Monica K. Wattana

Patient Satisfaction Surveys and Treatment of Pain in the Emergency Department (ED) 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 physicians 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, …

Prescription Opioid Guidelines and the Emergency Department

ABSTRACT 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 bu 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.

Venous thromboembolism in cancer patients

Venous Thromboembolism (VTE) is a major complication of cancer and is one of the leading causes of death in patients with cancer. The risk for VTE in this group of patients is increased several folds in hospitalized cancer patient and in those on active therapy. The short and long term consequences of VTE diagnosis in cancer patients are many including increased in mortality rate, bleeding while on therapy for VTE. It has, therefore, become important to identify the risk factors for cancer-associated VTE, develop guidelines for prevention strategies for high-risk patients as well as management of VTE when it complicates the course of cancer disease or its treatment with chemotherapy immunomodulatory agents, antiangiogenesis or hormonal therapy. Proper understanding of the epidemiology and pathophysiology of VTE and its risk factors in cancer patients is central to adequate prevention and management of this serious complication in cancer patients.

Depression and survival outcomes after emergency department cancer pain visits

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<0.001) were significant factors for survival. 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.

Cardiopulmonary resuscitation in the cancer patient

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.