309 Emergency Case Study

Table 3. The Recorded Chief Complaint for 309 Emergency
Department Visits (EDVs).
Chief complaint No. %
Pain 141 45.6
Abdomen 92 29.8
No specific site 15 4.9
Back 10 3.2
Chest 10 3.2
Headache 6 1.9
Mouth 5 1.6
Lower limb 4 1.3
Neck 4 1.3
Pelvis 3 1
Upper limb 1 0.3
Dyspnea 41 13.3
Vomiting 38 12.3
Fatigue/weakness 34 11
Altered consciousness 32 10.3
Fever 21 6.8
Bleeding 16 5.2
Diarrhea 15 4.9
Cough 13 4.2
Anorexia 11 3.6
Constipation 10 3.2
Care for catheter/intravenous line 7 2.3
Nausea 6 1.9
Dehydration 4 1.3
Jaundice 4 1.3
Urinary symptoms 4 1.3
Other 3 1
Skin symptoms 3 1
Edema 2 0.6
Insomnia 2 0.6
Suffocation 2 0.6
Agitation 1 0.3
Cardiac arrest 1 0.3
Convulsions 1 0.3
Dysarthria 1 0.3
Dysphagia 1 0.3
Hoarseness 1 0.3
Hypotension 1 0.3
Oral thrush 1 0.3
Rhinorrhea 1 0.3
Swelling 1 0.3
Alsirafy et al 3
Downloaded from ajh.sagepub.com by guest on April 16, 2015
Dyspneawas the secondmost common (13%) chief complaint in the current study. It is common in patients with advanced cancer, especially at the EoL.16 In the aforementioned Canadian population-based study, dyspnea was the most common symptomatic cause for EDVs during the last 2 weeks of life of dying patients cancer.1 It causes a significant negative impact on the quality of life of patients and their families,17 and a recent study showed that it was significantly associated with unavoidable
EDVs by PC patients with cancer.9 Better control of dyspnea and understanding the changes thatmay happen at the EoL by patients and their informal caregivers may help in avoiding EDVs.
Certainly the need to optimize symptom control is not limited to pain and dyspnea. Other symptoms may be distressing and many of the chief complaints in this study could have been managed without visiting the ED, like nausea, vomiting, cough, and constipation.
Some studies suggested that many of EDVs by patients with terminal cancer are avoidable.1,9,10 However, there was no agreement between studies regarding the definition of avoidable
EDVs. Delgado-Guay et al considered EDVs avoidable if the problem could have been solved in the outpatient clinic or by a phone call.9 While Wallace et al used a relatively broader definition for avoidable EDVs when they defined it as EDVs that could have been managed by home care teams or family physicians or managed in another setting, for example hospice.10 Barbera et al considered EDVs because of constipation and technical or mechanical reasons, for example prescription refill, avoidable.1 In the current study, EDVs that started during regular working hours and ended by home discharge were considered avoidable. This definition of avoidability is based on administrative data rather than depending on the evaluation of investigators as in previous studies.1,9,10 After discussions, we agreed that a definition based on administrative data would be more reproducible and avoids professional bias that may result from the variability in judgment of investigators on the avoidability of individual EDVs.
In our setting, 19% of EDVs during the last 3 months of life of patients with terminal cancer are potentially preventable.
These EDVs could have been possibly managed in an outpatient clinic or a day care facility. Although we included only inhospital deaths, we are not expecting much change in the rate when home deaths are included. This is because the available evidence from Saudi Arabia suggests that the majority of patients with cancer die in hospital.13 The percentage of avoidable
EDVs may be even higher than 19% because some of the reasons for out of hours EDVs could be managed effectively in an outpatient setting, like constipation and care for catheters.
The 19% prevalence of avoidable EDVs in our study is close to the 23% reported by Delgado-Guay et al,9 who used an avoidable EDV definition close to ours. On the other hand, it was much less than the 52% prevalence described by Wallace et al,10 who used a broader definition of avoidable EDVs that included medical care at home. The current results confirm that a notable proportion of EDVs may be avoidable. The 5% prevalence of avoidable EDVs during the last 6 months of life in the study conducted by Barbera et al was much lower than ours and that of other studies.1 This is because they considered
EDVs avoidable if they are due to constipation (1.8%) or due to avoidable technical or mechanical reasons (2.8%).1
Some strategies have been suggested to prevent unnecessary
EDVs. Uncontrolled symptoms, especially pain, are a major reason for EDVs by patients with terminal cancer.1,9 Uncontrolled pain was a chief complaint in almost half of patients included in this study and was the only chief complaint in 29%. Optimizing symptoms’ control with special attention to overcoming barriers to adequate pain control is likely to reduce unnecessary EDVs.
The availability of community-based PC service is another intervention that may help in reducing EDVs by patients with terminal cancer. The rate of EDVs among patients who receive
EoL PC at home is significantly lower than those who do not.18,19 Earlier admission to community home care services may be of particular benefit in reducing EDVs at the EoL.2
Two-thirds of the EDVs in this study started out of working hours. The availability of out-of-hour services, like phone call service, may help in reducing EDVs. Community PC services that included out-of-hour accessibility to PC providers was associated with significantly less frequent EDVs.19
Earlier integration of PC in the care of patients with terminal cancer may be another intervention to reduce EDVs at the EoL.
In a recent study, patients with terminal cancer who were referred early to PC (before the last 3 months of life) were significantly less likely to visit the ED compared to those who were referred late.3
Furthermore, coordination between services may contribute to preventing unnecessary EDVs at the EoL. For example, in the study conducted by Wallace et al,10 a significant proportion of out-of-hours EDVs by PC patients was initiated by the on-call general practitioner. Better communication between general practitioners and PC services may help general practitioners in managing the problems of patients rather than referring them to the ED.10 In one study, the access of general practitioners to a structured PC plan during out-of-hours was associated with significantly less frequent hospital admissions.20
Effective communication with informal caregivers of PC patients is also important.
Some of EDVs in the current study were due to changes that are likely to happen at the EoL, for example, anorexia and weakness. Educating caregivers about these changes may prevent the initiation of unnecessary EDVs by anxious caregivers.
It may be also useful to find predictors for EDVs by PC patients.21 This may be helpful in planning the care of PC patients who are more likely to visit the ED.
The results of the current study should be interpreted in view of its limitations. This was a single center retrospective observational study. In addition, patients who may have died at home were not included. For included patients, data of EDVs in other hospitals were not available.
Conclusions
The majority of patients who died of cancer in our setting and other settings visit the ED at the EoL. The main cause of EDVs
4 American Journal of Hospice & Palliative Medicine®
Downloaded from ajh.sagepub.com by guest on April 16, 2015 among patients with terminal cancer is uncontrolled symptoms, particularly pain. Many of these EDVs are potentially preventable.
Further research is needed to find and examine the
effectiveness of strategies to reduce EDVs at the EoL.