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What happens to patients the day after chemo

Better integration of primary and tertiary health care services is needed to improve the care of cancer patients, writes Annie May.

Chemotherapy outpatients have significant unmet needs following treatment, indicating an urgent need for improved continuity of care, says new Australian-first research.

This year alone, the Cancer Council Australia estimates that 115,000 new cases of cancer will be diagnosed in Australia. Figures also estimate that 50 per cent of cancer patients receive chemotherapy at some stage in their cancer illness.

Alongside the rising number of cancer cases, there is an increasing trend towards outpatient chemotherapy treatments.

However, there are many missed opportunities to improve care for these patients.

This is according to a study, led by Dr Heather McKenzie from Sydney Nursing School at the University of Sydney, which showed a number of patients made unplanned presentations to hospital for symptom management.

“Chemotherapy patients almost all receive care as outpatients, and while advances in cancer care and symptom management allow this to happen, care after treatment needs attention,” says McKenzie.

Over a 12 month period in 2007-2008, 316 of 518 cancer patients receiving chemotherapy at a major Sydney hospital’s ambulatory cancer centre made 469 unplanned presentations to either the cancer centre or the hospital’s emergency department.

“Well over half (73.7 per cent) made presentations within six months of receiving chemotherapy, with 88 per cent admitted,” says McKenzie.

The most frequent presentation symptoms were nausea and vomiting (45.2 per cent), pain (27 per cent), fever or febrile neutropenia (23.4 per cent), shortness of breath (19.3 per cent), dehydration (12.1 per cent), anaemia (8.8 per cent), fatigue (8.8 per cent), diarrhoea (8.8 per cent), and anxiety or depression (5.5 per cent).

“While patients are given a lot of information about the side effects of treatment, it is a lot for them and their carers to take in. Once home many have difficulties understanding it, and more importantly, how to respond,” says McKenzie.

“People will often delay seeking help, with our research showing it was common to delay for one to seven days. This can make the problem more complex, which is one of the reasons for the high number admitted to hospital on presentation.

Reasons for delaying seeking help included not wanting to bother busy hospital staff, not wanting to travel or not wanting to sit in a cancer centre or emergency for a long time. It was often just a case of the patient being confused, says McKenzie.

“If a patient is experiencing nausea or vomiting they can be unsure if this is something they should expect as a normal side effect or whether it is more serious.”

While some presentations are unavoidable, the study says the high number can be reduced with improved continuity of care and better integration of primary and tertiary health care services, says McKenzie.

“Our research highlights the importance of the continuity of care and the contribution of primary healthcare providers.”

Based on the study results, which also highlighted that patients want to stay at home, McKenzie and her colleagues are piloting an intervention program that involves community nurses as coordinators of community based care, working with GPs and cancer centres.

The intervention involves community nurses visiting the patient on day two – the day after treatment – to assess them, check on side effects and go over the education material to help them better understand what to expect and how to respond.

Nurses relay this information to the GP and cancer centre so both have updates information on the patient. If the nurse is concerned they contact the centre to discuss a course of action.

“Nurses are well educated on how to help reduce side effects in a timely manner, so many symptoms are dealt with before being compounded and needing hospital care,” McKenzie says.

The nurse will again visit the patient on day five, however they can contact the service between visits if they have concerns or need advice.

Supporting this type of intervention, Jodi McLeod, NUM Marrickville Community Health Centre, says nurses were placed to play a crucial role in improving care.

“Community nurses are often under recognised for their contribution in supporting cancer patients and carers to manage symptom experiences, and can play an active role in ensuring more appropriate utilisation of acute and primary care services,” says McLeod.

“But even more important is that patients will receive timely assessment, support and management of side effects associated with treatment, without having to leave their home.”

McKenzie says the complexity of the community nurse role highlights the skills and expertise they will bring to ensuring this group of cancer patients receive the required support and assessment.

“The research will test if regular patient-nurse contact with patients receiving outpatient chemotherapy will reduce the number of unplanned presentations to the emergency department and ambulatory cancer centre, and improve patients overall symptom management.”

An intervention like the one being trialled is also feasible, says McKenzie.

“If you consider the cost to the hospital system as a result of these unplanned presentations, reducing them by even 30 per cent will be a massive cost saver.

“And it’s also in the best interest of the patients.”

The study will be published in the journal Supportive Care in Cancer.

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