Prospective cohort study of an Australian cancer care services-led model of emergent care

Keywords: avoidable, cancer care, cohort study, department of emergency, emergent care, model of care.

People with cancer frequently experience acute complications related to their underlying disease or treatment of the disease that often require emergent care and hospitalisation.¹ In Australia, people with cancer access emergency departments (EDs) almost twice as often as those without a cancer diagnosis,² leading to significant clinical and economic burden.³ The need for emergent care is expected to intensify due to cancer therapies increasingly being delivered in out-patient areas,⁴ rising demand for cancer treatment, increasing complexity of cancer and treatments, increasing range of novel treatments, and an aging population with multiple comorbidities.^5,6

The management of acutely unwell people with cancer is often complex and requires interactions between several professionals and specialty.¹ This complexity can lead to difficulties in decision making and coordination of care, patient safety concerns and poor patient experiences and outcomes.⁷ Australian data demonstrate that people with cancer who attend EDs have higher acuity, management times, mortality and length of stay in the ED compared with the general population.^3,8 A substantial proportion of people with cancer presenting to EDs are experiencing disease- or treatment-related symptoms that may be more appropriately managed via their specialist cancer team or via alternative pathways of care provided in cancer care services (CCS).^9,10

Internationally and in Australia, there is increasing focus on innovative models of emergent care for people with cancer in the out-patient setting to relieve pressure on EDs and improve patient experiences and outcomes.^4,7 To the best of our knowledge, five published studies have described and/or evaluated Australian CCS-led models of emergent care: a rapid assessment clinic staffed by cancer nurses and oncologists,¹¹ nurse practitioner-led urgent assessment clinic and consultation services,^12,13 nurse-led symptom and urgent review clinics⁴ and a nurse practitioner providing emergent care within a chemotherapy unit.¹⁴ None of these studies described or evaluated long-standing models that organically developed within CCS in response to local need without dedicated funding.

Various CCS-led models or pathways of emergent care that aim to reduce avoidable ED presentations and hospitalisation have been reported or evaluated in the literature, in particular telephone advice services and unplanned care and assessment units (for further details, see Table 1).⁷ Many of these models or pathways emerged organically and pragmatically, building on and integrating with existing services to address local needs (e.g. telephone advice services), whereas other models are stand-alone healthcare services that required the investment of significant resources (e.g. oncology medical centres).⁷ Variations in locations, settings, funding schemes and healthcare systems, as well as methodological limitations in study designs, limited the translation of this knowledge without an understanding of local need.⁷ In addition, few of these studies explored the role of the patient and carer as valuable and active partners in accessing emergent care.⁷

Table 1.  Overview of CCS-led models of emergent care reported in literature review⁷
NP, nurse practitioner

Anecdotally, it has been observed that most Australian out-patient CCS provide varying levels and forms of emergent care for their patients as ‘business as usual’, outside of formal models of care. In many cases, emergent care is absorbed into planned care in busy out-patient departments. Although this approach is pragmatic, it may not be sustainable long term as the demand for emergent care continues to increase in the out-patient setting in line with growing pressure on EDs.⁴ Models of care are often developed to bridge service gaps rather than as a planned strategic response to an identified local need.¹⁵ It is vital that CCSs understand local need and consumer experiences and consider current literature when planning, developing, implementing and assessing models of care for their patients.

The aims of this study were to describe a long-standing, pragmatic, CCS-led model of emergent care in a large tertiary hospital in Australia and to quantify and profile emergent care provided over a 6-month period. The overarching aim of the study was to understand the scope of, and demand for the service.

In this study, emergent care was defined as care provided in response to an emergent health care issue, such as a change in condition (physical, emotional or psychosocial) that required input from a healthcare professional. This included infections, temperatures, treatment, or cancer-related symptoms (i.e. pain, nausea), falls and distress.

The aim of the CCS-led model of emergent care was to manage, treat and/or admit patients, avoiding ED presentations whenever feasible through pragmatic pathways of care, including: (1) telephone advice provided in out- and in-patient departments; (2) unplanned care provided in out-patient departments; and (3) facilitation of unplanned admissions via out-patient departments. Fig. 1 shows the pathways of care in the model of care during business hours and after-hours.

Fig. 1.  Pathways of care in the CCS-led model of care during business hours and after-hours.

All patients who are to receive treatment within the CCS are provided education and an information pack containing contact telephone numbers during business hours and after-hours. In addition, cancer care coordinators provide patients with their contact details if they have questions or concerns. After-hours (weekdays 1630–0800 hours, weekends and public holidays), patients known to CCS (and their carers) are encouraged to contact nursing staff in the in-patient wards for telephone advice. Patients with urgent issues after-hours are advised to present to the ED (Royal Brisbane and Women’s Hospital (RBWH) or elsewhere) and the cancer nurse will liaise with the ED via telephone and fax and hand over any relevant information.

During business hours (Monday to Friday, 0800–1630 hours), patients known to CCS (and their carers) are encouraged to contact a CCS nurse via telephone for advice. If they require review, the nursing and medical team will identify whether there is capacity to safely see a patient in the CCS out-patient department. If not, they will be directed to the ED. Patient calls are taken by a shift coordinator or clinic nurse in the out-patient areas. After-hours, the ward shift coordinator in the in-patient areas (or another senior nurse if appropriate) takes the telephone call. Only experienced oncology nurses are responsible for managing patient calls, with the use of a Clinical Telephone Advice Form that prompts data to be collected on the clinical situation, advice provided and subsequent actions taken. This form is not a triage tool. Advice is provided based on clinical experience. Medical advice is often sought on the appropriate course of action.

During business hours, patients can present to the CCS out-patient department (with or without a planned appointment) for additional unplanned care, where they are assessed, treated and discharged, or admitted to in-patient wards. Alternatively, patients who present to the ED can be transferred to a CCS out-patient department for management, pending capacity in the CCS. Patients who present for unplanned care are seen within general areas of the out-patient department during business hours. They are allocated space, resources and medical review within the general areas of the out-patient department on a case-by-case basis as per clinical need. Medical review of patients requiring unplanned care is largely provided by medical teams, in addition to covering planned care. A haematology resident is rostered in the out-patient department specifically to support the provision of emergent care between 1000 and 1830 hours (but also supports planned care).

Nursing care is provided by nurses in addition to planned patient care. At the time of data collection, no nurse practitioners were available to support emergent care provision. A range of procedures can be provided in the out-patient areas, including medication administration, intravenous fluids, antibiotics, blood products, dressings, central line management, ascitic drainage and investigations (e.g. coordination of imaging, blood collection, septic screens, electrocardiograms). Reviews are also facilitated in the out-patient space with consultative services (e.g. specialist palliative care services) and the multidisciplinary team (e.g. social work, psychology). There, reviews are initiated by medical and nursing teams based on clinical need.

We conducted an observational study to quantify and profile episodes of emergent care within the model of care over a 6-month period (March–September 2016) to determine who accessed care, why care was accessed, what care was provided and how the episode of care ended.

This study was conducted in the RBWH, a large tertiary referral teaching hospital located on the east coast of Australia.¹⁶ The CCS cares for people with all types of cancers and has three out-patient units and two in-patient wards.

Data were collected on all patients with ‘emergent care’ needs who: (1) accessed telephone advice; (2) accessed unplanned care within the out-patient departments (‘unplanned care’); and/or (3) experienced an unplanned admission via the out-patient department. Data were also collected on unplanned admissions into the CCS via the ED to contextualise findings and identify areas of need or potential expansion of the CCS-led model of care. Prospective data were not available on unplanned care provided in the ED for people with cancer unless they received an admission under a CCS physician. Interhospital transfers were excluded. Study size was determined by convenience sampling in the present descriptive exploratory study.

Data were collected prospectively by clinical staff and a project nurse. For unplanned care, data collected included the date and time of the episode of emergent care, the reason for the episode of emergent care, the emergent care provided and the outcome of the emergent care. Individual patient information was collected regarding cancer treatment, recent discharge, the presence of severe neutropenia (absolute neutrophil count <0.5 × 10⁹ L⁻¹) and whether the patient was known to the RBWH Specialist Palliative Care Service at the time of the episode of care. Data were not collected on emergent care provided at other healthcare facilities because we were interested in profiling our model of care to inform and improve future service provision.

Admission details (including the reason for admission) were recorded by the CCS bed manager (a senior nurse who manages all admissions). For unplanned care and telephone advice, data were collected on the reason for the episode of care, the care provided and the outcome of care by the nurse responsible for that episode of care. Due to the high number of calls received daily in the oncology clinics of the out-patient department, nurses working in this area only collected overall numbers of telephone advice for 1 week. All nurses and care coordinators in the in- and out-patient areas were asked to collate records of the telephone advice they provided.

Categories for the reason for the episode of emergent care were based on the relevant literature⁷ and clinical assessment by relevant clinical teams. Nursing staff involved in the project were educated regarding data collection, and descriptions were provided for each variable collected. Mortality outcomes were collected until 6 months after the initial episode of emergent care. Data were cross-referenced against hospital records by the project nurse for accuracy (e.g. date of birth, disease, reason for admission, recent treatment received).

Data were analysed in IBM SPSS version 26. Descriptive statistics were computed to describe all variables in this descriptive exploratory study.

An exemption of ethics approval was granted by the RBWH Human Research Ethics Committee because this project was deemed to be a service evaluation activity (Review no. HREC/15/QRBW/526). The principles outlined in the National Health and Medical Research Council document Ethical Considerations on Quality Assurance and Evaluation Activities were followed.¹⁷

Between March and September 2016, 1412 episodes of emergent care were provided within the CCS, including 307 episodes of telephone advice (237 patients; median 1 episode of telephone advice per patient, min-max 1–5), 825 episodes of unplanned care (484 patients; median 1 episode per patient, min-max 1–9) and 280 unplanned admissions (233 patients; median 1 admission per patient, min-max 1–6). Over the same time frame, 459 unplanned admissions occurred in 361 patients (median 1 admission per patient, range 1–6) via the ED. A flowchart of episodes of care in the CCS is shown in Fig. 2. Patient and disease characteristics for all episodes of care are provided in Table 2. The reasons for accessing emergent care are provided in Table 3.

Fig. 2.  Flowchart of episodes of care in pathways of emergent care in the CCS.

Table 2.  Patient and disease characteristics for all episodes of emergent care in the CCS
Unless indicated otherwise, data are presented as n (%)

Table 3.  Reasons for episodes of emergent care in the CCS

Overall, the most common reasons for calling were systemic anticancer therapy, advice regarding procedure or vascular access device/systemic anticancer therapy delivery (n = 93; 30.3%) or infections (n = 46 (15%); see Table 3). Most telephone calls did not necessitate a presentation to an ED. The three most common outcomes for telephone advice were: (1) advice provided and nil action required (n = 123; 40.1%); (2) present to RBWH ED or nearest ED (n = 102; 33.3%); and (3) present to CCS out-patient department (n = 85; 27.6%). Patients were advised to follow-up with their general practitioner (GP) for 11.7% of calls (n = 36). Most calls were made during business hours (n = 268; 87.3%) and lasted between 0 and 10 min (n = 121; 39.4%), with a combined time of 83 h over the study period. In all, 113 (36.8%) and 45 (14.7%) patients calling for telephone advice had received radiotherapy or systemic anticancer therapy respectively within the previous 30 days.

Of note, telephone advice was under-reported in the study due to clinical demands. In many cases, collection of telephone calls was overly burdensome on busy clinicians. In addition to telephone advice forms collected in the study, nurses working in oncology clinics recorded 15 calls in a standard 1-week period specifically for emergent care because their acuity precluded them from collecting data for the 6-month study period. This demonstrates an additional 390 in calls in a 6-month period (15 calls × 26 weeks). With this number included, the estimated overall number of telephone advice calls was at least 687 (with many still under-reported in other areas).

Overall, 66% (n = 541) of episodes of unplanned care were for patients presenting without a planned appointment. The average additional time (additional to planned or booked appointments) spent in the department was 2.5 h (95% confidence interval (CI) 2.3–2.6) per episode of care, with a total of 2027 h over the 6-month period. Most patients presenting for unplanned care had received systemic anticancer therapy (n = 54; 66.2%) within the previous 30 days. The most common reasons for unplanned care were management of reduced blood cell counts or deranged electrolytes and fevers or infections (Table 3); 18% of patients were severely neutropenic. Although 188 patients (23%) died within 6 months of the episode of care, only 72 (9%) were linked to the RBWH Specialist Palliative Care Service.

The most common reasons for unplanned admissions were fevers or infections (n = 60; 21.4%), disease (investigations of new, relapsed or progressive disease; n = 26; 9.3%), uncontrolled pain (n = 23; 8.2%) and nausea and vomiting (n = 20; 7.1%). Most unplanned admissions were for people who had received systemic anticancer therapy in the past 30 days (n = 176; 62.9%). In almost one-third of unplanned admissions, patients died within 6 months (n = 233, 31.5%), with the mean time to death being 103 days from the admission (95% CI 92.5–114.1 days).

During the study period there were an additional 125 unplanned admissions via the ED during business hours (Monday–Friday 0800–1630 hours) for cancer-related issues, including infections (n = 166; 36.6%), new, relapsed or progressive disease (n = 46; 10%), nausea and vomiting (n = 36; 7.8%) and uncontrolled pain (n = 29; 6.3%). In this population, 56.4% (n = 259) had received systemic anticancer therapy within the past 30 days and 98 patients (21.4%) were severely neutropenic (<0.5 × 10⁹ L⁻¹).

This study quantified and profiled emergent care provided in a pragmatic Australian CCS-led model of emergent care in a large tertiary hospital over a 6-month period. The data demonstrate that a substantial volume of emergent care was provided within the CCS-led model of care, in addition to planned cancer treatment, over the study period: 2027 h of unplanned care and 83 h of telephone advice (which was potentially under-reported). This highlights the significant role CCSs play in providing emergent care as part of ‘business as usual’.

The results of this study highlight that patients who had recently received or were currently receiving acute cancer treatment and experiencing associated side effects had the greatest need for emergent care (Tables 2, 3). Similar findings have been described in other studies reporting CCS-led models of care.^7,12 Most care provided in the model was for people experiencing cancer disease- or treatment-related issues, such as infections, nausea and vomiting, uncontrolled pain, equipment or medication advice or systemic anticancer therapy-related issues (Table 3). In addition, a significant number of patients were neutropenic when they were provided emergent care (17.8% of those accessing unplanned care, 15% of those with unplanned admissions). These findings indicate that CCS-led models of emergent care may be best placed to focus on people receiving anticancer therapies, as has been reported in other studies evaluating CCS-led models of emergent care.^4,7 The high incidence of cancer-related issues and specialised cancer care provided for this population also demonstrate a need for models of care led by cancer specialists and oncology nurses.

Our data indicated that although a significant amount of emergent care was provided during business hours, there is a potential need for more resources and longer operational hours to manage a greater number of episodes of emergent care for people with cancer. An additional 125 unplanned admissions occurred during business hours (0800–1630 hours) via the ED that could have been managed in the CCS. We were unable to capture emergent care provided in the ED that did not lead to an admission. Therefore, it was unclear how many episodes of this type of care may also be provided within the CCS out-patient departments rather than in the ED.

At the time of the study, all emergent care provided in the CCS was in addition to planned care booked into scheduling systems in out-patient departments or standard patient care in the in-patient wards (telephone advice only). No dedicated space, staff or other resources were provided towards the model, although the model was a long-standing practice. Data exploring the impact of the unplanned care on medical or nursing workloads or patient care, outcomes and experience in CCS were not collected. Anecdotally, it was noted that there could be long wait times for planned appointments when other patients required emergent care. Medical and nursing staff reported difficult shifts due to clinical acuity during busy times. Nursing and medical staff in the out-patient department had the option to advise patients to present to the ED if it was too busy to safely provide care for them in addition to planned care. However, patients often stated a preference to be cared for within the CCS.

Since this project was completed, the CCS has appointed a part-time nurse practitioner to support the provision of emergent care during business hours. The CCS is also seeking dedicated funding and designated clinical areas to expand the pragmatic CCS-led models of care. Appropriate policies and procedures are also required to safely deliver care.⁷ An economic evaluation is needed to justify dedicated resources being directed to the CCS to provide emergent care. An Australian economic evaluation of a nurse-led model of emergent care compared with ED care for people receiving system anticancer therapy demonstrated a return on investment of AUS$1.73 for every AUS$1 spent on establishing the new service.⁴ An effectiveness and cost-effectiveness study is currently underway within the CCS (led by the authors of this paper) to justify additional resources to expand the model of care. The data in the present study were collected in 2016; hospital records reveal an 8.5% increase in unplanned admissions during the same time period in the subsequent year (September 2017–18). This increase demonstrates local need for a CCS-led model of emergent care at tertiary hospitals similar to the RBWH.

Although the data demonstrate that our model of care provides a significant amount of emergent care for our patients, they also highlighted potential areas for improvement. Practices that have been shown to be effective in the literature include pathways or algorithms for managing patients with emergent care needs, dedicated space for ‘rapid assessment clinics’, the collection of patient-reported outcomes with alerts to clinicians and roles for nurse practitioners who provide emergent care to people with cancer.^4,7,12 Due to clinical acuity, our cancer nurses reported that they were unable to record all telephone advice provided; therefore, this service was under-reported and not accurately represented in this study. These challenges demonstrate there is a need for refinement of the telephone advice service so there is a single point of call (during business hours and after-hours) and standardised education and advice for patients and carers when accessing this service, as has been demonstrated to be successful in other CCSs in the literature.^7,12 Two Australian studies of emergency models of care^12,13 report on the use of a telephone triage toolkit that is available in eviQ (UKONS Toolkit¹⁸). This toolkit supports healthcare professionals to provide standardised triaged telephone advice 24 h a day for people receiving or who have received cancer treatment.¹⁸ A Rapid Assessment and Access Toolkit (Australia), Triage Tool and Telephone Advice Triage Log sheet are available on the eviQ website (https://www.eviq.org.au/clinical-resources/telephone-triage-toolkit/3637-triage-tool).

Many people with cancer who were provided emergent care were close to the end of life and potentially had palliative care needs at the time emergent care was provided; 31.5% of episodes of unplanned admissions were for people in their final 6 months of life. The literature reflects high ED use by people with cancer who are near the end of life.^19,20 Our data indicate a need for greater integration of specialist palliative care services for people undergoing acute cancer treatment in the out-patient space. It is recommended that Australian CCS-led models of emergent care have systems in place to identify people who are at high risk of dying and to conduct palliative needs assessments, anticipatory palliative care planning and needs-based referrals to specialist palliative care services in order to holistically care for their patients, as is recommended in national clinical standards and best practice guidelines.^21,22

The results of this study also suggest a potential disconnect between acute cancer care and primary care, with very few patients advised to follow-up with their GP when they telephoned for advice. GPs are integral to integrated and comprehensive cancer care and should be included throughout the optimal cancer care pathway.²³ Community models of care can provide business hours and after-hours care for people undergoing acute cancer care to support acute care facilities. eviQ provides health professional fact sheets for GPs on cancer side effects, supporting patients receiving anticancer therapy and managing common adverse effects of anticancer medicines (https://www.eviq.org.au/clinical-resources/health-professional-fact-sheets). It is recommended that CCS-led models of care use and assist in the development of resources that support greater integration between hospitals and primary care. Since this study, the RBWH CCS has strengthened links with primary care via the establishment of a GP daily help line, a shared-care project in haematology, the appointment of a GP liaison officer and (soon to commence) employment of a GP with special interest in oncology. There is great opportunity for primary care involvement in expanding the model of emergent care.

The provision of emergent care for people with cancer will become increasingly important in the years to come, in line with rising demand, increasingly complex patients and a greater number of cancer therapies provided in out-patient areas. Australian CCSs are tasked with the challenge of developing or expanding innovative, effective and cost-effective models of care to provide high-quality patient-centred care. Our data demonstrate that a pragmatic Australian CCS-led model provided a significant amount of emergent care for people largely receiving anticancer treatment and experiencing cancer-related side effects or complications. With appropriate resources, infrastructure, policies and procedures, similar models of care can meet the needs of patients and carers, and plan for a future with continually increasing demand on out-patient services and EDs under pressure. The challenge to leaders of CCSs is to develop customised models of care in partnership with consumers, in response to local needs, and to engage in ongoing evaluation of patient experience, service demands and the quality, safety and efficacy of the care provided over time.

The authors declare no competing interests.