Reducing avoidable observation stays in cancer patients requiring procedural interventions through standardized ED pathways.

Abstract

e23289 Background: Patients with cancer frequently present to the emergency department (ED) with symptomatic malignant pleural effusions, malignant ascites, or complications related to indwelling devices such as gastrostomy or nephrostomy tubes. These conditions often require procedures that are not routinely performed outside of regular working hours, resulting in potentially avoidable overnight hospital observation stays. The purpose of this Quality Improvement (QI) project was to reduce unnecessary observation admissions for such patients. Our specific aim was to achieve a 10% reduction in ED-to-observation unit admissions for patients awaiting these procedures. Methods: Through interdisciplinary collaboration, existing workflows for arranging procedures for ED patients were reviewed and standardized clinical pathways were developed. These pathways enabled eligible patients to be discharged from the ED with arrangements for completion of selected procedures within 48 hours. Inclusion and exclusion criteria were defined to ensure appropriate patient selection, and safety measures were incorporated through structured notification and follow-up processes. A retrospective chart review was conducted for eligible encounters before and after pathway implementation, applying consistent inclusion and exclusion criteria across both periods. Included cases were independently reviewed by two reviewers to determine whether patients could have been safely discharged if outpatient procedures had been arranged within 48 hours. Discrepancies were resolved by a third independent reviewer. Results: A total of 332 encounters were included. In the baseline period (n = 268), 76 encounters (29.7%) were deemed appropriate for discharge rather than observation. In the intervention period (n = 61), 15 encounters (34.8%) were judged to have involved avoidable observation stays. Among all encounters considered safe for discharge, a significantly higher proportion of patients were discharged during the intervention period. The mean time from discharge to procedure completion did not differ significantly between periods. Conclusions: Interdisciplinary collaboration enabled the development and implementation of feasible and effective clinical pathways that reduced avoidable observation stays. In addition to alleviating ED and hospital crowding, these workflows may confer financial, physical, and psychological benefits to patients. This model may be adaptable to other procedures and care pathways to further optimize resource utilization.