Nonscheduled consultation in oncologic patients. How many of them are true emergencies? An observational prospective study

Abstract

Oncologic emergencies have been extensively described and clearly defined. In oncology daily practice, cancer patients seek non-scheduled medical care in situations they perceive as a medical emergency, but which may not be a true emergency. The aim of the study was to identify the main symptoms leading to a non-scheduled consultation (NSC) and their relationship to the type of cancer, and to evaluate whether the diagnosis at discharge of patients admitted as result of a NSC correlates with a true oncologic emergency. This was a prospective observational study. Between July 2002 and April 2003, 365 NSCs were recorded. The most frequent baseline diseases were breast cancer (70), lung cancer (67), gastrointestinal cancer (52), lymphoma (42) and ovarian cancer (22). The most common symptoms for consultation were: fever (84), pain (81), cutaneous manifestations (26), dyspnea (23), bleeding (16) and abdominal distention (16). Overall, 114 of 365 NSCs (31%) resulted in admission. The most frequent symptoms resulting in admission were fever (42), pain (16), dyspnea (11), vomiting (9), neurologic manifestations (7), abdominal distention (6) and anuria (6). At discharge, only 30 patients (26%) admitted after a NSC were diagnosed with a defined oncologic emergency: febrile neutropenia (13), intestinal occlusion (12), obstructive uropathy (4) and abdominal perforation (1). True emergencies were not the most frequent causes of NSC at our institution.

Cancer pain as the presenting problem in emergency departments: incidence and related factors

“…Patients with gastrointestinal and genitourinary cancers and patients who had never received radiotherapy were more likely to visit the ED with pain as the chief complaint. Our finding that pain was the most frequent reason for cancer patients visiting ED is consistent with previous reports [2,3,5,14]. Despite the prodigious effort dedicated to relieving cancer pain in the two decades since the publication of the World Health Organization analgesic ladder [19], more than 50% of cancer patients across all disease stages still report pain [17,18].…”

“…However, 32.5% of ED visits made by cancer patients were shown to be avoidable [2], and for those resulting in admission, the true emergency rate was only 26% [3]. The high percentage of ED visits has been recognized as one indicator for poor-quality end-of-life cancer care [1].…”

Emergency department visits for symptoms experienced by oncology patients: a systematic review

“…The 18 included studies were published between 1995 and 2011 in seven countries: USA (n09), Taiwan (n03), France (n 02), Japan (n 01), Italy (n 01), Australia (n 01), and Argentina (n01) (see Table 4) [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Seventeen studies were published in English and one in French.…”

“…Although definitions were provided for 16 of the 28 Febrile neutropenia a)Fever (temp >38°C) and profound thrombocytopenia (<20×10 9 /l) [2] b)Absolute granulocyte count <500/mm 3 [5] c)Temperature >38.3°C and suspected neutropenia [12] d)Temp >38°C and absolute neutrophil count <1,000/mm 3 [14] e)Fever ≥100.4°F (in last 24 h) and ANC ≤500 cells/ml [15] f)White blood cell count <1,000/μl (or neutrophils <500/μl) with a core temperature above 38.3°C (or >38°C on 2 consecutive occasions) [16] Sepsis a) Blood: detection of microbial CO 2 by automated method of continuous blood culturing monitoring or urine: >50,000 colony-forming units of pathologic organisms/ml [15] b) Blood lactate >4 mmol/l or low BP (SBP <90 mmHg or 40 mmHg below usual) before fluid challenge or 1+ organ dysfunction (SpO 2 <95 % with fraction of inspired air O 2 >0.5, Cr >176 μmol/l or oliguria, international normalized ratio >2, Bili >78 μmol/l, Glasgow coma scale <15) [ c) Specific to abdominal pain [9] d) Generalized abdominal pain/tenderness, rebounding pain, tenderness localized in the R lower quadrant [17] e) All types of pain [7] Fatigue a) Weakness [5] b) Self-reported on 0-10 scale (severe07-10, non-severe00-6) [ [5] c) Glasgow coma scale score ≤12 [9] Dyspnea a) Shortness of breath [5,13] b) Subjective awareness of difficulty in breathing [11] Skin reactions a) All types of rash, blisters, vesicles, purpura [1] Anemia a) Hb 5.5 g/dl [2] b) Hemoglobin <8 g/dl [11] Infection a) Microbial documentation [2] b) No definition provided, but states 'confirmed' [14] Respiratory failure a) PaO 2 <60 mmHg & RR >30 breaths/min (necessitating mech. vent.)…”

Why do patients with cancer access out-of-hours primary care? A retrospective study

“…9 One study suggested that the proportion of 'true' emergencies in oncology patients presenting to a hospital emergency department was 26%. 10 Another study suggested that 32.5% of emergency department visits for patients with cancer were potentially avoidable. 11 Studies have consistently shown that pain is the most frequent symptom which prompts emergency department visits in patients with cancer.…”