Title

A Review of Emergency Department Visits by WRCC Haematology Patients

Type of Proposal

Oral presentation

Start Date

24-3-2015 11:00 AM

End Date

24-3-2015 11:50 AM

Faculty

Schulich School of Medicine Windsor

Faculty Sponsor

Caroline Hamm

Importance of the Project

Retrospective studies seeking to elucidate the reasons for, circumstances surrounding, and outcomes of emergency department (ED) visits by cancer patients are extremely few in number. This is surprising, as careful evaluation of such data can be used to eliminate many avoidable visits to the ED. Problems experienced by cancer patients should—ideally—be addressed as effectively as possible during routine follow-up visits with each patient's oncologist and/or palliative care physician. Although acute issues which require emergency intervention will inevitably arise, use of the ED by cancer patients may be indicative of ineffective clinical visits with their treating physician.1 In an additional, more general sense, a greater understanding of these visits will allow for a maximally beneficial allotment of scarce healthcare resources.

We focussed on hematology patients because these patients have been shown to be the most frequent users of the emergency department for febrile neutropenia.2 Additionally, the hematology service always comprises the largest percentage of inpatient beds. Since most patients on the inpatient service are admitted through the emergency department, focusing on this group of patients is the most reasonable choice. Knowledge of the reasons for ED visits by this patient population will lay the groundwork for new treatment protocols which can ameliorate the need to seek emergent care. This, aside from directly benefitting patients, will result in decreased costs associated with their care, especially if their admittance to hospital can be avoided (Perry et al (2010) contend the average patient in Ontario admitted to hospital from the ED stays 3.5 days longer and costs $685 more3).

In summary, the goal of this project was to identify actionable items that could be implemented to decrease the absolute number of emergency room visits by hematology patients in the Windsor Essex county region. The results of this study are currently being vetted through the Windsor Regional Cancer Program leadership, and will significantly affect the way palliative care services are administered in this region.

1. Barbera, Lisa. "Why do patients with cancer visit the emergency department near the end of life?."Canadian Medical Association Journal. 182.6 (2010): 563-568.

2. Baetz, Tara. “Febrile Neutropenia Quality Improvement Project.” Personal communication.

3. Perry and Alshurafa: Using admission from the emergency room to improve predictions of resource use and length of stay for acute inpatient admissions in Ontario. BMC Health Services Research 2010 10(Suppl 2):A21

Existing State of Knowledge

Current studies that exist are largely very general and focus on ED visits by groups of patients with a variety of cancers. A 2013 study conducted in Ontario sought to elucidate the relationship between the severity of symptoms in cancer patients (as expressed through ESAS scores) and their likelihood of visiting an ED within one week of having those symptoms assessed. In fact, 3.8% of patients indeed sought emergency care within one week. Pain, nausea and shortness of breath were all symptoms correlated with an increased likelihood of an ED visit. Most notably, the median survival of patients without an ED visit was 777 days, compared to 476 days in those with.1

1. Barbera, Lisa. "Do patient-reported symptoms predict emergency department visits in cancer patients? A population-based analysis." Annals of Internal Medicine. 61.4 (2013): 427-437.

Research Question

What are the reasons for, circumstances surrounding, and characteristics of Emergency Department visits by patients treated by the haematology service of the Windsor Regional Cancer Centre?

Methodology

A manifest of patients with at least one (benign or malignant) hematological diagnosis who have been treated at the WRCC and have been seen in the ED of Windsor Regional Hospital between November 1, 2012 and May 24, 2014 was generated through the Health Records Department. To determine the characteristics of these patients and assess the details of their ED visit(s), data was garnered from their oncologist's dictation in LOTUS Notes and the notes of attending ED physicians.

Your Findings

778 ED visits were examined. 286 (37%) visits resulted in hospital admission, average length of stay was 12.5 days, and 13% of admissions resulted in patient death. The most common presenting complaints were pain (n = 179, 23%), general weakness (n = 103, 13%), and fever (n = 62, 8%). The most common ED physician diagnoses were pain issues (n = 92, 12%), anemia (n = 75, 10%), and febrile neutropenia (n = 34, 4%). 59% of visits occurred outside of clinic hours. Interestingly, only 15% of ED visits were preceded by a phone call to the WRCC within two calendar days, and 30% of phone conversations resulted in the patient being directed to the ED.

These results suggest that interventions targeted at better pain and infection control may be most effective in reducing ED use by patients with haematological malignancies. Encouraging patients to phone the cancer clinic for direction prior to visiting the ED will likely also help accomplish this.

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Mar 24th, 11:00 AM Mar 24th, 11:50 AM

A Review of Emergency Department Visits by WRCC Haematology Patients