急診室內的癌症病患…當時的徵兆?


  【24drs.com】研究作者與其他專家都認為,7月1日臨床腫瘤期刊(Journal of Clinical Oncology)上一篇探討北卡羅來納州急診就醫情況、癌症病患急診的研究,為腫瘤醫學界的急救作為提出深入瞭解。
  
  北卡羅來納州教堂山分校的研究人員發現,該州在2008年約有410萬例急診就診,其中有27,644名癌症病患共就診37,760次;據估計,北卡羅來納州約有358,200名癌症存活者,依這個數據看來,一年約有7.7%的癌症病患看過急診。
  
  加州City of Hope醫學中心護理研究與教育主任、未參與該研究的Marcia Grant教授表示,這些結果有部分反映出健康照護趨勢。
  
  Grant博士表示,自從推動減少住院以及增加居家照護以來,病患、員工與家屬對於居家症狀之照護挑戰,在於並未跟上癌症病患的需求。她總結,照護場所從醫院診所轉變到居家,病患和家屬在家中對於症狀處置有所困難。
  
  北卡羅來納州教堂山分校的研究作者、護理副教授Deborah Mayer博士表示,疼痛、呼吸窘迫、胃腸道問題是癌症病患急診的前三大原因。
  
  Grant博士指出,應教育病患和照護者:疼痛不可以由非專業人士處置;疼痛處置仍是醫院員工的挑戰,由非專業人士教育病患和家屬就會導致急診就診。
  
  這篇研究也顯示,約半數就診(44.9%)發生在一般上班時間。
  
  Mayer博士不確定這些在日間急診的原因。她指出,很難知道這些在上班時間急診的案例是否與照護地點的距離有關,我們並無相關資料。也或許是因為執業醫師太過忙碌而無暇顧及未預約的患者。
  
  Mayer博士強調另一點研究發現:大部分的急診(62.3%)導致住院。全國而言,只有約12.5%的急診病患需要住院。
  
  Mayer博士表示,我們對於住院數這麼高感到驚訝,將另行使用保險給付資料庫探討這點,以更暸解這些癌症病患為什麼住院以及發生什麼事。
  
  Mayer博士等人的研究是迄今第二篇探討癌症病患使用急診的研究,第一篇是探討加拿大安大略省臨終急診情況的研究(CMAJ. 2010;182:563-568)。
  
  在他們的研究中,肺癌病患佔急診數的26.9%;乳癌、前列腺癌與大腸直腸癌病患分別佔6.3%、6.0%和7.7%,控制性別、年紀、何時、何日、保險、診斷位置之後,肺癌病患比其他類型癌症患者更可能住院。
  
  Grant博士認為,肺癌方面的研究結果可以改進。她表示,肺癌病患的呼吸窘迫是可預期的,是最常見的症狀之一;不過,並未教育員工和讓員工教家屬及病患如何處置這個呼吸短促問題。
  
  如果有些癌症病患急診是因為無法處置意料之外的問題,Mayer博士相信有解決之道,她認為我們可以想一些辦法,兒科醫師以前有很長一段時間是在非上班時間接到病童來電或就診。
  
  她表示,有些癌症計畫有設定緊急症狀處置的急診。
  
  病患教育是另一個解決之道。Mayer博士表示,我擔心,病患遭遇問題時是否知道打電話給他們的腫瘤團隊,有些基本的病患教育可以加強,例如疼痛和噁心嘔吐等症狀時該打給誰。
  
  Grant博士回應Mayer博士的部份論點,鼓勵健康照護專業人士接受病患教育訓練。
  
  她表示,顯然地,現在需要的是,專業人員須有所準備,應教育出院病患症狀處置—例如疼痛控制、呼吸困難之處置、噁心、嘔吐、腹瀉和其他症狀。
  
  Grant博士表示,出院時給病患教育單張或手冊並不足以提供教育,完善的出院衛教是重要的,需要為病患和家屬解說症狀處置,而不只是給他們手冊,和病患與家屬一對一的教育及討論最重要。
  
  Grant博士在City of Hope醫學中心參與改善造血細胞移植病患出院結果之計畫。
  
  她解釋,我們測試了幫助這些重症病患出院時處置感染、營養問題、疲勞、疼痛與其他症狀的一個介入方式,教材包括症狀控制,並全年無休提供電話諮商。
  
  Grant博士表示,須努力評估並擴展出院教育到所有癌症病患。之後,當居家症狀難以處置時,病患與家屬知道該打去哪裡。
  
  當建立好的教育和支持時,只有在沒有專業人員電話評估、或專業人員建議急診時,才會前往急診。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6570&x_classno=0&x_chkdelpoint=Y
  

Cancer Patients in the ED…Sign of the Times?

By Nick Mulcahy
Medscape Medical News

July 11, 2011 — A rare study that characterizes the use of the emergency department (ED) by cancer patients provides insight into a situation in need of some remedial action by the oncology community, suggest both the authors of a new study and an expert not involved with the study.

The study of ED visits in North Carolina appears in July 1 issue of the Journal of Clinical Oncology.

The investigators from the University of North Carolina at Chapel Hill found that of about 4.1 million ED visits in the state in 2008, there were 37,760 visits by 27,644 patients with cancer. With an estimated 358,200 cancer survivors in North Carolina, the numbers mean that 7.7% of cancer patients visited EDs in that year.

The findings are, in part, a reflection of healthcare trends, said Marcia Grant, RN, DNSc, director and professor of nursing research and education at the City of Hope Medical Center in Duarte, California, who was not part of the study.

"Since the push to decrease hospitalization and move much of the care of patients to the home and the family caregivers, the preparation of patients, staff, and families for the care of challenging symptoms at home has not kept up with the resulting needs of cancer patients," Dr. Grant told Medscape Medical News.

"Care is shifting from the hospital and clinic to the home, where patients and families get into difficulty with poorly managed symptoms," she summarized.

Reasons for Visits

Pain, respiratory distress, and gastrointestinal issues were the 3 top reasons that cancer patients visited EDs, according to the study authors, led by Deborah Mayer, PhD, associate professor of nursing at the University of North Carolina at Chapel Hill.

Educating patients and caregivers about pain cannot be left in the hands of nonprofessionals, warned Dr. Grant. "Pain management is still a challenge for staff, and education of the patient and family by uninformed staff will clearly result in emergency room visits," she said.

The study also showed that about half of all visits (44.9%) occurred during normal office hours.

Dr. Mayer was unsure of the reason for these daytime ED visits. "It is hard to know if the visits during office hours were related to geographic distance to the site of care, as we did not have that information. It may also be related to practices being so busy that they may not have the capacity to see unanticipated visits," she told Medscape Medical News.

Dr. Mayer emphasized another study finding: that a majority of the ED visits (62.3%) resulted in hospitalization. Nationally, only 12.5% of all patient visits to EDs result in hospital admissions, she and her coauthors point out.

"We were surprised by the high number of admissions, compared to other ED visits. We will be developing another study to explore this using claims data to better understand why these cancer patients are being admitted and what is happening to them," Dr. Mayer said.

The study by Dr. Mayer and colleagues is only the second to characterize a population-based sample of patients with cancer who use the ED. The first study looked at end-of-life visits to EDs in Ontario, Canada (CMAJ. 2010;182:563-568).

In their study, patients with lung cancer accounted for 26.9% of the ED visits; patients with breast, prostate, and colorectal cancers accounted for 6.3%, 6.0%, and 7.7% of visits, respectively. When controlling for sex, age, time of day, day of week, insurance, and diagnosis position, patients with lung cancer were more likely to be admitted than patients with other types of cancer.

Dr. Grant suggested that the lung cancer findings could be improved upon. "The respiratory distress experienced by lung cancer patients is to be expected; it is one of the most frequent symptoms. However, teaching staff and having staff teach patients and families how to manage this shortness of breath is not occurring," she said.

Ideas for Change

If some part of the problem of having cancer patients in the ED is due to oncology practices being unable to accommodate unanticipated visits, Dr. Mayer believes there are solutions. "I think we can get creative about that," she said. "Pediatricians have had sick child call in/visit times before normal office hours for a long time."

"Some cancer programs are also setting up urgent clinics to see patients for acute symptom management," she continued.

Patient education is another solution. "I wonder if patients know to call their oncology team when they start having problems. Some basic patient education may reinforce when and whom to call for symptoms like pain and nausea and vomiting," Dr. Mayer said.

Dr. Grant echoed some of Dr. Mayer's points and encouraged healthcare professionals to get trained in patient education.

"Clearly, what is needed is preparation of the professional staff that discharge patients and are responsible for teaching patients symptom management — pain control, dyspnea management, nausea, vomiting, diarrhea, and other symptoms," she said.

The practice of giving a cancer patient a printed handout at discharge is not sufficient education, said Dr. Grant. "Excellent discharge teaching is critical and requires a review with patients and families about symptom management, not simply handing them a booklet. One-to-one teaching and discussion with the patient and family is essential."

At the City of Hope, Dr. Grant has been part of a program to improve outcomes in discharged hematopoietic cell transplant patients.

"We tested an intervention to prepare these very sick (at discharge) patients to manage infections, nutritional problems, fatigue, pain, and other symptoms," she explained. "Teaching materials included specific aspects of symptom control and information on telephone access to a professional at the institution 24/7."

Efforts are needed to evaluate and expand discharge teaching for all cancer populations, said Dr. Grant. "Then, when symptoms become difficult to manage at home, patients and families know where to call, regardless of the time of day or the day of the week," she said about the benefits of discharge teaching.

When good education occurs and support is established, emergency visits will likely only be used "if no professional access by telephone occurs, or if the professional providing advice recommends that the patient go to the emergency room."

J Clin Oncol.2011;29:2683-2688.

    
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