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Objective To evaluate a modified emergency severity index (mESI)-based triage of cancer patients with coronavirus disease 2019 (COVID-19) in the emergency department (ED) and determine the associations between mESI level and ED disposition, hospital length of stay, and overall survival. Methods Medical records were retrospectively reviewed for all patients who presented to our institution's ED between March 22, 2020, and March 12, 2021, and tested positive for SARS-CoV-2. Results A total of 306 cancer patients tested positive for SARS-CoV-2, with 45% of patients triaged to level 2 (emergent) and 55% to level 3 (urgent). Among all patients, 61.8% were admitted to the hospital, 15.7% were admitted to the intensive care unit, 2.9% were sent for observation, and 19.6% were discharged. Although demographic and clinical characteristics did not significantly vary by triage level, we observed significant differences in ED length of stay (urgent = 6.67 h, emergent = 5.97 h; p

Patients with cancer represent a growing population of patients seeking acute care in emergency departments (ED) nationwide. Emergency physicians are expected to provide excellent, consistent care to all ED patients; however, emergency medicine (EM) education and training of acute oncology is lacking.To explore this topic, the Society for Academic Emergency Medicine Oncologic Emergencies Interest Group recruited experts in the field to provide a narrative description of the current state of EM education relating to acute oncology. This review of expert opinions explores the current state of acute oncology education in EM and identifies key content gaps that merit early investment.Current emergency physician training and knowledge relating to acute oncology likely reflects the American Board of Emergency Medicine Model of Clinical Practice. Key topics such as immunotherapy are absent from the most recent revision of the Model of Clinical Practice and consequently represent a knowledge gap for large numbers of emergency physicians. Additionally, there is limited penetration of guideline-based care for symptom management in the ED setting. As such, additional attention should be provided to training programs and research efforts to address these knowledge gaps.In conclusion, the current state of acute oncology education and training of emergency physicians is lacking and merits significant investment to assure the ability of emergency physicians to provide superior care for the growing population of patients with cancer.

PURPOSE: Emergency department observation units (EDOUs) have been shown to decrease length of stay and improve cost effectiveness. Yet, compared with noncancer patients, patients with cancer are placed in EDOUs less often. In this study, we aimed to describe patients who were placed in a cancer center's EDOU to discern their clinical characteristics and outcomes. METHODS: We performed a retrospective observational study that included all patients age 18 years and older who presented to our emergency department (ED) and were placed in the EDOU between March 1, 2019, and February 29, 2020. The patients' electronic medical records were queried for demographics, comorbidities, diagnosis at the time of placement in the EDOU, length of stay, disposition from the EDOU, ED return within 72 hours after discharge from the EDOU, and mortality outcomes at 14 and 30 days. RESULTS: A total of 2,461 visits were eligible for analysis. Cancer-related pain was the main reason for observation in more than one quarter of the visits. The median length of stay in the EDOU was approximately 23 hours, and 69.6% of the patients were discharged. The ED return rate for unscheduled visits at 72 hours was 1.9%. The 14- and 30-day mortality rates were significantly higher for patients who were admitted than for those who were discharged (14 days: 1.7% v 0.3%, P < .001; 30 days: 5.9% v 1.8%, P < .001). CONCLUSION: Our data suggest that placing patients with cancer in EDOUs is safe, reduces admissions, and reserves hospital resources for patients who can receive the most benefit without compromising care.

Background Emergency medicine (EM) resident training in oncologic emergencies is limited, and significant gaps have been identified. Although 90% of emergency medicine residency program directors recognize the importance of residency training in oncologic emergencies, there is no standardized oncologic emergency curriculum. Objective We propose a focused oncologic EM curriculum that serves as a complement to existing EM didactics curriculums to prepare EM residents to recognize and manage the most common oncologic emergencies. It will also allow for familiarization with constantly evolving therapies, such as chimeric antigen receptor cellular therapy and immune checkpoint inhibitors.Discussion This curriculum consists of 10 hours of didactic instruction, which can be incorporated into an already existing didactic curriculum. The curriculum encompasses education on the recognition, rapid diagnosis, and management of oncologic emergencies, with the goal of improving the EM resident's understanding of cancer complications. The suggested topics can be delivered in a variety of methods, allowing for flexible integration in an already existing emergency education curriculum. The proposed curriculum should be introduced during the first postgraduate year and then in the second or third year of the residency to reinforce the learning points.Conclusions Our proposal of a focused, standardized 10 hour program curriculum aims to help to fill the gaps in knowledge of oncologic emergencies. To assist in wide dissemination and standardization of these curriculum topics, outlines for each module are given in the article and we also propose creation of open access online lectures and content to be shared for education purposes.

Rapid advances in cancer immunotherapy using immune checkpoint inhibitors have led to significantly improved survival. Rapid identification of the toxicity syndromes associated with these therapeutic agents is very important for emergency physicians because the population of patients diagnosed with cancer is increasing and cancer therapies including immune checkpoint inhibitors have become the first‐line treatment for more and more types of cancer. The emergency medicine literature lags behind rapid advances in oncology, and oncology guidelines for rapid recognition and management of these emerging toxicity syndromes are not familiar to emergency physicians. In this review article, we discuss the clinical presentation and management of immune‐related adverse effects during the critical first hours of emergency care. We also suggest a workflow for the recognition and treatment of emergencies arising from serious immune‐related adverse effects, including but not limited to colitis, adrenal crisis, myocarditis, pneumonitis, myasthenic crisis, diabetic ketoacidosis, bullous pemphigus, and hemophagocytic lymphohistiocytosis. Rapid advances in cancer therapy are bringing new diagnostic and therapeutic challenges to emergency providers, and therefore it is crucial to raise awareness and provide guidelines for the management of new treatment‐related toxicities.

Objectives Pain and depression frequently co-occur in patients with cancer. Although pain is a common reason for emergency department (ED) presentation by these patients, depression frequently goes unrecognised during an ED visit. In this study, we assessed the risk for depression in patients with cancer presenting to the ED for uncontrolled pain and assessed the extent to which the risk for depression was associated with survival in this population. Methods Participants were consecutive patients with cancer taking Schedule II opioids (n=209) who presented to the ED of a tertiary cancer centre for uncontrolled pain. Risk for depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D), excluding the somatic symptoms. Survival was calculated from date of ED visit to date of death/last follow-up. Results The CES-D was completed by 197 of 209 participants (94.3%); of these, 81 of 197 (41.1%) had high risk for depression (CES-D ≥10). The mean survival time for the entire sample was 318 days (SD=33), with 84 deaths. Cox proportional hazards regression modeling showed that risk for depression and disease stage (CES-D ≥10: HR=1.75, 95% CI 1.11 to 2.78, p=0.016; disease stage: HR=2.52, 95% CI 1.20 to 5.30, p Conclusions Risk for depression was prevalent and associated with survival outcomes in patients with cancer presenting to the ED with uncontrolled pain. Screening for risk for depression in the ED may identify patients who need referral for clinical assessment of depression. Diagnosis and adequate treatment could improve health outcomes and survival rates for these patients.

On January 10, 2013, Mayor Michael Bloomberg announced a set of recommendations intended to guide opioid analgesic prescribing in New York City emergency departments. The intent and scope of these guidelines are discussed through an interview by an emergency medicine fellow with an expert in emergency medicine pain management and one of the authors of the guidelines. The guidelines are appended to the commentary.

Cardiopulmonary resuscitation (CPR) in the patient with cancer can be a lifesaving intervention after cardiac arrest. In this chapter, we will explore the use of CPR in patients with malignancy and consider how its use can alter cardiac arrest outcomes in terms of return of spontaneous circulation (ROSC) and survival to hospital discharge. In patients with malignancy, methods to improve CPR outcomes may be related to the deployment of care paradigms that include earlier provision of palliative and supportive care to minimize cancer-related symptoms while providing CPR to selected patients that are more likely to benefit from its use. Finally, we consider decision-making around the issue of family-witnessed resuscitation.

Background Cardiopulmonary resuscitation (CPR) after cardiac arrest is utilized indiscriminately among unselected populations. Cancer patients have particularly low rates of return of spontaneous circulation (ROSC) and survival to hospital discharge after CPR. Our study determines rates of ROSC and survival to hospital discharge among cancer patients undergoing CPR in our cancer center. We examined whether these rates have changed over the past decade. Methods This IRB-approved retrospective observational study was conducted in our cancer center. The ED and cancer center provide medical care for ≥ 115,000 patients annually. Cases of CPR presenting to the cancer center for years 2003–2012 were identified using Institutional CPR and Administrative Data for Resuscitation and Billing databases. Age, gender, ethnicity, ROSC and Discharge Alive using a modified Utsein template was used to compare proportions achieving ROSC and survival to hospital discharge for two time periods: 2003–2007 (Group 1) and 2008–2012 (Group 2), using traditional Pearson chi-square statistics. Results One hundred twenty-six cancer center patients received CPR from 2003–2012. Group 1 (N = 64) and Group 2 (N = 62) were similar; age (60 vs. 60 years), gender (63% vs. 58% male), and race/ethnicity (67% vs. 56% White). Proportions achieving ROSC were similar in the two time periods (36% Group 1 vs. 45% Group 2, OR = 1.47, 95% CI 0.72 - 3.00) as was survival to hospital discharge (11% Group 1 vs. 10% Group 2, OR 0.87, 95% CI 0.28 - 2.76). Conclusions ROSC after CPR in cancer patients and survival to hospital discharge did not change over time.

Emergency physicians (EPs) are faced with significant challenges regarding pain management, while preventing abuse of prescription opioids. Prescription monitoring programs (PMPs) are increasingly used to help allay the abuse of controlled substances. The objective of this study was to determine EPs' intention to use the Texas PMP within the framework of the Technology Acceptance Model. A cross-sectional, 24-item survey instrument was developed and distributed to EPs attending an emergency medicine conference. PMP nonusers reported a positive intention to use the PMP in the future, with attitude (β = 0.61, p < 0.01) as the only statistically significant predictor of intention. PMP users reported a positive intention to use the PMP, with perceived usefulness (β = 0.62, p < 0.01) as the only statistically significant predictor of intention for PMP users. This exploratory study provides a basis for understanding EPs' intention to use a PMP. The use of PMPs by EPs may lead to a decrease in prescription opioid abuse and improve patient safety related to opioid prescribing in the emergency department setting.

After receiving low marks in the latest Press Ganey patient satisfaction survey, an emergency physician (EP) was counseled by the medical director of his group, who stated that patient satisfaction metrics were an important component of performance evaluation, that financial incentives were tied to these results, and that suboptimal results influence hospital decisions regarding contract renewal for the entire physician group. During the physician's next shift, a 42-year-old female presented with pelvic pain. She was visiting from a distant city, and had a long history of both chronic and recurrent pain for which she had been taking hydromorphone 6 mg capsules every 3 hours for progressively increasing pain over 3 days. She had run out of medication, …