pice and palliative cares for last phase of disease.

Since pain is very common in advanced cancer patients [9], and patients with suppressed immunity are susceptible for infectious complications [10], disease progression requiring pain control, and in- fection requiring parenteral antibiotics were the most prevalent diagnosis in cancer patients’ emer- gency visits. Treatment related problems are com- mon in patients receiving anti-cancer treatments, and are unique diagnosis comparing with other pa- tients without malignancies [1]. However more than half of patients with disease progression and treat- ment related problems were discharged home after management in the CER, and these are conditions which specialized ED unit for cancer could have its benefits.

After establishment of an ED unit for cancer patients, there was significant decrease in the num- bers of patients admitted to inpatient unit, without significant increase in ED or inpatient unit length of stay, and the cost of ED care and inpatient care were reduced. However, the reasons for reduced cost of care are not well explained. Probably, protocol- based standardized care devoid of overutilization of unnecessary tests or delays in managements, and en- couragement of early transfer to hospice care center for those who have no effective treatment could all played role. And making it a rule for the oncology and hematology staffs to participate in the decision making during their daily rounds could also have affected.

Our study is limited as a single center, and to the best of our knowledge emergency department unit for cancer doesn’t exist elsewhere. So the administra- tive benefits of this unit that we intended to clarify may not be generalized. The data regarding diagno- sis were obtained automatically base on electronic medical record, and only one main diagnosis was assigned, so there is a chance that the patient had more than one main diagnosis. And since medical insurance system varies among different countries, our results of costs of care require caution in its interpretation.

Given the increasing incidence of cancer, and var- ious toxicities related to its treatment regimens, there is substantial interest in specialized management unit for oncologic emergencies in ED. Establishing this unit cannot be generalized, depending on the in- stitute’s size, manpower, financial status and treated patients’ pool. However, our ED unit for cancer have a valuable role in assessing and managing patients with cancers, not only progression of disease, but treatment with various toxicity and complications related to its treatment, and link to hospice and pal- liative care.

Acknowledgment: The authors acknowledge the contributions of nurse practitioners HJ Chang and JH Ok, who participated in the data collection.

References

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