Abstract
Background
The diagnosis of cancer is an emotive one. Patients who present to hospitals with a cancer diagnosis are often attended to with a quiet appreciation of eventual fatalism. Although family members accompanying such patients may project feelings of sadness and helplessness, the patients themselves usually appear to accept their diagnoses with a better emotional mindset.
Increasingly many communities are trying to better understand their cancer patient demographics, and developing strategies to address the various needs of cancer while managing an increasing number of patients in the ambulatory mode. 1 However, there have been very few attempts to understand the emergency department (ED) management of cancer patients in the Asian environment.2,3 Over the years, the ED at the Singapore General Hospital (SGH) has seen increasing number of patients with oncologic emergencies, such as neutropenic sepsis, malignancy-associated metabolic syndromes, and end-of-life issues. This ED, with an annual census of about 140,000, also serves as the emergency care facility for the largest cancer treatment facility in the country. Of the 140,000 annual ED visits, oncology-related attendances number about 4000. Because the mortality of chronic terminal illnesses seems to be higher in oncologic patients, 4 the tendency has been to admit such patients to the Medical Oncology Department (MOD) for further care. Indeed, this trend has also been seen in EDs elsewhere, where cancer patients tend to have longer ED length of stay (LOS) and higher admission rates. 5 Cancer is the most common cause of mortality in Singapore, contributing to 29.1% of all deaths in 2017. 6 In 2016, cancers were the largest contributor (17%) to life-years lost as a result of mortality and ill health in the country. 7
Palliative care for such patients in the ED has also been minimal. Physicians usually do not consider the ED, with its overcrowding and fast pace of work, as the ideal venue for provision of palliative care to oncology patients, 8 and frequently defer this mode of care to the in-hospital environment. However, patients increasingly wish to be managed as outpatients. Disposition is often influenced by fear of unsafely discharging such patients. Patients are often reluctant to be admitted, leading, sometimes, to a discharge against medical advice, which has its own negative consequences.
There is a dearth of research on palliative care in the ED. 9 In addition, there is increasing evidence that patients who receive palliative care at an ED tend to have shorter hospitalization, shorter LOS, and lower resource utilization. 10 The factors that contribute to the provision of palliative care involve socio-cultural norms that can differ significantly in different communities. The multi-ethnic, multi-cultural, and multi-religious composition of the Singapore population does not facilitate the provision of a standard set of religious support facilities for patients requiring palliative care. Ignorance of cultural and religious sentiments may also impede the provision of such care in a busy ED. Healthcare workers in such environments should be cognizant of the need to address acute palliative issues in oncology patients presenting to the ED. There is a need to study the characteristics of this sizable subset of ED patients to further guide meaningful and impactful initiatives in oncologic emergency care in an Asian environment.
Aims
The aim of this audit study was to determine the state of the current management of oncology-related emergencies presenting at the ED of the hospital. This would serve as a basis for proceeding with a series of initiatives to clearly define the characteristics of patients with oncologic presentations here, consider alternate forms of management, and subsequently develop an emergency oncology research agenda. This would include pharmacological, procedural, and palliative interventions that could potentially benefit the care of these patients. The data would also provide opportunities to address cancer-specific issues faced by patients presenting to our institutions.
Methods
We conducted a retrospective data audit of all ED patients with either cancer-related diagnoses or admission to the MOD at SGH from the ED in October 2018. Data items extracted from the hospital’s electronic medical record (EMR) system, included demographic profile, mode of arrival, triage complaint and category, triage vital signs, principal ED diagnosis, critical interventions carried out in the ED, ED disposition, disposition time and date, inpatient discharge time and date, and date of death if applicable. The Singapore Patient Acuity Categorization Scale11,12 which is used by all EDs in Singapore formed the basis for the triage categorization. From the vital signs measured at triage, the National Early Warning Score (NEWS)
13
was calculated. Owing to the very large variety of clinical presentations, the patients were categorized by type of triage complaint (TC), emergency clinical diagnosis (ECD), and primary cancer type (PCT). These resulted in creation of 11 TC, 17 ECD, and 14 PCT groups. Data, once collected, were anonymized and transferred to an electronic database. Simple statistical analysis was carried out using IBM SPSS version 21. Statistical differences for categorical variables—such as mode of arrival, types of investigations and interventions carried out, disposition after ED stay, and clinical outcomes—were obtained using the chi-square and Fisher’s exact test. For continuous variables, such as age, LOS, and NEWS, two-sample
Results
A total of 308 patient ED visit records with either a cancer-related diagnosis or subsequent admission to the MOD were extracted for the month of October 2018.
Patient demographics
Of these patients, 46% were men. The women were generally younger than the men (61.33 ± 13.63 years vs 67.36 ± 12.02 years, p = 0.063, confidence interval (CI) −8.94 to −3.13). 33.8% of all patients fell within the 61–70 years age group.
Mode of arrival and clinical outcomes
Self-referrals constituted 76.6% of all patients. These included those who arrived using their own transport or via public transportation. The remaining 72 (23.4%) came via ambulances (6.5% by public emergency ambulances and 16.9% via private non-emergency ambulances). Of those who arrived by non-emergency ambulance, 55.8% died during that episode of hospitalization, as opposed to 55.0% who arrived by public emergency ambulance and 23.3% of the self-referrals (p ⩽ 0.001).
ED LOS
The mean ED LOS for all patients was 4.25 h (interquartile range (IQR) 2.85–6.70 h). Although the average ED LOS did not differ much between ECD groups, the shortest was noted among patients with soft tissue tumors needing investigation (median 2.70 h) and the longest among those with endocrine and metabolic syndromes such as hyperkalemia and hypoglycemia (median 6.10 h) (Figure 1).
Emergency department length of stay by emergency clinical diagnostic group.
Patient mix
All the patients had primary cancer types (PCTs) which were categorized into 14 main groups (Figure 2). The commonest cancers were lung, colorectal, and breast. Together, these constituted 50.8% of the cancer mix in ED patients. Triage complaints or TCs (Table 1) were also very varied. Gastrointestinal, respiratory, and neurological complaints were the most common, while hematological and dermatological complaints were the least common.
Distribution of sites of primary cancer in the ED population.
Distribution of triage category by principal complaint.
ED triage
The distribution of Triage Categories is as given in Table 1. The commonest TCs for patients triaged to the Resuscitation Room (Priority 1) were cardiovascular and respiratory in nature, with complaints such as chest pain and breathlessness. Gastroenterological symptoms—such as nausea, vomiting, and abdominal pain—were commonest among those triaged to Priority 2. In Priority 3, gastrointestinal and respiratory symptoms, together with fever, were the predominant TCs.
In 28 (9.1%) patients, pain was the primary complaint. Most of these patients had breast, colorectal, lung, gynecological, and hepatobiliary cancers. While not the primary complaint, 70 (22.7%) other patients also presented with pain as one of their complaints. The number of patients by ECD is as given in Table 2. The commonest ECDs were respiratory, infective, and gastrointestinal in nature.
Emergency diagnosis cancer groups and their survival rates.
ED: emergency department.
The NEWS at triage was analyzed according to the TCs (Figure 3). Using one-way ANOVA, there was no statistically significant difference in NEWS between TCs (p = 0.673). This was also noted for NEWS across PCTs (p = 0.179) and across ECD groups (p = 0.622).
Distribution of NEW Scores by patients’ principal complaint at triage.
Clinical care provided during ED stay
The mean ED LOS was 4.25 ± 2.29 h (Table 3). There was no statistically significant difference in ED LOS across the different NEWS clinical severity groups by one-way ANOVA test (p = 0.457).
Patient clinical severity (by NEWS) in relation to ED length of stay.
NEWS: National Early Warning Score; ED: emergency department.
The p-value was calculated using the one-way ANOVA.
A total of 195 (63.3%) patients had critical interventions carried out at the ED. 98 (31.8%) patients received analgesia in the ED. Of those who received analgesia, 24.0% were Priority 1 patients, 36.0% Priority 2, and 23.0% Priority 3 (p = 0.071). 92 (29.9%) patients had intravenous (IV) antibiotics initiated in the ED prior to disposition. Of these, 39.0% were in Resuscitation, 25% in Priority 2, and 37% in Priority 3 (p = 0.058). Only 5 (1.6%) patients had other critical interventions. These include endotracheal intubation, central venous cannulation, insertion of drains, or administration of vasoactive agents.
Disposition after ED stay
291 patients (94.5%) were admitted to inpatient wards. Admission rates did not vary much among diagnosis groups. Only 1.6% were discharged directly from the ED with no follow-up arrangements. 2.3% were referred to the specialist clinics for further management, 0.6% either left without being seen or refused admission, 0.6% died soon after arrival at the ED, and 0.3% were transferred to other hospitals owing to previous follow-up there. There were no statistically significant differences in admission rates across age groups (p = 0.567) by the chi-square testing.
Patient outcomes after inpatient admission
Of the 308 patients, 17 were discharged from the ED alive, 291 were admitted as inpatients, and 95 (32.6%) patients died (Table 2) mainly after inpatient admission. Highest mortality rates occurred in those who presented with general symptoms (80.0%) such as general weakness, functional decline, and anasarca. Such patients were usually in the terminal stages of disease and had multiple sites of metastasis. They were followed closely by those with hepatobiliary (75.0%), respiratory (44.3%), and renal complaints (40.0%). As mentioned earlier, patients conveyed by ambulances had higher mortality compared to those who were self-referred.
Between triage categories, mortality rates were 55.0% for Priority 1, 22.2% for Priority 2, and 23.3% for Priority 3 patients (p < 0.001). Among NEWS severity groups, mortality was 93.7% for those at high risk (NEWS >6), 53.3% for those with medium risk (NEWS 5 and 6), and 26.0% for those at low risk (NEWS 0–4) (p < 0.001).
Inpatient average LOS
There was no statistically significant difference in mean in-hospital LOS between those discharged alive (mean 5.9 ± 10.1 days) and those who died during their inpatient admission (mean 5.5 ± 5.3 days) (p = 0.156).
Discussion
This study was conducted in an ED that serves a campus encompassing a large 1800-bed acute care hospital, SGH, and a multitude of national specialty centers, including the National Cancer Center of Singapore (NCCS). Being the only ED on campus, it receives a proportion of oncology patients on follow-up with the NCCS. The results of this study are an eye-opener to what more can be done for cancer patients arriving at an ED.
The ED is a readily accessible facility operating at all hours, unlike ambulatory medical oncology clinics that operate only during working hours. Therefore, many cancer patients present to the ED. Certain environmental challenges in the ED such as overcrowding, noise, lack of time, and limited privacy, although potentially of concern for all ED patients, particularly challenge the provision of quality care for people with advanced cancer. 14 This is reflected in the relatively small number of active treatments initiated at the ED for these patients, namely, 31.8% receiving analgesia, 29.9% receiving antibiotics, and 1.6% receiving other critical interventions. Many more definitive cancer-related, symptom-related measures and palliative interventions need to be considered for these patients.
Cancer is also not a single diagnosis. The site of the primary lesion and the presence of metastases will have a profound impact on the clinical presentation. With improved and novel treatments for many cancers, more patients are living longer. However, the side effects of newer treatments are increasingly seen in EDs. The medical needs of cancer patients are thus undergoing transformation, and emergency physicians may not always be keeping up with the rapid changes occurring in the field of medical oncology. With better education of healthcare workers on oncologic treatment modalities, the addition of early access oncology clinics and short stay protocols may allow a larger proportion of cancer patients to be discharged from the ED and managed as outpatients.
In addition to complications arising from the cancers and treatments, multiple comorbidities contribute challenges to the care of an increasing proportion of elderly cancer patients. 15 Socio-cultural variations in different communities can affect the disposition and certain aspects of care of cancer patients presenting to the ED. All these factors may eventually contribute to high rates of acute care hospital admissions in oncologic patients. 16
The NCCS runs a walk-in clinic that operates for 2 h daily on weekdays. As a result, we may not be able to capture the data for a small proportion of oncology patients who present to the clinic and are managed there. However, if these clinic patients require advanced care or aggressive resuscitation, they may still be transferred to our ED for stabilization before admission to the inpatient wards. This highlights the need for patient education in the right-siting of emergency care, so that patients with true emergencies will go directly to the ED for more appropriate and timely care.
More than a third of our cancer patients were aged 61–70 years. With life expectancies lengthening, an increasing proportion of the population in Singapore in their sixties are still working. Their oncologic condition places a heavy strain on their economic livelihood and can be especially debilitating in terms of function. This highlights the need for aggressive management approaches to maintain their functional status and active lifestyles.
Slightly more than half of the patients who arrived via ambulance died during their inpatient admission. This was double the mortality of those who arrived in their own vehicles. This shows that patients and members of the public are able to recognize when to appropriately call for an ambulance. Following this, ambulances can be further developed to initiate critical emergency treatments early instead of only transporting patients to a facility for treatment later. There is increasing awareness of the need to train paramedics in pre-hospital emergency and palliative care.17,18 This could potentially be helpful in the treatment of oncology patients. To our knowledge, literature on outcomes of pre-hospital treatment of oncologic emergencies is sparse. It seems intuitive, however, that if care was to be initiated early in the pre-hospital setting, patient outcomes might improve and average hospital LOS could be shortened. Ambulances should be considered as active and critical care components in the patient’s journey through the oncologic healthcare system.
A minority of the patients came via ambulance. Of these, however, a larger proportion came via private non-emergency ambulances. This suggests a need for education of oncology patients and their next of kin about when an emergency ambulance should be utilized. Appropriate and early use of emergency ambulances may mean more expeditious stabilization or palliation of ill patients.
Given the frequent overcrowding that occurs in many EDs, better methods of identifying, at triage, patients who may have a poorer outcome and deserve expedited treatment, are needed. Cancer patients, generally, tend to have a higher mortality than other groups. In this study, NEWS performed much better than the Triage Patient Acuity Categorization Scale in predicting mortality, although both showed reasonably good discrimination. The challenge would be to develop a risk score that could be even more discriminating so that some cancer patients with treatable emergencies may be identified earlier, so as to administer even more timely treatment and maximize survival. Even in situations where aggressive and invasive resuscitative measures may not be appropriate, terminal cancer patients on best supportive care with high-risk NEWS can benefit greatly from early palliative care if accurately identified.
From our data review, our oncologic patients had an ED LOS of about 4 h. The current method of data extraction did not allow us to further define whether most of the LOS was for work-up for disposition or awaiting transfer to an inpatient ward. Access block is a problem that is not exclusive to oncology patients, and there are ongoing efforts in many hospitals to address this. Meanwhile, patient care should be seamless, with further stabilization of their emergency conditions while awaiting placement in an inpatient bed, so as to further improve outcomes. 19 The 4-h wait at the ED provides opportunities to provide more care to these ill groups of patients with potential for better outcomes. Protocols can be explored with inpatient oncology teams to provide such seamless care 20 in EDs before the inpatient oncology bed becomes available. Early palliative care seems to significantly improve quality of life without affecting survival.21,22 In addition, palliative care in the ED has been shown to improve outcomes, patient and family satisfaction, and hospital LOS. 23 While access block still remains an issue and patients have to lodge in EDs, efforts should be made to explore ways to maximize the use of that time for patient benefit. Institution of treatment measures in collaboration with inpatient oncology teams may help lead to earlier resolution of symptoms and shorted overall inpatient LOS.
This study identified the common chief triage complaints—or TCs—in cancer patients presenting to our ED. These data can help focus further efforts in developing the ED’s capability in more thoroughly addressing such complaints. This may translate into additional training of emergency physicians and nurses in the recognition and initial management of oncologic emergencies. The overall effect, hopefully, would be better patient care and satisfaction, improved mortality, fewer inpatient admissions, and shorter hospital LOS for admitted patients. With the addition of early access oncology clinics, the better education of healthcare workers on oncologic conditions and adverse effects of oncologic treatment modalities may allow a larger proportion of cancer patients to be discharged and managed as outpatients. Allowing patients to be managed on an ambulatory basis would not only ease bed occupancy and thus ED and hospital overcrowding, it would also be in line with the wishes expressed by many oncology patients to be treated at home as far as possible. This will likely be cost-effective, although such cost savings will need to be quantified to realize its benefit and gain the support of hospital administrators and healthcare planners.
The main interventions that were instituted for our patients appeared to be analgesia and antibiotics. There would be a need to consider whether other forms of emergency management may help improve outcomes, such as palliative symptom management for respiratory distress, management of vomiting, and hydration for patients. EDs should be equipped to provide care at various points along a cancer patient’s journey, be it prevention and screening, acute care, or palliation. Indeed, there has increasingly been a call to focus efforts on improving emergency medicine within the context of cancer.24,25
Limitations
As discussed previously, a major limitation of this study is the inability to distinguish the main factors contributing to ED LOS. Owing to the way the data were collected, it is unclear if most of the LOS was attributable to ED evaluation and treatment as opposed to access block.
This data review sought to provide a preliminary overview of certain key characteristics and major features of the patient’s journey through the hospital system, particularly in the pre-hospital and ED setting. As such, more detailed information as to the inpatient discharge diagnosis and the breakdown of the individual diagnoses or cancer types (as opposed to groups) were not included. Variations throughout the year are also not reflected given that this was a descriptive study of oncologic patient visits within 1 month. A larger, more detailed study may be even more helpful in identifying areas for further efforts to improve oncologic emergency care. These data, however, serve to raise awareness of the need for dedicated efforts in improving oncologic emergency care, particularly in an Asian setting.
Conclusion
This current review indicates that there are a significant number of cancer patients who can potentially benefit from implementation of additional pre-hospital and ED interventions. Pre-hospital protocols may help with early, almost immediate stabilization or palliation of patients. ED protocols that are evidence-based and designed, in conjunction with oncology teams, may also provide integrated care options for delivery of seamless care between disciplines. The results of this study can have implications, not just for patients being managed at our hospital but also for emergency oncology patients in the country and region. The management of oncologic patients in EDs in Asia has not been well defined previously. These more aggressive approaches to treatment of oncological emergencies can potentially improve patient outcomes and comfort. Oncology service improvements in EDs need to be made known to the wider emergency care audience for greater future patient benefit.
The significant proportion of patients who have poor outcomes underlines the need for initiating active use of palliative approaches for the management of such patients at the ED. Patient and staff satisfaction will likely be greater with such palliative interventions. This can be the approach for the conduct of future integrated studies on oncologic emergencies in the ED.
Footnotes
Declaration of conflicting interests
Funding
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