Avoiding the ED: Planned Strategies for Unplanned Urgent Cancer Care

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The most common reasons cancer patients seek acute care are pain, fever, abdominal and respiratory concerns, and dehydration.
The most common reasons cancer patients seek acute care are pain, fever, abdominal and respiratory concerns, and dehydration.

Emergency departments (EDs) are fraught with all sorts of risks for healthy people, much less for people with cancer. Yet a patient with cancer who experiences a complication of the disease or its treatment may very well end up in the ED, often surrounded by contagions and disquieting bedlam. Frequently, visiting the ED is often a portal to hospitalization for these patients. Surely there is a better way.

Actually, there are 5 better ways, according to Nathan R Handley, MD, a hematology-oncology fellow at the Perelman School of Medicine at the University of Pennsylvania and an MBA candidate at the Wharton School, both in Philadelphia. In a recently published report, he and his colleagues describe clinical approaches that can reduce the occurrence of unplanned acute care visits for patients with cancer. Clinicians can implement the strategies individually or as part of a more integrative program for patients with cancer. The strategies were the result of a review of best practices for reducing unplanned acute care for patients with cancer, culled from literature published in 2000 to 2017. In addition, the researchers also reviewed several professional organizations' quality guidelines as well as 5 high-quality oncology care delivery models: the National Committee for Quality Assurance patient-centered medical home and patient-centered specialty practice, the Community Oncology Medical Home, the CMS Oncology Care Model, and the Commission on Cancer Oncology Medical Home.

The most common reasons cancer patients seek acute care are pain, fever, abdominal and respiratory concerns, and dehydration. In these circumstances, treatment is rendered in 1 of 3 settings: the emergency department, acute hospitalization, or 30-day rehospitalization. The researchers found one meta-analysis showed rates of readmission to the hospital ranged from a low of 31% all the way to 100%. With a rate of 25%, 30-day readmission rate was the highest for oncology patients compared with other types of patients.

The group found that all-cause hospitalizations — both planned and unplanned — are the most commonly reported acute care events in the literature. Planned acute care events are scheduled, whereas unplanned events are those for which neither patient nor clinician is prepared. Examples of planned vs unplanned include scheduled chemotherapy admissions, staged cancer surgeries, and scheduled stem cell transplantation vs visits for chemotherapy-induced nausea and vomiting, neutropenic fever, and symptomatic cancer progression, respectively. However, many episodes of unplanned acute care are often preventable; rates of hospitalizations perceived as preventable vary from 19% to 50%.  

Effective Strategies

Based on their review, the researchers evolved the following 5 strategies for reducing acute care visits for patients with cancer. 

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