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Emergency department disposition of non‐neutropenic febrile patients with cancer

Abstract Objectives National data reveal that 60% of the 4.5 million annual emergency department (ED) visits by patients with cancer result in admission. Many of these visits are due to a febrile illness. Current literature provides limited guidance on how to treat non‐neutropenic febrile ED patients. This study characterizes clinical outcomes of non‐neutropenic febrile patients with cancer presenting to an academic, Comprehensive Cancer Center affiliated ED. Methods Retrospective chart review of 101 randomly selected adult patients with active cancer presenting with a chief complaint of fever or a documented fever in the ED and an absolute neutrophil count above 1000 between October 2015 and September 2016. Descriptive statistics were calculated. Results The primary malignancies represented were hematologic (24%), gastrointestinal (13%), head and neck (13%), and genitourinary (8%). Sixty‐two percent were on chemotherapy, 15% on radiation therapy, and 12% were on targeted therapy. Severe illness outcomes occurred in 39% and 83% were admitted with a median length of stay of 4 days. Among admitted patients, 24% experienced a length of stay ≤2 days. A return visit to the ED or an in‐system hospitalization within 7 days of the index visit occurred in 10% and death occurred within 7 days of the index visit in 4%. Conclusion A majority of patients presenting to the ED with non‐neutropenic fever are admitted (83%), of whom nearly a quarter experience a length of stay of ≤2 days with infrequent serious illness outcomes. Future efforts should focus on the development of risk stratification tools in this population to avoid potentially unnecessary hospitalizations.


Background
The American Cancer Society estimates that there were >16.9 million Americans with a history of cancer alive on January 1, 2019 and an additional 1.8 million were expected to be diagnosed in 2020. 1 Cancer is the second-leading cause of death in the United States. 1 In 2020, there were an estimated 606,520 cancer deaths in the United States. Cancer prevalence is increasing because of the aging population and the increasing success of cancer therapies, thus contributing to the growing number of cancer survivors. Of the >136 million patient visits to US emergency departments each year, 2 3 million or more have cancer. 3 Almost two-thirds of these visits result in hospital admission. 4 The number of patients with cancer seeking acute care in the ED is steadily increasing. These patients seek acute care for a variety of reasons, 5 including but not limited to new infection, chemotherapy side effects, acute or chronic pain related to their cancer or cancer treatment, and non-oncologic acute pathologies. 6 It is important to further characterize this population in order to more effectively risk-stratify and treat these patients.

Goals of this investigation
Fever is a leading ED presenting symptom (14.4%) in patients with cancer. 6 Current research relating to the population of infected patients with cancer is focused on risk stratification for mortality and morbidity, predominantly in a neutropenic population. 7-9 Several risk stratification scores, 10

The Bottom Line
In a retrospective review of 101 adult patients with active cancer and fever presenting to the emergency department, a majority (83%) were admitted, and nearly a quarter (24%) had a length of stay ≤2 days, suggesting an opportunity for risk stratifying patients with cancer and fever in the ED to prevent potentially unnecessary hospitalizations.

Study setting and patient selection
All patients presenting to the ED of an urban, academic tertiary care center over the study period of October

Study design
This was a retrospective chart review of patients meeting inclusion criteria. Trained chart reviewers confirmed inclusion and exclusion criteria before completion of full chart reviews. All chart abstractors used a codebook, received directed training in chart review, and completed the same 3 standardized chart reviews as training. Patient outcomes of interest were abstracted from the chart and included severe illness. This project was approved by the local institutional review board.

Main results
Severe illness outcomes occurred in 39% of all patients, most commonly because of systolic hypotension <100 mmHg in the admitted group (25%) and repeat ED visits or hospitalization within 7 days of the index ED visit in the discharged group (25%) (

LIMITATIONS
This manuscript reports the experience of a single site ED affiliated with a Comprehensive Cancer Center. As a result the experience in non-academic settings may differ; however, it can be postulated that the rate of admission would be even higher in settings without an affil- Soft tissue 0 (0%, 0%-21%)* 11 (13%, 7%-22%)
iated cancer center and its associated outpatient resources. Further characterization of this population is required but was limited in this analysis because of the retrospective nature and chart review study design employed. Additionally, owing to the chart review study design, repeat ED visits, repeat hospitalizations, and mortality were limited to in hospital system occurrences and may be underrepresented in our study population. In order to limit bias, key variables and outcomes were limited to easily identifiable and consistently recorded variables in the electronic medical record. Because of the study time period immunotherapy was not recorded; however, the rapid adoption of these novel therapies is likely to increase the population of non-neutropenic fever and should be assessed in future studies. Also, admission decisions are complex and some patients may have been admitted for other, non-fever-related considerations. Lastly, there is a lack of published ED based literature in this population to which to compare our findings.

DISCUSSION
Much of the unscheduled care for patients with cancer and nonneutropenic fevers occurs in EDs across the country. An analysis of the US Nationwide Emergency Department Sample from 2006-2012 revealed that 4.2% of all ED visits were by patients with cancer. 17 As a result, additional attention is warranted on the ED management of this population for key presentations, such as fever (14.4% of ED visits by patients with cancer). 6 Although neutropenia is a particularly high-risk clinical scenario, it represents a minority of fever cases (3.4% of all ED visits). 6 Little attention has been devoted to the larger proportion of patients with non-neutropenic fever warranting this pilot study.
Serious illness outcomes were observed in both the discharged and admitted groups (Table 2). Of note, a quarter of these outcomes in the discharge group were repeat ED visits or hospitalization within 7 days of the index ED visit. This emphasizes the need for close outpatient follow-up when discharging this patient population. The most common serious illness outcome noted in the admitted group was hypotension (25%), which is indicative of potential sepsis in a febrile population and consistent with a likely need for admission. The data indicate the admitted patients were more commonly diagnosed with infectious etiologies in the ED (76%) compared to the discharged group (38%).

CONCLUSION
A majority of patients presenting to the ED with non-neutropenic fever are admitted (83%), of which nearly a quarter experience a length of stay ≤2 days with infrequent serious illness outcomes. These data sug-gest an opportunity for practice improvement and future efforts should focus on the development of risk stratification tools to aid in the admission decision for this patient population to avoid potentially unnecessary admissions.