Monday December 05, 2016
A Canadian urgent clinic just for cancer patients
This year, more than 200,000 Canadians will be diagnosed with cancer. Many end up at a hospital ER to deal with the side effects of chemo and radiation. A hospital in the U.S. and a clinic in Winnipeg say there's a better way.
They can bypass the ER of their local hospital and head straight to an urgent care clinic just for cancer patients. Two years ago, just such a clinic opened its doors at Johns Hopkins Medicine in Baltimore. The University of Texas Southwestern Medical Center has one. Here in Canada, an urgent care clinic for cancer patients opened in Winnipeg in December 2013. The clinic is located on the main floor of the CancerCare Manitoba building. The clinic in Baltimore is open 12 hours a day on weekdays; the one in Winnipeg keeps similar hours.
Unlike generalists like me who work in ERs, the people who work in urgent cancer clinics are staffed by physicians, nurse practitioners and physician assistants who are experts in cancer. Patients can make an appointment to come to the clinic, or they can call a help line.
The big idea behind an urgent care clinic just for patients with cancer is that they often suffer symptoms such as pain, nausea, fever, chills, mouth sores, severe shortness of breath, and symptoms and signs that are similar if not identical to strokes. The symptoms may be caused by the cancer or the chemo and radiation used to treat the cancer. Their illness is complicated, and it often takes experts to unspool what is going on -- hence the need for specialists who can pin point the diagnosis fast, and without doing unnecessary testing.
Another reason for avoiding the main ER is that patients on chemo with low white blood cell counts are at risk of contracting infections that they can't fight off. For that reason, a trip to your average ER could be hazardous to their health.
To me, this makes a lot of sense. Working right next to a cancer hospital, I see lots of patients who develop a fever while on chemo. I order a blood count. If white blood cells are low due to the chemo, and the patient has a fever, then they need to be admitted to hospital and given intravenous antibiotics.
I've seen patients who have cancer that has spread to the liver and the chest, or patients whose cancer has caused fluid to build up around the heart. I've seen patients who are in a coma because they have swelling in the brain caused by the cancer spreading there. Many of these severe complications of cancer are easy to diagnose. However, we're seeing more and more cancer patients whose treatment has become too complex for me to get up to speed in a hurry. It makes me wish we had a go-to clinic for urgent cancer patients here in Toronto.
The urgent clinic for cancer patients in Winnipeg has been good for patients. Compared to the ER, they've seen wait times drop from 5 hours to less than 30 minutes. Being seen by a cancer specialist familiar with the patient's history means reduced duplication of tests and treatments, fewer hospitalizations and lower stress. For the system, it means hundreds fewer trips to the ER each year. Cancer patients are generally more complex. They spend more time in the ER, and require more testing and more referrals to specialists. Each cancer patient who avoids an unnecessary trip the ER saves the system a lot of money, and frees up a stretcher that would have been occupied for hours if not days
I'd like to see more urgent care cancer clinics across Canada. It's not feasible in every part of every province. Experts estimate that up to 15 per cent of cancer patients need urgent care at least once during the course of their cancer treatment that could run for years. To justify having a clinic with dedicated staff available five days a week, they probably need to see 15-20 or more patients per day at the clinic. To see that many patients a day, they need to be caring for 2,000 patients or more.
It may be more feasible to staff the clinic with nurse practitioners and physician assistants than with cancer specialists. The problem is that the start up costs money. It takes several months to demonstrate savings to the hospital in visits to the ER. Still, I think the savings are there, which is why I think the idea of an urgent care clinic just for people with cancer is a smart idea.