Potentially Avoidable Admissions and Prolonged Hospitalization in Patients with Suspected Colon Cancer

Abstract

Background

Suspicion of cancer in the Emergency Department (ED) may lead to potentially avoidable and prolonged admissions. We aimed to examine the reasons for potentially avoidable and prolonged hospitalizations after admissions from the ED for new colon cancer diagnoses (ED-dx).

Methods

A retrospective, single-institution analysis was conducted of patients with ED-dx between 2017 and 2018. Defined criteria were used to identify potentially avoidable admissions. Patients without avoidable admissions were examined for ideal length of stay (iLOS), using separate defined criteria. Prolonged length of stay (pLOS) was defined as actual length of stay (aLOS) being greater than 1 day longer than iLOS.

Results

Of 97 patients with ED-dx, 12% had potentially avoidable admissions, most often (58%) for cancer workup. Very little difference in demographic, tumor characteristics, or symptoms were found, except patients with potentially avoidable admissions were more functional (Eastern Cooperative Oncology Group [ECOG] score 0–1: 83% vs. 46%; p = 0.049) and had longer symptom duration prior to ED presentation {24 days (interquartile range [IQR] 7–75) vs. 7 days (IQR 2–21)}. Among the 60 patients who had necessary admissions but did not require urgent intervention, 78% had pLOS, most often for non-urgent surgery (60%) and further oncologic workup. The median difference between iLOS and aLOS was 12 days (IQR 8–16) for pLOS.

Conclusions

Potentially avoidable admissions following Ed-dx were uncommon but were mostly for oncologic workup. Once admitted, the majority of patients had pLOS, most often for definitive surgery and further oncologic workup. This suggests a lack of systems to safely transition to outpatient cancer management.

Appendices

Appendix 1

Tool for potentially avoidable admissions for patients with newly diagnosed colon cancer

• 1. Potentially avoidable admission

• 2. Insufficient information

• 3. Unavoidable admission

Use the below criteria to identify patients safe for ED discharge. All criteria must be met to qualify for “potentially avoidable admissions”. If any criteria not met then the patient has “unavoidable admission”. If there is incomplete information to complete the criteria then the patient falls in category 2 “insufficient information”.

Condition	Potentially avoidable admission criteria
General	No persistent hemodynamic instabilitya
	Afebrileb
	No markers of peritonitis/perforation per laboratory values/physical exam/imaging
	No urgent need for intervention
	No concurrent diagnosis requiring admission
	Tolerating oral diet or implied
	Pain controlled with oral medications
Bleeding/Anemia	No transfusion requirement
Obstruction	No computed tomography (CT) read of high grade obstructionc
	Evidence of bowel function in ED or immediately prior

1. ^aSystolic blood pressure <90 mmHg for 3 hours or greater
2. ^b36 ^oC < patient’s temperature < 38 °C
3. ^c50% or greater difference in diameter of bowel between proximally dilated and distally collapsed bowel

Appendix 2

Resolution criteria for ideal length of stay (iLOS) during colon cancer admissions

Admitting condition	Resolution criteria
Anemia/Bleeding	Per notes, no sign of active bleeding
	No blood transfusions over previous 24 hours
	Definitive or presumed source of bleeding
	Three consecutive stable hemoglobin recordings each separated by at least 6 hours OR
	Two consecutive stable readings separated by at least 20 hours
Obstruction	Return of bowel function (flatus, bowel movement, ostomy output, etc.)
	Regular diet is tolerated
Sepsis	Source of infection identified
	If indicated, source control is obtained
	Leukocytosis down trending over 24 hours
	The patient is on definitive antibiotic therapy or completed antibiotics
	The patient has either completed antibiotics, is on a oral regimen, or a peripherally inserted central catheter or midline has been placed for outpatient intravenous antibiotic therapy
Peritonitis	Operative procedurea
	Improvement in physical exam
Pain Control	Pain controlled on oral regimen
	Requiring one or fewer administrations of IV pain medication over proceeding 24 hours
Medical Condition Unrelated to Colon Cancer	Required inpatient workup complete
	Inpatient need for treatment resolved

1. When multiple criteria per condition, resolution date is the latest date all criteria met
2. All criteria as per MD/PA/NP/RN note review
3. ^aIf the patient underwent an emergent, urgent, or palliative surgical procedure before resolution of admission condition for symptomatic management, then the patient is excluded from iLOS