Download Local data - University of Calgary

Quality
Improvement
& Health
Information
medicine quality improvement
Malignant Pleural Effusion
FINAL REPORT
Introduction
Pleural effusions in patients with malignancies are frequent complication of a
variety of advanced cancers. These are often difficult to treat and result in
recurrent dyspnea as well as frequent hospital visits for multiple treatments.
The usual approach to patients with symptomatic malignant pleural effusion
(MPE) is to perform repeated pleural taps (thoracentesis), or to place an
intercostal catheter and attempt pleurodesis with a sclerosing agent such as talc
or a tetracycline. The first approach is resource intensive (requires multiple visits
to physician or ultrasound department), painful and only partially and temporarily
effective in relieving symptoms. The second requires a 10-14 day hospitalization,
can only be performed in a portion of patient who undergo chest tube placement,
can be significantly painful and has been associated with severe pulmonary
complications.
A new procedure has been developed; using a
long-term tunneled catheter inserted into the
pleural space. This catheter can permit selfdrainage by the patient or home care nurses on a
regular basis at home. It is thought that the use of
this catheter will assist in avoiding emergency
visits, acute care hospitalizations and repeated
procedures for these patients, enhancing quality of
life for patients and reducing health care costs. The
catheter can be safely inserted as an outpatient procedure
under local anesthesia.
In order to better understand the current management of
malignant pleural effusions in the Calgary Health Region, and to
evaluate the potential impact of a new treatment approach for
this disease, the Malignant Pleural Effusion project was initiated
and completed as part of the Calgary Health Region (CHR)
Quality Improvement and Health Information (QIHI) program via
the Medicine Quality Council.
Participants
Team leader:
 Dr. Alain Tremblay, Department of Medicine, Division of Respiratory
Medicine
Team Members:
 Lori Forand, QI measurement and evaluation specialist in QIHI
 Linda Perkins, Concurrent Review Coordinator QIHI
 Sheila Cloutier, Home care, CHR
 Lee Johnson, TBCC outpatient clinic manager
 Patricia Barclay, TBCC Dyspnea clinic nurse
 Trish Clark, Palliative Clinical Nurse Specialist TBCC
 Dr. Neil Hagen, Senior Leader Medical Services & Palliative care medicine
TBCC
 Brent Wylie, FMC Respiratory Services
Sponsors:
 Marlene Mysack, Senior Leader Patient Care Services TBCC
 Dr. Sid Viner, Medical Director, PLC site
 Medicine Quality Council / Quality Improvement and Health Information
(QIHI) program
Data collection team
 Dianne Burnand, Janet James Whalen, Bev Campbell
Methods
In order to gain the most out of this evaluation, simultaneous sub-studies were
conducted, each addressing various issues related to Malignant Pleural
Effusions.
A retrospective analysis on hospitalized patients treated for malignant pleural
effusion was conducted for CHR adult hospitals during a calendar year. This was
followed by a prospective data collection on a cohort of inpatients treated for
MPE and a comparable group of outpatients treated with the Pleurx catheter.
Thirdly, a prospective database of all patients undergoing Pleurx placement was
maintained and analyzed. Finally a literature review was completed to review
published experience with the Pleurx approach to the treatment of MPE.
The remainder of this report details the findings of these studies.
Malignant Pleural Effusion
FINAL REPORT
2
Retrospective analysis
A retrospective analysis of the CHR health record database was performed to
assess the scope of this clinical problem. The records were queried for the period
of fiscal 2000/2001. Full datasets can be found in appendix 1.
A total of 561 inpatients were detected with malignancy and pleural effusion or
MPE, accounting for a total of over 10,000 hospital days. A total of 160
intercostal catheters and 153 thoracentesis were performed in this inpatient
population. Thirty three attempts at pleurodesis were documented, suggesting
that the majority (80%) of patients undergoing chest tube placement do not
qualify for this procedure. In fact, only 6 % of the total group of patients received
pleurodesis.
Table 1: Patients hospitalized with malignancy and pleural effusion or malignant pleural effusion
% of
%
Total
ALOS
CHR
CHR Site:
Total
Total
Deaths**
Male
Female
Deaths
Days
(days)
Resident
Cases
% CHR
Resident
FMC
285
51%
65
23%
5,079
17.8
119
166
198
69%
PLC
161
29%
40
25%
2,855
17.7
61
100
131
81%
RGH
CHR IP
Total
115
20%
30
26%
2,126
18.5
52
63
102
89%
561
100%
135
24%
10,060
17.9
232
329
431
77%
* Includes all IP discharges with one or more malignancies with pleural effusion and Malignant Pleural Effusion
alone (ICD code 197.2)
** This represents a death during the reported hospital stay.
ALOS - average length of stay (total days divided by total discharges)
Data from patients with malignancy, pleural effusion and chest tube placement
was analyzed separately in table 2 to identify patients in which the MPE clearly
represented an important clinical problem for the patient. We found 160 patients
accounting for over 2600 hospital days meeting these criteria.
Table 2: Inpatients with MPE with an Insertion of Intercostal
Catheter for Drainage
Site Identifier:
FMC
PLC
RGH
CHR Adult Sites
Total
108
33
19
160
Total Days Stay
1,819
596
204
2,619
ALOS (days)
16.8
18.1
10.7
16.4
Malignant Pleural Effusion
FINAL REPORT
3
It was also found that patients treated under the care of Respirologists had the
shortest LOS of all specialties who had admitted at least 10 patients across all
sites (Table 3).
Table 3: Average LOS according to admitting physician specialty
FMC
PLC
Most Responsible Physician Service
01 Family Practitioner
10 Internist
16 Nephrologist
18 Respirologist
30 General Surgeon
31 Cardiovascular Surgeon/Cardioth
50 Obstetrician & Gynaecologist
55 Intensivist
66 Haematologist
74 Oncologist
Total
44
12
10
12
18
63
30
10
11
63
ALOS
21.2
13.2
43.2
10.0
17.4
12.3
17.4
23.2
28.5
18.8
Total
60
31
16
20
4
3
3
12
-
ALOS
24.1
11
9.1
20.6
14.3
8
12.7
13.7
-
RGH
Total
74
17
14
5
2
-
ALOS
22.3
12.5
8.9
19.2
8.0
-
Total
Average
LOS
22.6
11.9
43.2
9.3
19.1
12.4
16.5
19.1
20.8
18.8
The conclusion from these data is that patients with MPE are commonly seen as
inpatients in the CHR, that their LOS are prolonged, and that only a small
minority (6%) receive pleurodesis, the only treatment know to result in long term
control of this problem, short of the new approach being evaluated currently.
Malignant Pleural Effusion
FINAL REPORT
4
Prospective analysis
A) Hospital cohort
Three data coordinators within the Region’s three adult acute care sites collected
daily data over a five-week period from March 4th through April 8th 2002. Data
coordinators visited all inpatient acute care units, except for peri-partum, pediatric
and psychiatry units, on a daily basis to locate any suitable patients. Data was
gathered using daily chart reviews and patients were followed until their
discharge from acute care.
Three elements were required for a patient to be included in the study. The
patient was required to be diagnosed with a malignancy, to have documentation
of a pleural effusion for which they were being actively treated, either with chest
tube or a therapeutic thoracentesis (draining > 200ml of fluid).
Full details of this cohort can be found in appendix 2.
B) Pleurx cohort
A convenience sample of 18 patients undergoing Pleurx catheter placement was
selected from the larger Pleurx database (see below). The selection criteria for
these 18 consecutive patients was residence within the Calgary City Limits and
procedure before April 17th, 2002, in order to avoid inaccuracies in re-admission
data from patient outside the CHR and so that a 3 month follow-up be ensured
within the timeline of this project.
Data Collection
Descriptive data was collected on the Hospital cohort regarding specific
interventions performed in hospital to compare with the retrospective data. Data
were collected on patients in both groups regarding hospital admissions and LOS
for the period 3 months pre and post procedure or admission for comparison.
Results
In the 5 week data collection period, 13 inpatients were identified with actively
treated malignant pleural effusions. This is consistent with the previous finding of
160 patients receiving intercostal catheters over one year (13.3 / month) in the
retrospective analysis.
Malignant Pleural Effusion
FINAL REPORT
5
11 chest tubes were placed with 3 patients enduring more than one chest tube.
Repeated thoracentesis occurred in 2 patients both of whom were at PLC. It
should be noted that only 2/13 hospitalized patients (15%) actually underwent
pleurodesis, including only one of three patients with 2 chest tubes. This number
which concurs with the retrospective data is extremely low given that pleurodesis
is the only way to achieve long term symptom control short or using the Pleurx
catheter.
Mean and median LOS for these patients are seen in table 4. The main
indications for remaining in hospital other than
MPE were diagnostic workups or palliative pain
Table 4: LOS for Hospital MPE
management.
Cohort (*67 day outlier excluded)
Site
Mean
Median
FMC
20.4*
25.0
The Pleurx cohort consisted of 18 patients with
PLC
27.3
30.5
symptomatic pleural effusions referred for
RGH
20.7
19.0
treatment. 5 patients had the procedure while
admitted in hospital, but none were admitted specifically for the procedure.
Discharge home was facilitated by the procedure in 4 patients, while the 5th was
transferred to hospice. All 13 other procedures were performed as outpatient
procedures in the FMC bronchoscopy suite or TBCC Dyspnea clinic.
The CHR health record database was searched to identify all inpatient
admissions in the CHR for the period of 3 months pre and post catheter
placement or hospital discharge for each group. This data is summarized in
tables 5 & 6.
The Pleurx patients and Hospital patients had similar numbers of hospital
admissions per patient in the 3 months prior to intervention (0.59 vs. 0.4), but the
Pleurx group had higher number of inpatient days than the Hospital group (6.05
vs. 2.6 days / patient) suggesting that the Pleurx group were not necessarily in
better health to start off.
The situation changed dramatically in
the 3 months post intervention with the
Pleurx patients experiencing much
lower readmissions (0.24 vs. 1/patient)
and hospital days (1.41 vs. 8 / patient)
than the hospitalized cohort. This is
strong evidence that the Pleural
catheter approach avoids hospitalization.
In addition, the actual admission days
Table 5: Hospital Admissions 3 months Pre
and Post intervention
Hospital
Pleurx
Cohort
Cohort
Admissions
Pre/patient
0.4
0.59
Admissions
Post/patient
1
0.24
Malignant Pleural Effusion
FINAL REPORT
6
(see table 4) associated with the
intervention for the Hospital group are
not represented in this analysis,
suggesting that an even larger number
of hospital days could potentially be
avoided.
Table 6: Hospital Days 3 months Pre and
Post intervention
Hospital
Pleurx
Cohort
Cohort
Hospital Days
Pre/patient
2.6
6.05
Hospital Days
Post/patient
8
1.41
This analysis demonstrates that in
patients with malignant pleural effusions and similar pre-procedure
hospitalizations rates, treatment with a tunneled pleural catheter (Pleurx) leads to
fewer hospital readmissions and hospital days than the standard treatment. This
also confirms that the minority of patients treated as inpatients for MPE receive
pleurodesis, which is in fact the only other way to obtain long term symptom
relief.
Malignant Pleural Effusion
FINAL REPORT
7
Pleurx Database
The placement of indwelling long term tunneled pleural catheter for home
drainage of malignant pleural effusions first became available in the CHR in
October 2001 at the Foothills Medical Center site, based out of the
Bronchoscopy Suite and operated by the Respiratory Medicine division as well
as the Respiratory Services department. Procedures are performed on
outpatients and FMC inpatients by a member of the Respiratory Medicine
division (Alain Tremblay), and assisted by a respiratory therapist.
The procedure was expanded to a specialized clinic at the Tom Baker Cancer
Center (Dyspnea Clinic) in January of 2002. This clinic is operated by Dr.
Tremblay and Pat Barclay, RN. Strong support from the palliative care team is
provided Patricia Clark.
All patients in whom a Pleurx catheter insertion was attempted were entered in a
database. The main purpose of the data base was to monitor patient
demographic, primary tumor sites, complication rates, spontaneous pleurodesis
rates, and survival. A summary of the first 53 insertions follows.
A total of 48 patients underwent 53 procedures. (3 patients received bilateral
drains, 2 patients had a second successful insertion after the first failed). Mean
age was 62.8 years, with a range of 35 to 87.
Diagnosis in 53 Pleurx Patients
Other
22.6%
Breast Canc er
18.9%
Mesothelioma
Ovarian ca
7.5%
7.5%
Unknow n primary
5.7%
Lung cancer non-smal
37.7%
Malignant Pleural Effusion
FINAL REPORT
8
Lung cancer and breast cancer comprised over 50% of cases, which was
expected as these are common tumors, and both are associated with MPE as a
frequent complication of disease. It should also be noted that lung cancer is the
number one cancer killer for both men and women (more than breast, prostate
and colon combined) and that breast cancer is the most common non skin
tumour in women. This emphasizes the importance of effective palliative
treatments for patients with these tumours.
Of note, 3 patients with mesothelioma were treated with 4 catheters (one patient
received sequential bilateral drains) with good success in relieving dyspnea. This
is a significant achievement for a disease in which no therapy has ever been
shown to modify its course.
Complications have been minimal. Five attempted insertions were unsuccessful
(9.4%). Two patients had loculated fluid confirmed on subsequent ultrasound,
one had tumour involvement of the skin making catheter placement impossible,
one had insufficient remaining pleural fluid because of recent tube drainage, and
one had a clot blocking the catheter immediately after insertion. The last 3 have
had successful reinsertion attempts. In all, 96% of all effusions treated had an
eventually successful Pleurx tube placement.
One patient (2% of catheters) experienced a cellulitis at the insertion site and
required outpatient P.O. antibiotics.
Significant improvement in dyspnea was noted in the majority of patients.
Unfortunately it was not feasible to follow patients with detailed symptom scores
and quality of life questionnaires as part of routine clinical care (see literature
review below).
So far 11 of 48 inserted catheters have been removed following spontaneous
pleurodesis (23%) at a mean 47 days post catheter placement. None of these
patients have had recurrence of symptomatic effusion on the treated side.
None of the effusions treated with a Pleurx required an alternative drainage
procedures such as ultrasound guided thoracentesis at any point since
this technique has been introduced in Calgary.
Only one patient has visited an emergency room for catheter or effusion
related problems (cellulitis). This is likely achieved by eliminating the need for
recurrent emergency thoracentesis.
Malignant Pleural Effusion
FINAL REPORT
9
At least 12 patients have died, 11 with a catheter in place, although some of the
mortality data is incomplete, given that several patients were lost to follow-up
most likely because of death, without us knowing a specific mortality date. The
mean survival after tube placement in these 12 patients was 89 days. Incomplete
data makes calculations of overall median survivals unreliable.
All patients were referred to Home Care for assistance with the drainage
procedure. The CHR Adult Home Care nursing team was specifically trained for
this procedure. Patients living outside the CHR also had homecare referrals,
associated with detailed instructions provided to the respective Home Care
teams. There is no doubt that the strong support of the Home Care teams has
been essential to the success of this approach. This has also frequently made
the need for increased home care services apparent more rapidly (e.g. institution
of palliative care support at home), likely reducing return hospital visits.
In summary, this prospective database on all patients treated with a Pleurx
catheter in the CHR confirms that a large majority of referred patients with MPE
can undergo successful placement of the catheter on an outpatient basis in a
simple procedure room. Complications rates are minimal. Our growing
experience confirms that the catheters are well tolerated and offer symptomatic
improvement in a large majority of patients.
Malignant Pleural Effusion
FINAL REPORT
10
Literature Review
A review of published literature on the use of tunneled pleural catheters for the
treatment of MPE was performed to answer some of the questions which were
beyond the scope of the data available as part of this project, such as quality of
life and cost-benefit analysis. Three papers were found which addressed the use
of the Pleurx catheter in the management of MPE.
Putnam1 conducted a large multi-center randomized controlled trial comparing an
indwelling pleural catheter vs. doxycycline pleurodesis. 144 patients were
randomized. Hospitalization time for the procedure was 1.0 days for the catheter
group and 6.5 days for the pleurodesis group. Quality of life as measured with
the Guyatt CRQ and Borg scores were similar in both groups up to 90 days of
follow-up. 21% of pleurodesis patients had late failures as compared to 13% of
the Pleurx patients (p value non-significant). It should be noted that the
pleurodesis attempt and success rates seen in this (and other research studies)
greatly exceeds what is seen in day to day practice. This is likely because of
patient selection for study entry by the exclusion of poor performance patients as
well as those no found to be fit for pleurodesis.
In a follow-up study, Putnam2 studied the economics aspects of the Pleurx
approach in a retrospective comparison of 100 consecutive Pleurx patients (60
outpatients / 40 inpatients) and 68 consecutive pleurodesis patients at The
University of Texas M.D. Anderson Cancer Center. The groups were similar in
terms of demographics, tumour sites and median survival (3.4 months). Median
LOS was 7 days for pleurodesis patients vs. 0 days for outpatient Pleurx patients.
Early (7 day charges) were lower for the outpatient Pleurx group than for both the
inpatient Pleurx group and the pleurodesis group.
A third paper by Pollack3 describes a series of 28 patients with symptomatic MPE
who had 31 effusions treated. Catheters were placed under ultrasound guidance
with a 100% successful insertion rate. The authors describe improved dyspnea in
94% of patients at 48 hours and 91% at 30 days. Spontaneous pleurodesis was
achieved in 42% of patients, and only 7% of patients required hospital time for
care related to the catheter.
These 3 studies confirm that the treatment of MPE can be successfully achieved
with an indwelling pleural catheter with excellent impact on quality of life,
avoidance of hospitalization, minimal complications and at a lower cost than the
traditional approach of pleurodesis.
1. Putnam JB, Light RW, Rodriguez RM, et. al. A Randomized Comparison of Indwelling Pleural Catheter
and Doxycycline Pleurodesis in the Management of Malignant Pleural Effusions. Cancer 1999;86:1992-9
2. Putnam JB, Walsh GL, Swisher SG, et. al. Outpatient Management of Malignant Pleural Effusion by a
Chronic Indwelling Pleural Catheter. Ann Thorac Surg 2000;69:369-75
3. Pollack JS, Burdge CM, Rosenblatt M, et. al. Treatment of Malignant Pleural Effusion with Tunneled Long
Term Drainage Catheters. J Vasc Interv Radiol 2001;12:201-8
Malignant Pleural Effusion
FINAL REPORT
11
Impact of Implementing New Approach
It is believed that this new approach to the treatment of patients with MPE can,
will, and in fact has already started to revolutionize the care of this common
problem. This approach should lead to improved patient outcomes in addition to
improved resource utilization for the health system as a whole.
Impact on patients

Avoidance of hospitalization for MPE treatment
This is a very significant benefit, given the short (median 3 months)
survival of these patients and the prolonged hospital stay associated
with pleurodesis as well as the increased re-admission rates seen in
patients not treated with the Pleurx.

Avoidance of repeated thoracentesis
Avoidance of repeated painful procedures is an obvious improvement in
the palliation of this patient population. As seen in our prospective
database, no patient treated with a catheter required subsequent
thoracentesis.

Avoidance of the risk of toxicity associated with sclerosing agents used for
pleurodesis

Increased patient control over symptoms
Many patients have been able to travel outside the city, with the
reassurance that their pleural effusion will be controlled during their trip
by ongoing self drainage procedures. Others have golfed, gone hunting
and participated in fitness classes with a catheter in place. Emergency
room visits related to the treated effusion have been virtually eliminated.

Effective, rapid and persistent symptom control in the majority of
unselected patients with low complication rates
In fact, the only patients who have failed Pleurx treatment are patients
who had previously undergone (failed) attempts at chest tube
placement and pleurodesis, or who have had repeated thoracentesis.
These procedures are well known to lead to loculation of pleural fluid,
making subsequent drainage near impossible.

Improved patient quality of life
All of these benefits add up to improve quality of life for patients with
terminal illness suffering from MPE.
Malignant Pleural Effusion
FINAL REPORT
12
Impact on resource utilization

Decrease in hospital admissions and hospital days
This was clearly demonstrated in our data and confirms the published
literature. It is easily conceivable that the 160 patients identified in the
retrospective analysis could all have been treated as outpatients,
eliminating the associated 2619 hospital days incurred (table 2). As
well, this outpatient treatment would be expected to reduce subsequent
re-admissions to hospital by over 75% and reduce hospital days by over
80% (Tables 5 & 6).
It is also suspected that a significant proportion of the 561 patients
identified in table 1, while not candidates for pleurodesis, would benefit
prom the Pleurx, leading to similar decreases in hospital days.

Decrease in the need for ultrasound guided thoracentesis
The elimination of the need for repeated thoracentesis would reduce the
cost and workload of diagnostic ultrasound services in the region, an
already overburdened service.

Decreased emergency room visits
As noted only one patient visited the emergency room for a catheter /
effusion related problem (cellulitis). This is a significant improvement
achieved by avoiding the need for emergent thoracentesis commonly
preceded by an emergency room visit for increasing dyspnea.

Need for funding of outpatient catheter related drainage supplies
The main catheter related costs relate to supplies required for home
drainage of the effusions. While this cost is not negligible, it appears to
be more than overcome by the reduction in hospital days. The question
of the specific source of funding for this remains unresolved at this time.
Malignant Pleural Effusion
FINAL REPORT
13
Conclusion
A new approach to the treatment of malignant pleural effusion has been
evaluated in the CHR as part of a Quality Improvement and Health Information
project.
This analysis has demonstrated that this approach is feasible, can successfully
treat the majority of patients with MPE with substantial advantage and higher
success rates than the current standards. Overall, an improved quality of life can
be obtained for treated patients.
This report has also detailed that this approach is associated with dramatic
reduction in hospital admissions and inpatient hospital days, leading to
substantial savings for the health system as a whole.
Perhaps the most important indication of the success of this approach is the
rapid increase in referrals received from Calgary Respirologists, Oncologists and
Thoracic Surgeons to our clinic requesting that their patients be treated with this
modality.
It is suggested that outpatient treatment of patients with MPE with chronic
indwelling pleural catheters should be the first line of treatment for patients
suffering from MPE. For this to be achieved, commitment from Regional and
Provincial health care administration bodies will be required to ensure adequate
funding and support of such a program. This is especially important with regards
to providing adequate support for outpatient clinics specializing in the
management of these patients, the funding of home supplies for patients and the
ongoing support of home care nursing services.
With the appropriate reallocation of resources, it is expected that this program
can continue to grow in the Calgary Health Region and eventually be expanded
to benefit patients Province wide.
Malignant Pleural Effusion
FINAL REPORT
14
Malignant Pleural Effusion
FINAL REPORT
15
Appendix 1 – Retrospective data
Table 1: Patients hospitalized with malignancy and pleural effusion or malignant pleural effusion
% of
%
Total
ALOS
CHR
CHR Site:
Total
Total
Deaths**
Male
Female
Deaths
Days
(days)
Resident
Cases
% CHR
Resident
FMC
285
51%
65
23%
5,079
17.8
119
166
198
69%
PLC
161
29%
40
25%
2,855
17.7
61
100
131
81%
RGH
115
20%
30
26%
2,126
18.5
52
63
102
89%
CHR IP Total
561
100%
135
24%
10,060
17.9
232
329
431
77%
* Includes all IP discharges with one or more malignancies with pleural effusion and Malignant Pleural Effusion alone (ICD
code 197.2)
** This represents a death during the reported hospital stay.
ALOS - average length of stay (total days divided by total discharges)
REPORT PARAMETERS AND DEFINITIONS
This report presents cases where there was a malignancy and pleural effusion documented on the patient record. The
data was taken from the health record database and includes all the Calgary Health Region inpatient discharges with a
diagnosis of malignancy (ICD-9-CM diagnosis codes of 1400-2399) that also had a diagnosis of pleural effusion (ICD-9CM diagnosis codes 511*) in fiscal 2000/01. Note: If the patient has Secondary Malignancy of the Pleura, I have included
these cases in the report whether they had pleural effusion as an additional code or not. All other malignancies require an
additional code of pleural effusion to be included.
If you have any questions or concerns about the way in which the report was generated, please contact Jill Gay at 5413459.
Malignant Pleural Effusion
FINAL REPORT
16
Table 2: Malignant Pleural Effusion - Institution To (on
Discharge)
Site
Institution to:
Total
F
No Transfer
HOME CARE PROGRAM
UNCLASSIFIED FACILITY/HOSPICE
DR.VERNON FANNING CALGARY
BANFF MINERAL SPRINGS
GLENMORE PARK AUX HOSP CALGARY
MEDICINE HAT REGIONAL HOSPITAL
PETER LOUGHEED HOSPITAL
SUNDRE GENERAL HOSPITAL
BASSANO GENERAL HOSPITAL
BROOKS HEALTH CENTRE
CARDSTON MUNICIPAL HOSPITAL
CLARESHOLM GENERAL HOSPITAL
CROSS BOW AUX HOSPITAL CALGARY
HIGH RIVER GENERAL HOSPITAL
LETHBRIDGE REGIONAL HOSPITAL
OUT OF PROVINCE/COUNTRY HOSP
ROCKYVIEW GENERAL HOSPITAL
Foothills Total
No Transfer
HOME CARE PROGRAM
UNCLASSIFIED FACILITY/HOSPICE
FOOTHILLS PROVINCIAL HOSPITAL
DIDSBURY HOSPITAL
DR.VERNON FANNING CALGARY
MEDICINE HAT REGIONAL HOSPITAL
PINCHER CREEK MUNICIPAL HOSP
BOWCREST NURSING HOME CALGARY
BROOKS HEALTH CENTRE
CHINOOK NURSING HOME CALGARY
CROSS BOW AUX HOSPITAL CALGARY
HANNA HEALTH CARE COMPLEX
OUT OF PROVINCE/COUNTRY HOSP
Peter Lougheed Total
No Transfer
HOME CARE PROGRAM
UNCLASSIFIED FACILITY/HOSPICE
FOOTHILLS PROVINCIAL HOSPITAL
BEVERLY CENTRE INC CALGARY
FATHER LACOMBE NURS HOME CALG
HIGH RIVER GENERAL HOSPITAL
MAYFAIR NURSING HOME
NURSING HOME
Rockyview General Total
211
44
8
3
2
2
2
2
2
1
1
1
1
1
1
1
1
1
285
106
29
7
5
2
2
2
2
1
1
1
1
1
1
161
74
23
9
4
1
1
1
1
1
115
P
R
% of
Site
74%
15%
3%
1%
1%
1%
1%
1%
1%
0%
0%
0%
0%
0%
0%
0%
0%
0%
100%
66%
18%
4%
3%
1%
1%
1%
1%
1%
1%
1%
1%
1%
1%
100%
64%
20%
8%
3%
1%
1%
1%
1%
1%
100%
LOS
(days)
3,364
845
186
180
15
150
25
62
29
10
26
9
20
115
17
7
14
5
5,079
1,529
585
152
52
21
84
16
44
13
29
63
175
62
30
2,855
1,117
376
367
50
66
2
5
53
90
2,126
ALOS
(days)
16
19
23
60
8
75
13
31
15
10
26
9
20
115
17
7
14
5
18
14
20
22
10
11
42
8
22
13
29
63
175
62
30
18
15
16
41
13
66
2
5
53
90
18
Malignant Pleural Effusion
FINAL REPORT
17
Table 3: Location of
admission
Entry Category:
Total
Foothills Medical Centre
Clinics
6
Direct
161
Emergency
Department
117
FMC Total
284
Peter Lougheed Centre
Clinics
4
Direct
58
Emergency
Department
97
Day Surgery
2
PLC Total
161
Rockyview General Hospital
Clinics
17
Direct
26
Emergency
Department
72
RGH Total
115
CHR Total
Deaths
ALOS
CHR
Resident
2
24
47.8
16.2
5
92
39
65
18.7
17.8
100
197
0
11
20.8
17.7
2
42
29
0
40
17.9
5.5
17.7
85
2
131
2
6
9.4
21.8
14
22
22
30
19.5
18.5
66
102
135
17.9
430
560
Malignant Pleural Effusion
FINAL REPORT
18
Table 4: LOS according to
specialty of admitting MD
FMC
Most Responsible Physician
Service
01 Family Practitioner
10 Internist
12 Cardiologist
15 Gastroenterologist
16 Nephrologist
18 Respirologist
28 Pediatrician
30 General Surgeon
31 Cardiovascular
Surgeon/Cardioth
32 Neurosurgeon
34 Orthopedic Surgeon
39 Urologist
44 Pediatric Orthopedic Surgeon
50 Obstetrician & Gynaecologist
55 Intensivist
57 Anesthesiologist
60 Otolaryngologist
64 Psychiatrist
66 Haematologist
72 Geriatrician
74 Oncologist
PLC
RGH
Total
44
12
4
1
10
12
18
ALOS
21.2
13.2
13.0
14.0
43.2
10.0
17.4
Total
60
31
3
16
20
ALOS
24.1
11
10.3
9.1
20.6
Total
74
17
1
14
5
ALOS
22.3
12.5
2
8.9
19.2
63
1
2
30
10
1
11
1
63
12.3
17.0
18.0
17.4
23.2
5.0
28.5
47.0
18.8
4
4
3
3
3
2
12
-
14.3
22.5
8
12.7
22.3
20.5
13.7
-
2
2
-
14.0
8.0
-
Table 5: Average LOS according to admitting physician
specialty
FMC
PLC
Most Responsible Physician
Service
Total ALOS Total ALOS
01 Family Practitioner
44
21.2
60
24.1
10 Internist
12
13.2
31
11
16 Nephrologist
10
43.2
18 Respirologist
12
10.0
16
9.1
30 General Surgeon
18
17.4
20
20.6
31 Cardiovascular
Surgeon/Cardioth
63
12.3
4
14.3
50 Obstetrician & Gynaecologist
30
17.4
3
8
55 Intensivist
10
23.2
3
12.7
66 Haematologist
11
28.5
12
13.7
74 Oncologist
63
18.8
-
RGH
Total
74
17
14
5
ALOS
22.3
12.5
8.9
19.2
2
-
8.0
-
Total
Average
LOS
22.6
11.9
10.8
11.2
43.2
9.3
19.1
12.4
17.0
21.0
14.0
16.5
19.1
22.3
20.5
5.0
20.8
47.0
18.8
Total
Average
LOS
22.6
11.9
43.2
9.3
19.1
12.4
16.5
19.1
20.8
18.8
Malignant Pleural Effusion
FINAL REPORT
19
Table 5: Cases with a Malignancy and a procedure code for Pleurodesis, by Site
Total
LOS
(Days)
ALOS
(Days)
1
29
29.0
20
216
10.8
Pleurodesis
Chemical
Pleurodesis
2
33
16.5
1
10
10.0
Pleurodesis
Chemical
Pleurodesis
1
14
14.0
Site:
FMC
PLC
RGH
Procedure:
Pleurodesis
Chemical
Pleurodesis
CHR
Resident
Male
5
0
Female
16
1
5
1
1
15
2
1
12
3
2
0
6
1
1
3
0
1
7
0
8
65
8.1
5
3
CHR Adult
SiteTotal
33
367
11.1
12
21
Pleurodesis codes include - Pleurodesis (34.6) and Chemical Pleurodesis (34.92)
13
1
7
23
Table 6: Inpatients with MPE with an Insertion of Intercostal Catheter for
Drainage
Site Identifier:
FMC
PLC
RGH
CHR Adult Sites
Total
108
33
19
160
Total Days Stay
1,819
596
204
2,619
ALOS (days)
16.8
18.1
10.7
16.4
(Fiscal 2000-2001)
Malignant Pleural Effusion
FINAL REPORT
20
Appendix 2 – Retrospective data
MALIGNANT PLEURAL EFFUSION STUDY
Results:
Sample
In one month of data collection across 3 adult CHR acute care sites in a 4 week study period,
a cohort of 13 patients was found that met the inclusion criteria. Another 57 patients admitted
with pleural effusion were also followed but did not end up meeting inclusion criteria for 2
main reasons:
a. they did not receive any active treatment for their pleural effusion in terms of having a
thoracentesis, a chest tube or pleuroedesis.
b. they did not have a confirmed diagnosis of cancer by way of pathology confirmation or a
documented history of cancer. The profile of these observed but not included patients is
found in Appendix I.
 Patients by Site:
FMC --6
PLC -- 4
RGH – 3


2/13 patients came from outside the Calgary Health Region
11/13 patients were found on medical units, 2/13 on surgical units
Patient Profile
Day of admission to hospital as an inpatient was examined for provisional diagnosis, admitting
physician service , route of admission, and presenting complaints.
Table 1 – Diagnosis on Day of Admission
Primary Dx on Admit Day
NYD - Dyspnea
Pleural Effusion
Pneumonia
Cancer - Lung
Cancer - Lung
Cancer - Bowel
Cancer - Breast
Cancer - Lymphoma
Dehydration
Fracture - Lower Limb - Leg
Gall Bladder Disease
Gall Bladder Disease
GI Bleed - Lower
Secondary Dx on Admit Tertiary Dx on Admit Admitting MD service
NYD-Suspected Cancer
Pleural Effusion
Pleural Effusion
Dehydration
Pleural Effusion
Pleural Effusion
Pneumonia
Leukemia (remission)
Myelodysplasia
Cancer - Breast
Oncology
Hematology
Hospitalist
Pulmonary
Oncology
Palliative
Pulmonary
Family Medicine
Family Medicine
Orthopedics
Surgery- General
Surgery - General
Hospitalist
Presenting Complaints:
The number of patients with a confirmed pleural effusion on their day of admission to hospital was
6/13. The opinion of the data reviewers was that the pleural effusion was the major reason for an
inpatient admission for these 6 patients. All other effusions were found part way through the
inpatient stay. Details of findings are found below. .
Table 2 Chest X-Ray Results Indicating Pleural Effusion.
Malignant Pleural Effusion
FINAL REPORT
21
Cancer on
Admit Day
Confirmed
CXR Date
Admit Day
Suspected
Day 7
X-Ray RESULT
Large pleural effusion
Presumably, some of the confluent density in
the (L) lung represents pleural fluid
Confirmed
Admit Day
Confirmed
Day 7
Confirmed
Confirmed
Day 14
Admit Day
Confirmed
Confirmed
Confirmed
Admit Day
Admit Day
Admit Day
Suspected
Day 12
RUL collapsed and R hydropneumothorax,
Right Pleural Effusion occupies 40% of R
hemithorax
pleural effusion both evident, only right sided
tapped
There is a large R. pleural effusion ie
secondary atelectasis in the RML and RLL
worsening pleural effusion
CT scan on admit; no xray; lge pleural eff;
hemithorax
Large(L) sided pleural effusion
Lung is complete white out
right sided pleural effusion has increased; left
sided not change
No Malignancy
No Malignancy
No Malignancy
Day 15
Day 9
Day 6
bilateral with increased in left and right sides
small bilateral effusion
mod bilateral pleural effusions
Readmit
Last 60 days
Y
N
N
N
N
N
Y
N
Y
N
N
N
N
Signs and Symptoms on Presentation to Hospital
 12/13 patients presented with SOB, of these 2 had chest pain, 3 had a persistent
cough and 2 had both cough and chest pain.
 7/13 patients were documented as palliative either on day of admission or some pint
in their inpatient stay.
Route of Admission
 7 patients came in through Emergency
 3 were direct admit requests from physicians
 2 were direct admits from ambulatory clinics
 1 was transferred from an out of region site
Discharge Disposition
 5 patients died in hospital (1 was waitlisted for hospice)
 4 went home with home care support
 3 went home (1 was potentially needing long term care placement)
 1 went to hospice
Final discharge was similar in every case to the predicted destination for all cases which did not
die in hospital.
Code Status (Documented):
 Level 1 Full Code - 2 cases
 Not Documented – 3 cases (will default to full code )
 Level 2 – Partial Code – 7 cases
 Level 3 Care and Comfort – 1 case
Malignant Pleural Effusion
FINAL REPORT
22
All patients who were designated as palliative were either code level 2 or 3. Code status did
not have any direct correlation with amount or type of treatment that was rendered.
Treatment Profile
Table 3 Combinations of Treatments Used for Pleural Effusions
Thoracentesis 1
N
N
N
N
Y
Y
Y
Y
Y
Y
Thoracentesis 2
N
N
N
N
N
N
N
N
Y
Y
Chest Tube 1
Y
Y
Y
Y
N
Y
Y
Y
N
Y
Chest Tube 2
N
N
N
Y
N
N
Y
Y
N
N
Pleurodesis
N
N
Y
N
N
N
N
Y
N
N
FMC
PLC
1
1
1
2
1
1
1
1
1
1
4
6
Over this small sample of 13 patients, 10 chest tubes were placed with 3 patients enduring
more than one chest tube. Repeat throacentesis occurred in 2 patients both of whom were at
PLC. .
System Utilization Information
Length of Stay
With only 13 cases in this study, the median and mode are the more stable estimates. The range
in LOS for all patients was 3 to 67 days as an inpatient. Data below is presented with and without
the 67 day case included in the FMC analysis.
Table 4 Length of Stay for Malignant Pleural Effusion Cases
Site
FMC
PLC
Mean
28.2 (with outlier)
20.4 (without outlier)
27.3
Median
25,0 (with outlier)
25.0 (without outlier)
30.5
RGH
20.7
19.0
Mode
25.0
8.0 *smallest
mode
reported)
13.0
*smallest
mode
reported
RGH
1
1
Range
3 to 67 (with outlier)
3 to 37 (without outlier)
8 to 40
13 to 30
Appropriateness s of Inpatient Bed Usage
Malignant Pleural Effusion
FINAL REPORT
23
3
Table 5 Care Level Found on Each Day of Stay for Study Patients
Care Level on Day of Stay
Intensive Care
Acute Care
Palliative
Skilled Nursing(Stable pt/Stable Tx plan)
Community Management Possible
Total Days of Stay Reviewed
FMC
PLC
RGH
12
61
58
3
19
50
42
4
169
4
36
11
109
31
7
2
62
In the malignant pleural effusion patient population, most of the higher level care need days
(acute level), occurred intermittently when procedures were being done with skilled nursing or
palliative care days in between procedures. If less procedures were happening in sequence, then
the overall use of inpatient bed days would likely decrease. Under current practices, the care
required following chest tube insertions, thoracentesis and pleuroedesis is heavily dependent on
24 hour nursing care and observation. This study population showed few potential community
management days that could be diverted from inpatient care given the current treatment
practices. Provision of high levels of home care (2 to 3 visits per day) might offset some of the
skilled nursing days in which the treatment plan is being supervised to completion in a patient
with ADL deficits. Palliative care days can also include dealing with negotiation of next staps and
destinations with patients and families. Other than decreasing the wait time for accessing
hospice and palliative home care, there may not be much room to reduce these level of care days
especially when palliative treatments of symptoms is still being frequently adjusted.
Patients in this study were also complex in terms of the number of reasons for lingering in
hospital other than to treat the pleural effusions. These reasons were combinations of social and
family issues as well as medical conditions other than pleural effusions. The following table
outlines the factors contributing to the hospital stays.
Malignant Pleural Effusion
FINAL REPORT
24
Other Reasons Why Patient Stayed in Hospital
Reason
No other reason other than the pulmonary Embolism to be in
hospital
Undergoing diagnostic workup
Undergoing diagnostic workup and
Undergoing treatment for palliation not related to the PE and
Post-Op complication
Surgery needed
Post-Op complication
Undergoing diagnostic workup
Undergoing treatment by rehab therapists
Undergoing treatment for palliation not related to the PE
Palliative pain management
Undergoing diagnostic workup
Family/Social Issues
Undergoing treatment by rehab therapists
Undergoing treatment for palliation not related to the PE
Palliative pain management
Undergoing diagnostic workup
Organizing Care Centre Transfer
Family/Social Issues
Termination of life in acute care environment preferred
Palliative pain management
Organizing palliative care in the community
Palliative pain management
Organizing palliative care in the community
Palliative pain management
Organizing palliative care in the community
Undergoing diagnostic workup
Family/Social Issues
Undergoing treatment by rehab therapists
Undergoing treatment for palliation not related to the PE
Palliative pain management
Surgery needed
Organizing palliative care in the community
Undergoing diagnostic workup
Organizing Care Centre Transfer
Undergoing treatment by rehab therapists
Undergoing treatment for palliation not related to the PE
# of
Patients
Site
1
1
1
1
1
PLC
RGH
FMC
PLC
PLC
1
1
FMC
PLC
1
FMC
1
RGH
1
RGH
1
FMC
1
FMC
1
FMC
Malignant Pleural Effusion
FINAL REPORT
25