You are the Chief Information Officer (CIO) for a local health system. Your organization held its annual strategic planning session and decided that there needed to be a change in

Mini Review

Maryam Beigom Mobasheri1, Rahim Behtar2, Sanambar Sadighi3

A B S T R A C T

According to the studies the rate of emergency departments use among cancer pa- tients exceed those of general population; however, there are differences based on cancer type, initial treatments, socioeconomic status, disease stages, health insurance status and so on. Patients’ symptoms and the severity of complications are varied as well. The emergency departments are actively involved in different stages of cancer management such as primary diagnosis, ongoing treatments and end-of-life period. Cancer patients usually have more serious complications and need more specialized cares at the end of life period, during chemotherapy and surgical treatments. Under- standing the reasons for such visits could be useful in the development of dedicated interventions for preventing unnecessary emergency department visits, which is dis- cussed in this mini-review.

Keywords: Cancer emergency, Emergency Department, Acute cancer representa-

tions, Emergency cancer management, End-of-life care

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Received: May 2019 Accepted: June 2019

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Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran. Medical Emergency Department, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran. Department of Medical Oncology, Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran.

Challenges with the Emergency Departments Use among Cancer Patients; a Mini Review

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*Corresponding Authors: Maryam Beigom Mobasheri Cancer Research Center, Cancer Institute of Iran, Tehran University of Medical Sciences, Tehran, Iran. Tel: (+98)21 66581638 Email: [email protected]

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INTRODUCTION:

The International Agency for Cancer Research (IARC) reported that 18.1 million new cancer cases and 9.6 million cancer deaths happened in 2018 based on the global cancer statistics with focusing on geographic diversity in 20 regions of the world1. The most common cancers in males were the stomach, pros- tate, colorectal, bladder, and lung cancers while breast, colorectal, stomach, thyroid cancers and leukemia were the most common cancers among females1. It reported that about 110,000 cancer cases and nearly 56,000 pa- tients died of cancer in Iran in 20182. Cancer increasingly recognized as a chronic disease rather than a fatal illness. Recently there are substantial achievements, related to the different biomarkers and predictive factors, novel molecular targeted therapeu- tics and improved imaging and surgical techniques. However, there is much work to do for patients to re- ceive ongoing high-quality care with the right special- ized expert oversight in a suitable place at the appro- priate time. Emergency representations are another aspect of can- cer treatment. The aim of the present review is showing the emergency representation involvement in different stages of cancer management such as primary diagno- sis, ongoing therapies and end-of-life period.

Primary diagnosed cancer patient in emergency departments In the United Kingdom, about 20%–25% of new cancer cases diagnosed following an initial presentation to the hospital emergency departments with the age of older than 70 years3. Patients who primary diagnosed with cancer in the emergency departments have more ad- vanced disease and poorer outcomes. Chest complaints, anemia, bowel obstruction, abdominal pain, and gen- eralized weakness are included in the symptoms on presentation3. According to a study in emergency de-

partment use by recently diagnosed cancer patients in California, the most emergency department visits (68%) occurred within 180 days of diagnosis. The inci- dence of emergency department use for all cancer types was 17% in 30 days, 35% in 180 days and 44% in 365 days of diagnosis4.

Factors associated with emergency de- partment attendance in cancer patients The emergency department uses varied according to the age groups, ethnicity, health insurance, socioec- onomic status, disease stages and initial treatments. Patients with higher stages of cancer visited the emer- gency departments more than whom with lower stages. Frothy percent of Patients who treated with chemother- apy, 48.6% of patients with surgical removals, 27.1% of whom with radiation therapy and 9.5% of patients who exposed to hormone therapies visited the emergen- cy departments within 180 days of diagnosis. Patients with lung, breast, colon and prostate cancers were the most emergency department visitors within 180 days of diagnosis4. Bringing together data from 30 original studies and more than one million patients in five countries identi- fied three demographics, five clinical, and 13 environ- mental factors associated with emergency departments attendance by patients with cancer in their last month of life5. The demographic factors (men; 58.2% and black race), clinical factor (lung cancer; 59.5%), and environmen- tal factors (low socioeconomic status and no palliative care 59.4%) was associated with an increased risk of emergency department attendance by patients with can- cer in their last month of life5.

Initial treatments and symptoms The causes of emergency department visits in cancer patients treated with antineoplastic were; 63% due to the tumor, 31% due to the chemotherapy toxicity and

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6% due to other causes. Fever or infection in 65%, pain in 50% and febrile neutropenia in 42% of the patients with chemotherapy toxicity was reported. Management of the pain, fever and the neutropenia declared as the most pressing concerns with the patients6. Cancer patients in their last month of life who suffer from more significant comorbidity, lung or head and neck cancer and a higher number of previous emergen- cy department visits are among whom visited the emer- gency departments multiple times7. Among the advanced cancer patients who died in the hospital within seven days of an emergency depart- ment visit, the most common symptoms in order are breathlessness, pain, body weakness or lethargy, and decreased appetite or anorexia. These are general symptoms associated with progression of the disease and may indicate that the patient is approaching the ter- minal phase8,9. In the emergency departments attendance with cancer in six final months to two last weeks of life, the most common reasons of the visit were abdominal pain, dyspnea, pneumonia, malaise and fatigue, and pleural effusion10. Results of a study in the United States in six years esti- mated that among a total of 696 million emergency de- partment visits in adult patients, a total of 29.5 million (4.2%) made by cancer patients11. The most common cause of emergency department visit was breast, pros- tate and lung cancer. Pneumonia in 4.5%, nonspecific chest pain in 3.7% and urinary tract infection in 3.2% of adult cancer patients were the most common primary reasons for their attendance. Septicemia and intestinal obstruction were associated with the highest odds of in- patient admission11. The study of three health centers in Texas from a total of 3.4 million emergency department visits, cancer pa- tients were older and more hospitalized than non-can- cer patients. Pneumonia, influenza, fluid and electrolyte

disorders, and fever were significant predictive factors for hospitalized cancer patients while coronary artery disease, cerebrovascular disease, and heart failure were essential factors for non-cancer patients’ hospitaliza- tion12.

DISCUSSION: Studies show that the rates of emergency departments use among cancer patients exceed those of the general population. However, there are differences in study pop- ulations by cancer type, initial treatments, age groups, socioeconomic status, disease stage and health insur- ance status. Patients’ symptoms varied according to the cancer type, disease stage and initial treatments. Cancer patients in their end of life period usually have more se- vere complications as well as those with chemotherapy and surgical procedures. These patients typically need more specialized attention than none-cancer patients visiting the emergency departments. Numerous patients usually crowd emergency depart- ments and the staffs are generally busy with their work, so the cancer patient, especially whom with low immu- nity and upper disease stages, may not receive adequate cares in the proper time. It is essential to identify whether patients with cancer were attending emergency depart- ments because of the low facilities of oncology clinics to accommodate them, and emphasized that emergen- cy department staffs need to be adequately trained and supported to offer optimum care to these patients13. Cancer patients consumed more emergency department resources than Non-cancer patients. Given the differ- ences in characteristics and diagnoses between these two groups, emergency department physicians must pay special attention to cancer patients and be familiar with their unique set of oncologic emergencies12. Nurses usually play an essential role in cancer treat- ment, training of the patients and management of the cancer symptoms and also developing a patient-cen-

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tered treatment. Nurses may have an active collabora- tion to improve the quality of care and reduce poten- tially avoidable emergency department visits13. Close to the end of life period of many of the cancer patients, emergency department visits may be avoida- ble. Realizing the reasons for emergency departments visits could be helpful in the development of appropri- ate interventions for preventing their occurrence10. It must be focused on pre-emptive management of breathlessness and pain to improve end of life care strategies. The patients’ families should be prepared for symptoms like body weakness and appetite loss, which may signal a progression of the disease by the community programs. Supportive and palliative care interventions will need to implemented in the emer- gency department setting for managing the advanced cancer patients8. Chemotherapy-related emergency department pres- entations have considerable clinical and cost implica- tions for patients and the healthcare system. Strategies to improve emergency department management of chemotherapy complications which have significant clinical and cost implications for patients and reduction in preventable emergency department presentations have substantial effects to boost cancer patients’ quali- ty of life and reducing the cost of cancer care. After re- ceiving chemotherapy, Patients require the specialized care to manage distressing symptoms, as they are at significant clinical risk because of immunosuppression and may not exhibit the usual signs of critical illness. A team approach in emergency department staffs may improve care for patients receiving chemotherapy and increase the effective use of healthcare resources14.

CONFLICT OF INTERESTS: The authors have no conflict of interests to declare.

ACKNOWLEDGMENT: This research supported by the Cancer Research

Center, Tehran University of Medical Sciences.

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partment utilization: an analysis of data from the Nationwide Emergency Department Sample. JAMA oncology. 2017 Oct 1;3(10):e172450-. Yang Z, Yang R, Kwak MJ, Qdaisat A, Lin J, Begley CE, Reyes-Gibby CC, Yeung SC. Oncologic emergencies in a cancer center emergency department and in general emer- gency departments countywide and nationwide. PloS one. 2018 Feb 20;13(2):e0191658.

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ORIGINAL RESEARCH Open Access

Language diversity and challenges to communication in Indian emergency departments Katherine Douglass1* , Lalit Narayan2, Rebecca Allen3,4, Jay Pandya3,5 and Zohray Talib2,6

Abstract

Background: Communication in emergency departments (ED) in India is complicated by the country’s immense language diversity. Prior research has revealed challenges in language and communication as barriers to care. Our objective was to quantify language diversity among clinicians in Indian EDs and better understand issues related to clinician-clinician and clinician-patient communication.

Methodology: A cross-sectional survey of ED clinicians was conducted. Survey participants were recruited in- person and through email at six partner sites in India. ANOVA and binary logistic regression were used for subgroup analysis. Semi-structured interviews were conducted with ED clinicians. Interview data was analyzed using the rapid assessment process to determine predominant themes.

Results: 106 clinicians completed the survey. On average, clinicians spoke 3.75 languages. Seventy-one percent used a non-English language to speak to fellow clinicians most of the time, and 53% reported at least one critical incident over the last year where poor communication played a part. Interviews revealed challenges including low health literacy, high patient volume, and workplace hierarchy.

Conclusions: This study is the first to document the impact of language diversity and communication barriers in Indian EDs. The results highlight the need for effective strategies to improve communication between the multiple languages spoken by clinicians and patients.

Keywords: Emergency Care, Communication, Language, India

Background In the emergency setting, communication is essential to provide efficient and effective patient care, especially given the context of high acuity, limited availability of patient history, and high patient volumes. Prior studies indicate that communication challenges in the Emer- gency Department (ED) can have a negative impact on quality and safety of care and the patient’s subjective ex- perience [1]. An Australian emergency communication

study cited that the main cause of critical incidents in their hospital system, namely adverse events that re- sulted in patient harm, was poor and inadequate com- munication between clinicians and patients [2]. Good communication is the foundation of great clinical care in the emergency department. Physician communication is positively correlated with patient adherence to treat- ment. One meta-analysis indicated that there was a 19% increased risk of non-adherence with patients of physi- cians who communicated poorly [3]. Additionally, good clinician-patient communication in the emergency de- partment during life-threatening cardiac events has been

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected] 1Department of Emergency Medicine, The George Washington University School of Medicine & Health Sciences, 2120 L St., NW Suite 450, Washington, DC 20037, USA Full list of author information is available at the end of the article

International Journal of Emergency Medicine

Douglass et al. International Journal of Emergency Medicine (2021) 14:57 https://doi.org/10.1186/s12245-021-00380-7

associated with decreased subsequent post-traumatic stress reactions [4]. In India, linguistic alignment of providers and patients

is even more complex due to the immense language di- versity that exists within the country. There are over 22 official languages that are spread over the regions of India, and at least 122 different spoken languages [5]. While many of these languages are regional, migration patterns continue to contribute to a diversity of language in any local setting. Similar to other countries, a phys- ician in training in India may grow up in one region, ob- tain their medical degree in another, and complete their specialty training in yet again another region. Unique to India, however, each of these regions is likely to have a different primary spoken language. Therefore, physicians in training in India are not only learning medicine, they are often learning the languages of their patients along the way. These factors result in a multilingual health care environment where ensuring language alignment presents a challenge. Language barriers in the health care setting are neither

a novel nor a foreign problem. In the United States indi- viduals with limited English proficiency are documented to have worse healthcare access and report lower quality of care when compared to individuals proficient in Eng- lish [6]. Additionally, language barriers have been re- ported as one of the greatest causes of health care disparities in a cross-sectional study of pediatric emer- gency departments [7]. Effects of language barriers can range from misunderstandings to compromising quality of care [8]. An in-depth language and culture study per- formed at a pediatric hospital in South Africa investi- gated the communication between English-speaking doctors and Xhosa-speaking patients and parents. The study documented that even when physicians and par- ents were using the same words, those words held differ- ent meanings for each group. This led to what they concluded to be a clinically significant discordance in understanding. Thus begins to unravel the cultural com- plexities that are entwined with language diversity [9]. Communication in the health care setting is not only

stymied by language diversity, but a host of barriers that include health literacy. An extensive 2011 systematic re- view of the literature reported the low health literacy is associated with poorer health outcomes and poorer use of healthcare services [10]. A recent study sampling English-speaking and Spanish-speaking ED patients to investigate health literacy using language congruent tools found that 93% of Spanish-speaking patients sampled had limited health literacy [11]. Self-reported reading ability and years of school completed have been shown to be adequate predictors of health literacy [12]. This study was undertaken to better understand the

challenges to effective communication in the ED in

India, including but not limited to language. The field of Emergency Medicine is in its infancy in India. Emer- gency Medicine was recognized as an independent spe- cialty by the Indian government in 2009. Pre-hospital care and trauma responses have been described as “dis- organized and inadequate” by India’s own emergency experts [13]. Government-sponsored EM training pro- grams only produce 48 emergency physicians each year to serve a population of over 1.3 billion. To contribute to closing this gap in education and training, some pri- vate hospitals in India have partnered with US academic institutions, including the Ronald Reagan Institute of Emergency Medicine at the George Washington Univer- sity, to provide post-graduate emergency medicine train- ing for physicians. Our department has affiliations at numerous hospitals across India [14]. A previous study and first-hand experience have revealed significant gaps in language and communication in Indian EDs. This mixed-methods study aims to examine communication issues experienced by health care providers at six hospi- tals in India.

Methods A cross-sectional survey and semi-structured interviews of ED clinicians was conducted from May to July 2017. Study sites were recruited from an open invitation dis- tributed to program directors at the ten education and training partnership programs active at the time of the study. Six sites were chosen based on positive responses from the program director combined with convenience for the research team, including Aster CMI in Banga- luru, BGS Global in Bengaluru, Aster in Wayanad, Aster MIMS in Kozhikode, Baby Memorial in Kozhikode, and Aster Kottakkal. Survey and interview participants were recruited via convenience sampling of physicians, nurses, and paramedics working in the ED. ANOVA and binary logistic regression were used to perform subgroup ana- lysis. The study design and materials were submitted to the Institutional Review Board of our institution and de- termined to be exempt from review. The interview guide was adapted from previous re-

search examining the impact of language diversity in a trilingual E D[15]. Student researchers were trained by the study lead in interview procedures. The interview guide was piloted and minor changes were made based on feedback for clarity and language. See Additional file 1: Appendix A for the interview guide. Verbal consent was obtained from all interviewees. Interviews were conducted in person and recorded by the student inter- viewer using a voice recording device. Most transcrip- tions were completed by the interviewer, and a transcription service was used to transcribe the rest (www.datagainservices.com). All personal identifying in- formation was withheld from transcriptions, and

Douglass et al. International Journal of Emergency Medicine (2021) 14:57 Page 2 of 8

transcriptions were securely stored and only accessed by study team members. Transcriptions were analyzed using a rapid analysis

technique to identify predominant themes by the non- student members of the research team [16]. Two co- investigators developed a matrix in Microsoft Excel identifying coded domains related to each interview question. Each interview was deductively analyzed using the established codes. To assess consistency across the analysis team, each of the members performed rapid summary analysis of two common transcripts. The remaining transcripts were divided among study team members for analysis. The final matrix compiled all re- sults and provided a visual summary of major themes and subthemes across stakeholder groups.

Results Quantitative data One hundred six clinicians completed the survey includ- ing 42 doctors (9 consultants and 33 post-graduate trainees), 45 nurses, and 19 paramedics. See Table 1 for survey results. On average, respondents spoke 3.75 lan- guages. None of the respondents were monolingual. Flu- ency in the majority language at the hospital was reported by 93% of doctors, 84% of nurses and 95% of paramedics. Fluency in English was reported by 100% of doctors, 71% of nurses and 63% of paramedics. Type of clinician, age, gender, and time in clinical practice did not predict the number of languages spoken or fluency in the majority language. Doctors were more likely to report fluency in English, compared to other clinicians (p < 0. 003). Seventy-one percent of respondents reported that they

used a non-English language to speak to their fellow cli- nicians most of the time. Sixty-four percent felt that in- formation was lost or changed when English medical knowledge was explained in a different language. Seventy-three percent reported prior training in commu- nication, including a majority of paramedics and nurses. Fifty-three percent reported at least one critical incident over the last year where poor communication played a part. Time constraints, language, and differences in med- ical knowledge were the most frequently identified bar- riers in these incidents. Seventy-seven percent of respondents reported that long working hours either al- ways or sometimes affected the ability to effectively communicate. Sixty-six percent of respondents reported that information is always or sometimes lost in transla- tion when explaining medical concepts to patients in an- other language.

Qualitative data In total 106 interviews were completed and analyzed. See Table 2 for descriptions of respondents. Thematic

analysis of the results revealed two major sub-types of communication in both the communication between pa- tient and provider, and communication between pro- viders. Within each type of interaction, we found themes of language discordance and concordance. Elaborating on this, when the two parties communicating are speak- ing different languages, there were challenges. However, even when the two parties communicating were speak- ing the same language, significant challenges in commu- nication were still identified.

Patient-provider communications Various issues were identified in interactions between patients and providers, with illustrative quotes provided in Table 3. In communication scenarios between pa- tients and providers, there are obvious challenges in cases of language discordance. We identified 20 clini- cians in our interviews who reported not being fluent in the majority local language. Questioning revealed that these clinicians were, for the most part, from a different state and were training or working in a hospital in which the language spoken by the majority was different or un- known to them. Additional challenges were described when patients spoke a different language than the local language, and the absence of wide-spread translator ser- vices was noted. Even in locations where translator phones were available, these services were not available at all times. Beyond the issue of not speaking the same language,

the issue of inadequate communication at various times in the medical experience was also a common barrier. For example, challenges occur when there was a mis- match between patient expectations and actual pro- cesses, such as during triage when a patient expectation of immediate evaluation may clash with triage protocols. Additionally, health literacy was a factor in patients’ un- derstanding of a medical situation. Explaining a complex medical process to a person with less experience or edu- cation is challenging. This was sometimes even com- pounded by some languages not having analogous words to explain medical phenomenon. Providers would often have to rely on creating metaphors to explain physio- logic processes by evoking shared understanding of na- ture, flowers, or trees. Another commonly described theme was difficulty

with what are known as “bystanders.” Bystanders are the family and friends of a patient in the emergency depart- ment. It was

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