Keywords

Emergency Nursing and Oncologic Emergencies

In 2011, the American Nurses Association recognized emergency nursing as a specialty practice. As a challenging and unique profession, this clinical practice area prepares nurses to provide prompt interventions to stabilize or prevent further patient deterioration. The fast-paced, high-acuity setting commands refined critical thinking, clinical assessment, communication, and prioritization skills. Additionally, emergency nurses (ENs) care for a diverse patient population with various medical conditions and acute care needs [1].

Of significance is the Emergency Nursing Association (ENA), founded in 1970 as the premier professional nursing association, devoted to illustrating the future of emergency nursing. The mission of ENA is to further excellence in emergency nursing [2].

Reflective of the diverse nature of healthcare, emergency medicine has multiple subspecialties. As such, different emergency departments (EDs) provide care to specific patient populations and health concerns. Some of the subtypes include trauma, stroke, cardiac, burn, neuro, disaster response, pediatric, and adult [3].

The same variations that exist in emergency medicine and EDs are also depicted among ENs. It is not surprising to find that most ENs assume multiple roles over the course of their career. Some of these roles include trauma, triage, flight, critical care transport, pediatric, burn center, geriatric, and charge nurse [3].

Professional advancement has also led to further specialization of ENs. This year, the Board of Certified Emergency Nursing recognized four different subspecialty professional certifications, including the Certified Emergency Nurse, Certified Flight RN, Certified Pediatric Emergency Nurse, Certified Transport Registered Nurse, and Trauma Certified Registered Nurse [3]. Notably, as professional advancement continues to detect emerging areas of subspecialty in emergency nursing, additional professional certifications, education, and targeted programs have been created to support quality care [3].

One emerging subspecialty is Oncologic Emergency Nursing (OEN) , a clinical practice designed to provide care for patients presenting with cancer emergencies.

Consider this: the 5-year survival rate for all cancers increased from 39% in 1960 to nearly 70% in 2019 and thanks in part to new cancer treatment modalities, increased survival rates have led to approximately 15 million people in the United States with cancer. The majority of these individuals likely experience oncologic emergencies requiring an ED visit [4]. OEN is among the healthcare teams that assume multiple roles in the ED to provide quality care and ensure optimum health outcomes for the patients presenting with oncologic emergencies.

This chapter identifies high-frequency and high-risk conditions that an OEN may encounter when caring for an ED oncologic patient. For each condition, we then present a number of case studies to illustrate several medical diagnoses, associated risk factors, presenting signs and symptoms, potential causes, contributing factors, anticipated diagnostics, corresponding interventions, case dispositions, and specialty nursing considerations. We conclude with discussions of the impact of the pandemic (novel coronavirus) on cancer patients and an overview of regulatory bodies that guide ED practice in the oncologic setting.

Triage and General Assessment of Oncologic Emergencies

Triage

At triage , patients presenting to ED will encounter the triage nurse as the first medical professional. The role of the triage nurse is to identify patients needing immediate attention and then prioritize among those who do not require immediate life-saving interventions. Triage tools, such as the Emergency Severity Index (ESI) , are used to standardize the approach and to predict patient disposition and ED resource use [5]. The ESI is a reliable and valid tool that is now in its fourth version [5], and is the most commonly used ED triage system in the United States [6]. The tool provides clinically relevant grading of patients into five groups from 1 (most urgent) to 5 (least urgent). This stratification is based on patients’ acuity and resource needs [7].

Typically, patients with cancer have an ESI level of 1, 2, or 3 because of their potential to use multiple resources due to the complexity of their condition. Beyond the primary assessment is the need to screen for patients’ cancer diagnoses, last treatment and modality, and any other significant surgeries or procedures [7].

General Assessment

ED nurses’ ability to perform an accurate initial comprehensive patient assessment after triage is imperative in order to recognize the urgency and treatment needs of patients and to develop baseline data from which any changes in the condition of patients may be measured against [8].

Omission of accurate and timely patient assessments has been reported to result in adverse patient outcomes [9].

The EN can also expect the medical team to order laboratory tests. General labs should be assessed on almost all cancer patients, as treatment and disease processes may alter values from day to day and can likely provide additional insight into the underlying issue. Obtaining a complete blood count (CBC) with differential and comprehensive metabolic panel (CMP) is indicated for the vast majority of patients with a concurrent cancer diagnosis. Determining a patient’s pancytopenia status, electrolyte levels and overall metabolic status are critical, as many abnormalities may not have associated symptoms in early stages. Early detection and correction of imbalances may prevent patients from incurring further injury or deterioration [10].

Although patients with cancer may present with an array of medical emergencies, this population is also at a high risk for infection. As such, sepsis should always be considered. Any signs or symptoms of infection should be promptly noted and addressed, as these patients are immunocompromised and have little physiological defense mechanisms. The presence of a central line also increases infection risk [11]. Timely collection of blood cultures and prompt administration of broad-spectrum antibiotics for any suspected infection can significantly improve the patient’s prognosis [12].

Frequent ED encounters for patients with advanced cancer may also indicate a patient nearing end of life [13]. Patients with advanced cancer may benefit from conversations about advance care planning and code status to ensure their wishes are followed in the care trajectory. Although such conversations may be difficult, they can significantly improve the patient and family experience. Sending patients home with hospice from the ED is, at times, a feasible and appropriate option [14].

Chief Complaint: Chest Pain and Shortness of Breath

Patients presenting with chest pain and shortness of breath should be evaluated immediately for acute myocardial infarction via EKG. If EKG results do not suggest an acute MI, additional diagnostics should be employed to determine the underlying issue [15]. Chest pain and shortness of breath in cancer patients can be caused by various conditions that are common among cancer patients. These include pulmonary embolism, pleural effusion, pneumonia, spontaneous pneumothorax due to tumor burden, pericardial effusion, and cardiac tamponade [16]. See case studies in Table 6.1 illustrating a number of presentations involving these chief complaints [17,18,19,20,21,22,23,24,25]. Due to coagulopathies and bleeding tendencies, cancer patients may be at higher risk of cardiopulmonary-related adverse events [26]. As increasing numbers of patients receive immune checkpoint therapy, some cardiac presentation may represent immune-related adverse effects [27].

Table 6.1 Case studies: chest pain and shortness of breath
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Tumors are known to cause collections of fluid proximal to tumor location. Depending on known lesions, tumors in the thoracic cavity may provide further insight into contributing conditions [28]. Pleural effusions are a high-frequency finding in lung cancer patients or patients with lung metastases. In recurrent pleural effusions, patients may have a Denver catheter drain placed to manage the fluid collection and reduce symptoms. If pleural effusion is identified, patients may require thoracentesis. This will likely alleviate any shortness of breath or chest pain symptoms almost immediately [29].

Patients undergoing cancer treatment may also reduce their activity, placing them at higher risk of developing thrombosis, leading to pulmonary emboli. The patient may be asymptomatic but should be treated with daily injections of anticoagulants. It is important to evaluate the patient’s clotting times and platelet counts, as this may exclude them as candidates for anticoagulation therapies [30].

Chief Complaint: Altered Mental Status

Altered mental status (AMS) is a frequent chief complaint in oncologic patients presenting to the ED [31]. These mentation changes can result from metabolic disturbances, structural changes (such as metastatic disease or intracranial hemorrhage), or infection [32]. Ruling out the most life-threatening conditions is critical, as interventions are time-sensitive and require prompt identification to achieve desirable outcomes [33]. Table 6.2 illustrates presentations involving altered mental status [34,35,36,37,38,39,40,41,42,43,44,45].

Table 6.2 Case studies: altered mental status
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Patients may present with varying degrees of AMS based on causative factors [32]. They may present as confused, somnolent, inattentive, or with seizure activity, both focal and widespread. Consider the type of cancer, risk factors associated with metabolic changes, infection risk, metastatic disease, and bleeding risk. Associated presenting symptoms and vital signs will also assist in identifying the underlying cause. Obtaining a thorough history from a family member or caregiver may also provide relevant information to AMS’s cause, including the onset of mentation change, medications, medical history, and significant events. While the presence of malignancy creates an increased likelihood of atypical differential diagnoses, it is important to consider still acute ischemic stroke, hypoglycemia, and other common underlying conditions for patients presenting with changes in mentation.

Most oncologic patients presenting to the ED with AMS should receive a STAT head CT to determine if there is hemorrhage, as oncologic patients on active treatment are at higher risk for thrombocytopenia leading to bleeds [33]. Additionally, patients with known brain metastases are at risk due to the highly vascular nature of neoplasia. In addition to diagnostic imaging, a CBC and comprehensive metabolic panel (CMP) should be obtained. Platelets and white blood cell count may indicate additional causes, such as bleeding or infection. Many treatments cause pancytopenia and electrolyte disturbances that may be relevant to the patient’s condition. Disturbances in electrolytes, bilirubin, and ammonia may cause changes in mentation. For example, hypo and hypernatremia can cause significant mental status changes and a common metabolic disturbance in certain lung cancer types. Ammonia can also cause AMS and may be present in cancers with hepatic involvement. All these components of the initial workup will assist in identifying the cause of AMS.

In the presence of new metastases identified in diagnostic imaging, corticosteroids can reduce edema around the lesion and subsequently diminish AMS symptoms [46]. If an acute ischemic stroke is suspected, it is critical to verify the platelet count to determine if the patient is an appropriate candidate for tissue plasminogen activator (tPA) [47]. If an infection is suspected, the patient should promptly receive broad-spectrum antibiotics. Timely administration of antibiotics can significantly improve patient prognosis in the presence of sepsis, with AMS being a frequent symptom indicating infection [48]. Patients with metabolic imbalances will improve upon the correction of the underlying disease process. Neurosurgery or neurology services may be consulted to address any neurological interventions based on ED findings [49].

Throughout the ED encounter, the EN should perform frequent neuro assessments to detect early deterioration signs. Placing the patient in semi-fowlers, elevating the head of the bed to 30 degrees or higher, and ensuring proper body alignment may also benefit patients with increased intracranial pressure [50]. Any changes in status should be immediately communicated with the provider. If steroids are ordered, they should be administered at scheduled times to reduce associated edema [49].

Chief Complaint: Back Pain

While back pain is a common chief complaint in EDs, the presence of back pain with cancer diagnoses can indicate metastatic spinal cord compression (MSCC), a time-sensitive emergency that requires prompt intervention. Although back pain is the most common complaint with MSCC, patients may also present with numbness, pain, or tingling in their extremities, bowel or bladder retention or incontinence, and even paralysis or gait disturbances. Patients with breast, lung, prostate, and renal cancer, as well as lymphomas and myelomas are at the highest risk, with men outnumbering women 2:1 [51]. See case study in Table 6.3 [51, 52].

Table 6.3 Case study: back pain
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Presenting symptoms will depend on the level of involvement and the degree to which the metastatic lesion is invading the spinal column. The degree of vertebral lesion invasiveness directly correlates with symptom severity. Symptoms may be alleviated with steroids by reducing the pressure on the spinal column [53]. Although symptoms may improve, these patients are at high risk for falls due to sudden sensory and motor function disturbances [54]. The patient’s position may influence symptoms, activity level, level of involvement, and lesion location. Identifying a patient’s position that reduces pain is important, and those with severe pain should be log rolled to avoid further injury. Range-of-motion assessments should also be conducted with caution, as they can cause additional injury in the presence of osteolytic lesions. These patients are at high risk for spinal instability, pathological fractures, and caudal equine syndrome.

Assessing for urinary retention and post-void residual are also necessary to determine if urinary catheter placement is necessary. Although patients may feel that they have fully emptied their bladder, there may be significant post-void residual, causing additional complications if not completely emptied. Patients may not state any bladder or bowel malfunctions due to loss of sensory perceptions, so assessment is necessary, regardless of patients’ perceptions.

The radiological imaging modality of choice is magnetic resonance imaging (MRI) without contrast. If the patient cannot tolerate an MRI, a CT or X-ray may reveal findings but are not sensitive [55]. Treatments may include corticosteroids, radiation therapy, surgical intervention, and palliative chemotherapy [56]. Spinal cord metastases indicate late stages of cancer, and depending on patient functional status, treatment focus may be symptom management. Patients with MSCC may be candidates for advance care planning conversations, as this condition indicates advanced disease and poor prognosis [57].

Chief Complaint: Abdominal Symptoms

For patients with a concurrent cancer diagnosis, abdominal symptoms may indicate a variety of medical emergencies. Table 6.4 illustrates a number of presentations associated with these symptoms [58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80]. Oncologic patients are at high risk for bowel obstruction due to medication and antineoplastic treatments. Without prompt gastric decompression or surgical intervention, this can progress to perforation and severe infection. These patients may also present with nausea and vomiting due to the obstruction [81].

Table 6.4 Case study: abdominal symptom
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Cancer-related treatments may also cause acute kidney injuries (AKI) present as abdominal pain, oliguria, and flank pain. Depending on cancer location and gastrointestinal involvement, disease progression may be the primary factor causing pain or obstruction. Location of the pain, severity, onset, aggravating and alleviating factors, as well as medical and oncologic history is important in determining the cause of abdominal pain and necessary interventions. Due to pancytopenia caused by many treatments, bleeding and infection should also be considered if indicated in clinical presentation [81].

Unfortunately, cancer treatment frequently causes nausea and vomiting. Prevention of dehydration and symptom management are most important in chemotherapy-induced nausea and vomiting and depending on the severity, patients may require scheduled administration of multiple antiemetics. Sensations, including smell and taste, are also impacted with chemotherapies, and something as innocent as perfume may trigger emesis. Nurses should avoid wearing any creams, lotions or perfumes with strong scents that may trigger episodes of nausea and vomiting [82]. When attempting oral intake, small volumes of plain food and drink are best, as foods with strong flavors or smells may also increase the risk for emesis or even aspiration. Additionally, elevating the head of the bed to prevent aspiration is an important safety measure, as vomiting episodes may be sudden without warning [83].

In addition to upper GI symptoms, cancer treatments can cause lower GI symptoms such as constipation and diarrhea. Severe constipation can develop with both treatment and symptom management therapies, such as opioids for pain management. All cancer patients should be on a stool softener to prevent fecal impaction that can lead to additional complications. Before administering an enema, platelet levels should be verified to ensure no bleeding risk. In cases of diarrhea, dehydration can quickly progress and electrolyte imbalances may occur. Prompt replacement of fluids and electrolytes is necessary to prevent further complications related to electrolyte deficiency. While treatments can induce adverse events, patients with previous stem-cell transplants may experience similar symptoms due to graft-versus-host disease (GVHD) . In these cases, tacrolimus levels should be monitored and steroids are generally the treatment of choice [84].

Ascites and abdominal distention are commonly seen in patients with metastatic peritoneal disease. Ascites may be recurrent and require frequent removal of peritoneal fluids via paracentesis. For patients with recurrent ascites due to metastatic disease, a peritoneal drain may be indicated to allow the patient to self-drain fluid build-up in the abdomen and prevent frequent ED visits. Patient education and discussion with the primary oncologist will help determine if the patient is an appropriate candidate for peritoneal catheter placement [85].

With cancer patients being at high risk for infection, the presence of colitis, gastritis, and diverticulitis should also be assessed to determine if a patient requires antibiotic therapy. Infection should always be addressed in any cancer patient presenting with abdominal symptoms to prevent further deterioration [81].

Abdominal symptoms are common for both general ED patients and cancer patients and are caused by various conditions. The patients’ medical and oncological history can guide patient diagnoses, including cancer type and associated events leading up to the ED encounter. Evaluation of laboratory findings, including hepatic functions, pancreatic enzymes, CBC and CMP, is also essential in determining an appropriate treatment course.

Chief Complaint: Infection

Many cancer patients undergoing treatments experience pancytopenia, including neutropenia. This places them at significantly higher risk for developing an infection and becoming septic. Patients may present initially with a fever and neutropenia and otherwise stable vital signs. That said, these patients have a minimal metabolic reserve and no immune defense mechanisms, so they can quickly decline without the initiation of appropriate interventions. A central line is frequently standard in patients receiving chemotherapy regimens. This direct access to the bloodstream also places patients at higher risk for bacteremia and sepsis [86].

Development of a sepsis protocol and standing parameters for early interventions can help decrease the time from door to antibiotic administration, resulting in more favorable outcomes. Once the infection source is identified, antibiotic therapy should be tailored based on the organism’s susceptibility to promote antibiotic stewardship [87].

Patients presenting with fever can be quickly identified as having a potential infection or sepsis. Some patients experience a condition called “tumor fever ,” which is the most frequent cause of pyrexia unrelated to infection. This is most commonly present in leukemias, lymphomas, sarcomas, renal cell carcinomas, and patients with liver metastases, but may present in any type of cancer. Although the cause may be unknown, patients should be treated as if an infection is present until otherwise ruled out [88].

There are some cases where patients are afebrile but exhibit tachycardia, tachypnea, or hypotension. These may indicate infection but are nonspecific in cancer patients. These could be caused by many other conditions common in cancer patients, including anemia, dehydration, or different physiological responses to malignancy. Infection is frequently the culprit in these cases, but does not rule out other diagnoses. Additionally, ED nurses should identify if the patient is taking any medications that could reduce the temperature before ED arrival, such as acetaminophen or ibuprofen. This may mask the fever and cause infection to be overlooked [88]. Table 6.5 illustrates typical presentations for neutropenic fever and sepsis [89,90,91,92,93].

Table 6.5 Case studies: infection
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Chief Complaint: Newly Diagnosed Cancer in the Emergency Department

Although less common, patients may present to EDs without a cancer diagnosis, only to be diagnosed during treatment in the ED [94]. These situations can be high acuity and high stress, as the patient’s medical management may be complicated, and the emotional stress of the patient and family will likely be heightened. The initial presentation will vary based on underlying cancer diagnosis but may range from nonspecific complaints to a growing tumor site. Regardless of the final cancer diagnosis, the patient and family will need significant psychosocial support to begin their journey as cancer patients [95].

For patients without established primary care, the ED may be their only access to medical services. Unfortunately, patients presenting with an invasive solid tumor without prior cancer diagnosis tend to have a poor prognosis. Patients diagnosed with cancer in the ED are usually in late stages of the disease, with a 75% higher risk of being diagnosed as stage 4 cancer, versus stage 1 [96]. These patients may not have access to healthcare in a primary care setting, causing them to utilize the ED for access to treatment. Patients may not have symptoms severe enough to prompt an ED encounter until cancer has progressed. Delays in cancer diagnosis significantly increase the likelihood of metastatic disease being present upon initial diagnosis. Because of the poor prognosis, advance care planning should be discussed with the patient and family to ensure the quality care that supports the patient and family’s wishes. Generally, solid tumor patients will not require immediate antineoplastic therapy in an emergency setting. ED nurses should focus on symptom management, oncologic plan of care post-ED visit, and appropriate supportive services such as social work, case managers, nutritionists, and pain management specialists [96].

In contrast with solid tumors, different types of acute leukemias may present as a medical emergency and require prompt cancer treatment and immediate antineoplastic therapies. These cancers are frequently diagnosed in the ED and are sometimes only identified via blood work. Patients with acute leukemias tend to have nonspecific symptoms of infections. The proliferation of immature white blood cells causes insufficient immune defense mechanisms required to fight an infection, and this may be the only indication of the underlying issue. An analysis of blood work and subsequent bone marrow biopsy will identify the specific cancer type and appropriate treatments. These patients are at high risk for sepsis due to an ineffective immune system and coagulopathies due to increased blood viscosity and thrombocytopenia secondary to leukemia [97].

Patients with newly diagnosed leukemia should be regularly monitored for status changes, as they can quickly deteriorate. Those with a white blood cell count of 50,000 or greater will require immediate therapy to reduce the number of immature blasts in circulation. The type of cancer will determine the induction phase of treatment, which the ED nurse will likely initiate. Due to the high-risk and time-sensitive nature of induction therapies, protocols should be developed by both emergency and oncologic departments to ensure there are no administrative barriers that may prevent the patients from receiving immediate induction therapy in the ED. This collaboration between these specialties can be a significant factor influencing the patient’s care course and subsequent outcome [97].

The ED nurse’s role in newly diagnosed cancer patients is essential for their quality-of-life trajectory. Ensuring adequate education and resources can completely alter the patient’s experience in the presence of a life-changing diagnosis, such as cancer. Although not all patients will be candidates for curative therapies, providing patients with all potential treatment options and plans of care will ensure they are on track for course best suited to their medical and psychosocial needs. Along with coordinating the various services, including patients and families, the care team should be prioritized by the ED nurse once medically stabilized [97]. Table 6.6 illustrates presentations for newly diagnosed acute myeloid leukemia and acute promyelocytic leukemia [98,99,100,101,102,103,104,105].

Table 6.6 Case studies: newly diagnosed cancer in the ED
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Chief Complaint: Malignancy Progression, Antineoplastic Treatments, and General Medical Emergencies

Complications may arise with patients throughout the course of their cancer diagnosis. These may arise both from disease progression and impact on physiological processes and antineoplastic therapies and the associated adverse effects. These can range from mild to severe, and a thorough patient medical history can help determine the underlying cause. As previously mentioned, treatments can cause pancytopenia resulting in anemia, thrombocytopenia, and neutropenia. These can lead to more severe complications such as infection or bleeding if not promptly addressed with the appropriate replacement or supportive therapy [106].

Disease progression will generally be related to the tumor’s location and associated symptoms. Patients with primary or metastatic osteolytic lesions may develop pathological fractures as the disease progresses. These osteolytic lesions may initially cause the patient mild-to-moderate pain at the tumor site with an acute event producing a pathological fracture [107]. Patients with large abdominal or thoracic tumors can develop superior vena cava syndrome as the tumor grows, placing pressure on blood’s systemic return to the heart. Certain neuroendocrine tumors can cause significant disturbances in hormonal and metabolic function, possibly resulting in diabetes insipidus, acute adrenal crisis (Addisonian crisis) and hypophysitis [108]. The tumor location and associated symptoms will greatly assist with determining differential diagnosis and appropriate treatments.

While cancer itself can produce adverse events seen in an emergency setting, the treatments patients receive can also have severe therapy-related adverse events. Patients who have received a stem-cell transplant (SCT) may also present with graft-versus-host disease (GVHD) complications . These can affect all organs and systems and are frequently treated with high-dose steroids [109]. Along with pancytopenia and associated conditions, many chemotherapies are nephrotoxic and cardiotoxic. Depending on the patient’s ability to tolerate the treatment and underlying comorbidities, some patients may have more severe reactions than others [110]. Reviewing the patient’s wallet insert that identifies the antineoplastic agent they are receiving may be beneficial. Obtaining this information as early as triage can help determine the differential diagnosis as well as medical management [110].

Dedication of resources to cancer treatment research has led to new therapies, emerging as first-line treatments producing promising outcomes. One of these recent advances is the increase of immunotherapies. Although these generally have a lower risk of associated adverse events, immunotherapies such as chimeric antigen receptor (CAR) T-cell therapy can induce specific emergent conditions, most frequently being cytokine release syndrome (CRS) and CAR-related encephalopathy syndrome (CRES) . These emergent conditions may develop after receiving immunotherapies and must be treated timely to prevent long-term deficits. CRS and CRES have specific grading systems that should guide medical management and determine the severity of the condition [111].

Patients with cancer may have comorbidities, such as diabetes, hypertension, psychiatric conditions, cardiac dysrhythmias, and other chronic illnesses, and patients may present with conditions completely unrelated to their cancer or treatment. General medical emergencies such as ischemic stroke, myocardial infarction, or diabetic ketoacidosis (DKA) should still be considered, even in the presence of concurrent cancer, if the clinical presentation is consistent with the noncancer-related condition [112]. Notwithstanding, precautions should be taken when determining therapy for the medical emergency and how the patient’s cancer may impact the typical course of management. For example, patients exhibiting signs of ischemic stroke may not be candidates for tissue plasminogen activator (tPA) based on platelet count, coagulation studies, and bleeding risk. All factors should be considered when determining medical management for the patient. The ED nurses’ role is imperative to ensure a holistic approach to patient care [113]. Table 6.7 illustrates the wide variety of patient presentations discussed above [114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144].

Table 6.7 Case studies: malignancy progression, antineoplastic treatments, and general medical emergencies
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Chief Complaint: End of Life in Advanced-Stage Cancer

Although advances in oncologic treatments have greatly improved the overall survival rate of cancer, end of life, patients with advanced cancer disproportionately represent cancer-related visits to emergency departments. The high-acuity and fast-paced environment in the ED has been conventionally felt to be incompatible with end-of-life (EOL) discussions. The delicate topic is rarely addressed in EDs and can increase the psychosocial burden on the patient and family, increased costs, and futile care initiation. By providing a holistic approach and initiating conversations to establish care goals, the ED can help enhance the value and quality of care for EOL cancer patients [13]. Table 6.8 describes a typical presentation for a cancer patient presenting to the ED at the end of life [145,146,147].

Table 6.8 Case study: end of life in advanced-stage cancer
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Although the ED is not typically a setting where EOL discussions occur, initiating a palliative care (PC) consultation to assist with determining care goals with the patient and family member can greatly assist ED personnel in navigating the complex sequelae of the dying process in all domains [13]. Patients and families will require substantial physical, emotional, and spiritual support to ensure a smooth transition to hospice care. The ED nurse plays a central role in coordinating this care by ensuring all necessary services can provide expertise and guidance for the multifaceted needs associated with dying. These will include palliative, pain, hospice, nutrition, social work, case management, chaplaincy, and other multidisciplinary services based on the patient and family’s unique needs. This experience can be the difference between a traumatic and peaceful death for both the patient and their loved ones [13].

As a gateway to hospitalization, the ED plays a vital role in the quality and value of EOL cancer patients’ care. It is the tendency of ED personnel to choose life-saving interventions over meaningful conversations about advance care planning (ACP) . EDs should ensure proper training and education are provided to staff to provide quality care and ensure dignity, compassion, and comfort for EOL patients. Altered mental status, dyspnea on minor exertion, and poor performance status (ECOG 3 or 4) were found in previous studies to be the “Triple Threat” predictors of mortality in advanced cancer. Patients with two or more of these conditions had a predicted 30-day mortality of 49% (95% CI. 34%, 64%) [145]. This may be used as a triage screening tool to identify advanced cancer patients who may benefit from care goals conversation.

In 2014, the Institute of Medicine (IOM) released the report, “Dying in America,” calling for significant reform of the healthcare system to improve the quality and value of EOL care in America. The report cited recommendations to improve EOL care, including patient-centered and family-oriented EOL discussions, professional education and development of palliative care, healthcare policies to support EOL initiatives, and public education and engagement [148].

The National Quality Forum endorses multiple ED visits within the last 30 days of life to indicate poor-quality cancer care. Additional indicators of poor-quality cancer care include admission to the intensive care unit (ICU) within the last 30 days of life, death in the ICU, curative chemotherapy treatment in the last 14 days of life, and hospice admission for less than 3 days before death. ED nurses should advocate for EOL cancer patients to avoid poor-quality outcomes, enhance care value, and provide a positive experience for patients and families [148].

Ideally, these conversations would be initiated in an outpatient setting allowing ample time for discussion between providers, patients, and families. However, this is not always the case, and patients may only find out they are dying upon presentation to the ED. Although it may be perceived as challenging or inopportune, initiating a discussion of care goals in the ED can be one of the greatest gifts a nurse can provide to a patient [149].

Pandemic Response: SARS CoV 2 – Novel Coronavirus

Novel coronavirus disease (COVID-19), also termed SARS-COV-2, has emerged as a global threat and healthcare concern [150]. The virus first cases were reported in Wuhan, China, and marked the beginning of a global pandemic that completely upended daily life and the world’s healthcare system [151]. Human-to-human transmission of COVID-19 occurs via respiratory droplets (by coughing or sneezing) and through direct contact with infected individuals or indirect contact with fomites of the affected individuals’ environment [150]. Since its outbreak in China at the end of 2019 and until the April 5, 2020, the pandemic has affected > a million persons and caused 62,773 deaths worldwide [152].

COVID 19: An Enhanced Threat to Cancer Patients

It is believed that patients with comorbid conditions, if infected, are at a heightened risk of manifesting complications associated with the virus [153]. Patients with cancer therefore remain at the forefront of this concern. Based on a recent Chinese cohort, patients with cancer had an increased risk of suffering severe events (intensive care unit admission, assisted ventilation or death) compared to those without cancer (39% vs. 8%, p = 0·0003) [154]. The threat the virus poses to medically compromised and noncompromised populations has therefore prompted extensive operational safety measures.

Preventing Cancer Patients from COVID-19 Exposure from ED to Disposition

Notably, public safety measures in place are designed to reduce preventable hospital admissions and elective procedures [155]. These measures do not fully serve the interests of patients with cancer, who require continuous care inclusive of, but not limited to, diagnostic tests and therapeutic interventions. In this sense, both limitations in medical care and potential COVID-19 exposure could be risky, or even fatal [156].

It is for these reasons that remarkable efforts are taken by hospital personnel to screen for exposure to COVID 19 at hospital entry points. The oncologic ED is a main entry point for patients with cancer and as such, it adheres to the guidelines and recommendations put forth by the Center for Disease and Control (CDC) [157]. We share our adapted screening and preventative measures below.

Screening for COVID-19 and Safety Measures

  • Staff member(s) are stationed near all ED and facility entrances (outdoors if weather and facility layout permit), or in the waiting room area, to ensure patients are screened for symptoms and fever before entering the treatment floor.

  • Patients are provided with a face mask upon ED entry.

  • Patients are screened for fever or symptoms consistent with COVID-19.

  • Patients are directed to designated waiting areas which are divided to separate symptomatic from asymptomatic.

  • Patients are separated by at least 6 feet; the area for symptomatic patients is at least 6 feet away from the area for patients without symptoms.

  • For patients in need of urgent care, ED providers are notified immediately.

  • Alerts and signs are posted in strategic places around the ED and the facility at large, with instructions for patients with fever or symptoms of respiratory infection.

Considerations for ED Staff

  • Staff members in charge of screening patients remain 6 feet away from the patient until he or she is determined to be symptom-free and afebrile (temperature is determined by active temperature monitoring).

  • Screening staff wear facemasks and shields (for source control) but do not need to wear PPE if they are separated from patients by a physical barrier such as glass or plastic window.

  • Screening staff ensures these interactions as brief as possible by limiting the interaction to screening questions only.

  • For staff members who must be within 6 feet of a patient, they are required to wear appropriate PPE, including an N95 or higher level respirator, gloves, and eye protection.

Post Patient Screening and Treatment Room Assignment

  • Notification of direct patient care staff of the presence of a symptomatic patient.

  • Safe and prompt transfer of symptomatic patients from triage to treatment rooms.

  • Posting of appropriate isolation signs outside treatment rooms to communicate status.

  • Immediate disinfection of waiting areas occupied by symptomatic/exposed patients and surfaces that were within 6 feet of the symptomatic patient; this is in addition to the regular (frequent) baseline cleaning and disinfection process that occurs for the entire waiting area.

  • Items that cannot be disinfected remain with the patient or discarded.

Regulatory Standards for Oncologic Emergency Departments: Brief Introduction

Healthcare organizations that achieve accreditation through a Det Norske Veritas (DNV) or The Joint Commission (TJC) “deemed status” survey are determined to meet Medicare and Medicaid requirements and may receive payment from the Center for Medicare and Medicaid Services (CMS) . Accreditation does not protect a hospital from an additional CMS survey. All healthcare organizations are still subject to a CMS survey based on a complaint or a validation survey [158]. Validation surveys usually occur within 60 days of the accreditation survey; however, TJC, in collaboration with CMS, has been working on redesigning the validation survey process. The objective of the redesign is to eliminate the validation survey and for CMS to oversee the accreditation process; thus, both may survey an organization at the same time [159].

CMS developed comprehensive Conditions of Participation (CoPs) and Condition for Coverage (CfC) that hospitals and other healthcare entities must meet to initiate or continue their participation in the Medicare and Medicaid programs [158]. All hospitals, including acute care, critical access, long-term care, children’s, psychiatric, and cancer hospitals, are included. There are various key conditions of participation chapters for hospitals, and they all involve Emergency Services to varying degrees. Table 6.9 lists CMS subpart chapters applicable to an emergency setting but is not all-inclusive list of the regulatory standards [158].

Table 6.9 Center for Medicare & Medicaid Services subpart chapters
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Emergency services, one of the optional services that may be reviewed by CMS, are often an integral part of most hospital surveys. Thus, any organization with an ED will need to adhere to these standards. Table 6.10 displays additional subchapters that each hospital must examine to ensure compliance although some areas may not apply [158].

Table 6.10 Center for Medicare & Medicaid Services optional hospital services chapters
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An emergency preparedness plan is required by all healthcare facilities. These guidelines will ensure compliance and demand a proactive approach to adequately plan for natural and man-made disasters. The CMS State Operations Manual, Appendix Z, Emergency Preparedness will guide the development of a comprehensive plan and will likely involve collaboration between the ED and the organization to meet the expectations or standards [160].

CMS is the single largest payer for healthcare in the United States, and the CoP health and safety standards are the foundation or minimum standards for its beneficiaries. There are other federal laws that all oncologic urgent or EDs or centers must follow. They include but are not limited to the Emergency Medical Treatment and Labor Act (EMTALA) , originally part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) passed in 1986 to address anti-dumping issues. Although motivated by the highly publicized anti-dumping incidents, EMTALA was intended to prevent inadequate care and delay or denial of treatment of an emergent condition for the uninsured person to include pregnant women seeking medical advice. EMTALA is a federally mandated social policy calling for access to healthcare that hospitals and physicians must address [160, 161]. EMTALA violations are also reported to other regulatory entities listed in Table 6.11. Of note, the most common violation is an inappropriate Medical Screening Examination [161].

Table 6.11 Reporting violations of the Emergency Medical Treatment and Labor Act (EMTALA)
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The CMS State Operations Manual interpretive guidelines Appendix V is devoted to Emergency Services and EMTALA and provides direction with the EMTALA demands [162]. CMS is responsible for all investigations of EMTALA violations and is partially responsible for enforcements through citations, often designated as “Notice of Termination from Medicare,” which gives a hospital 23 days to come into compliance. A plan of correction will need to be submitted with credible evidence of compliance beyond the date of reinspection. On day 19, a notice of termination is published in local newspapers, unless a plan has been submitted, accepted, and re-survey shows compliance within the 23 days [163].

Possible EMTALA violations need to be reported by the receiving hospital within 72 hours, and healthcare organizations have significant sanctions for failure to report, to include termination from Medicare participation. Some states require any healthcare employee with knowledge of a violation to report timely. CMS expects organizations to self-report violations. However, organizational practices vary. Blatant violations may go uncited, while minor or even marginal incongruities may receive punitive enforcement. Often, this variability is related to the interpretation of the law. The Government Accounting Office has reported the variability to Congress, calling for improved consistency. Currently, the inconsistencies continue [162].

Any EMTALA or CMS investigation or validation survey is very demanding for most hospitals. Every detail of hospital operation is often under intense scrutiny. The evaluation of compliance is very black and white, and there is no gray. Either you are compliant, or you are not. Also note, there are no pre-termination appeal rights under EMTALA [158].

COP investigations often lead to “lengthy citations for every dirt mark or dust covering found on any location in the facility. Inspectors are reported to literally surveyed facilities using magnifying glasses and flashlights” [163]. Oncologic hospital administration or nurse leaders do not expect CMS or EMTALA surveys to be as concrete as they are known to be and may struggle significantly. Even minutes are reviewed in detail. There is no gray, only black and white, when determining compliance during a CMS survey. Again, either you are compliant, or you are not [163].

There are two types of citations that CMS can issue. The “condition-level” is considered more serious and indicates that a hospital is not in substantial compliance. A “standard-level” deficiency is cited when a hospital is out of compliance with one aspect of the regulations and it is considered less severe than the condition-level citation. Most surveys have a mix of both types once the final report is released. The hospital has only 10 days to submit a correction plan once they receive the Form CMS-2567 report. If the plan of correction is not accepted as written, the hospital is asked to submit a revised plan [158].

When surveyors determine that the hospital’s noncompliance from regulatory standards constitutes an immediate threat to patients’ health and safety, they will issue an “Immediate Jeopardy” (IJ) [164]. An IJ determination forces a hospital to immediately stop and correct the underlying problems and is considered the most serious type of violation. Once a hospital or healthcare organization receives an IJ citation, it is given a short time frame to fix the deficiency. If the organization fails to address the IJ as CMS demands, CMS will terminate the facility’s Medicare and Medicaid funding. Losing accreditation has a significant impact and can be devastating since the government is the largest payer, and loss of accreditation will affect hospital insurance rates, among other things. It may erode a hospital’s infrastructure quickly; physicians stop sending patients, the staff starts leaving, and an organization quickly spirals downward [164].

Over the last few years, there have been several oncologic hospitals that have been surveyed by CMS. The plans of correction are considered public knowledge and are available for review online. They are an excellent source of information to strengthen your organization. Hospitals grow significantly after a survey, becoming stronger and more focused.

Interdisciplinary Collaboration

An essential aspect of providing high-quality care to cancer patients in the ED is the interdisciplinary team’s collaboration and cohesion. As displayed in the case studies in this chapter, the cancer patient requires many different needs when presenting to the ED and will encounter many different teams. The collective plan must be centralized around the patient and family and closed-loop communication is vital to preventing errors and for the administration of appropriate treatment.

The cancer patient population’s needs require multidisciplinary care to address all aspects and provide holistic and comprehensive care. Communication between teams is essential for preventing errors and identifying issues in the plan of care. High-reliability organizations promote a just culture environment, seeking to improve systems and prevent human error. This means facilitating an environment where every healthcare team member feels supported to identify patient safety issues and speak up when advocating for the patient and family [164].

Recommendations to promote interdisciplinary collaboration include discussions from all stakeholders with practice changes and an opportunity to provide input, professional practice recognition from interdisciplinary members, and establish clear policies and procedures that clearly and concisely delineate role responsibilities. Another great tool for enhancing teamwork is interdisciplinary high-fidelity simulation exercises [165]. This can reveal strengths and opportunities for improvement without patient safety being jeopardized.

This textbook is an excellent example of interdisciplinary collaboration in action. The information can help physicians work more effectively with their nursing partners by providing information relevant to their scope of practice and how it applies to oncologic emergencies while adhering to the regulatory requirements. As the field of oncologic emergencies continues to evolve, the integration of multidisciplinary teams must continue to develop cohesively to create a useful model for patient-centered care.