Background: Inpatient hematology and oncology treatments continue to advance rapidly, now with the routine use of Chimeric Antigen Receptor T-Cell (CAR-T), Bispecific T-Cell Engager (BiTE), Tumor Infiltrating Lymphocytes (TIL) therapies, immunotherapy and targeted therapy These advanced therapies can be associated with potentially life-threatening toxicities such as cytokine release syndrome, neurotoxicity, capillary leak syndrome and other forms of rapid deterioration requiring immediate nuanced management by clinicians familiar with their use. Simultaneously, there has been a nation-wide recognition of the utility of specialized Oncology Hospitalists to care for hospitalized cancer patients, with evidence of improved quality and efficiency outcomes. Although our hospital has a longstanding Hospitalist physician-led rapid response team (RRT) program, the team had little training or experience with the care of complex cancer patients or advanced cellular therapies. We therefore adapted our RRT structure to include an Oncology Hospitalist in RRT calls to floors within the cancer hospital and adjacent outpatient Hematology and Oncology clinics. Here we describe the steps involved in incorporating Oncology Hospitalists into the pre-existing RRT structure.
Purpose: We sought to tailor the care provided during rapid response calls for cancer patients by substituting an Oncology Hospitalist for the General Medicine Hospitalist during RRT activations in hematology and oncology treatment spaces.
Description: The RRT at our hospital is composed of dedicated resource intensive care unit (ICU) nurses, a respiratory therapist, and a hospitalist. Starting July 1, 2024, for RRT activations within the floors of the cancer hospital and outpatient hematology and oncology clinics, an Oncology Hospitalist responded with the RRT in place of the General Medicine Hospitalist. Inpatient criteria for RRT activation were unchanged, although our project overlapped with an increased institutional attention to timely RRT activation. A workflow for the RRT to respond to outpatient clinical deterioration events was also developed. A clinical pathway accessible in the electronic medical record was created for chemotherapy infusion hypersensitivity reactions. Participating Oncology Hospitalists were trained using in-person simulation sessions and dedicated education on complications of advanced cancer therapeutics. Maintenance of certification in Advanced Cardiac Life Support was required. In-service education sessions were provided to floor nurses, clinic staff, and General Medicine Hospitalist staff for awareness. Over the first 12 months, Oncology Hospitalists responded to 477 RRT calls. The leading causes for activation were hypotension (24%), hypoxia (20%), tachycardia (12%), and general staff concern (10%). Qualitative feedback from the hematology and oncology inpatient teams was overwhelmingly positive and primarily reflected appreciation for the responding Oncology Hospitalists on the RRT being familiar with the cancer therapies, associated adverse reactions, and appropriate management.
Conclusions: Oncology Hospitalists have an important role in the acute management of clinical deterioration events for cancer patients. The addition of these physicians to the team allows the RRT to deliver expert-level management for cancer-specific clinical decompensation.