How Cleveland Clinic’s Medical Oncology Intensive Care Unit Improves Outcomes

Onc ICU leadership (from left to right): Humberto Choi, MD, (Associate Onc ICU Director), Tiffany Lang (G62 MICU RN Manager), Simon Mucha, MD, (Onc ICU Medical Director), Deepa Jagadeesh, MD, (Hematology Champion), Elisha Fleig PA (APRN/PA Manager)

Written by Simon Mucha, MD, Humberto Choi, MD, Elisha Fleig, Heather Torbic, Tiffany Lang

Approximately five percent of patients with cancer will require intensive care unit (ICU) care for management of acute life-threatening conditions often due to complications from the underlying cancer or toxicity from cancer-directed therapies. In Cleveland Clinic’s Medical ICU, 20% of patients have a diagnosis of cancer that is being actively managed. We expect these numbers to increase further as progress in cancer treatment leads to increased survival.

Resource utilization, morbidity and mortality of critically ill patients with cancer remain high.1,2,3 The complexity of their underlying illness, rapidly evolving oncologic therapies and distinct treatment-related toxicities make ICU management needs of critically ill patients with cancer uniquely challenging. Therefore, Cleveland Clinic’s main campus Medical ICU developed a dedicated Medical Oncology ICU team to best meet these complex care needs. This team has been operational since February 2023.

A dedicated team committed to Oncology ICU care

The Medical Oncology ICU is an interdisciplinary team led by core medical intensivists with expertise in the care of critically ill patients with oncologic and hematologic disorders, dedicated critical care pharmacists, experienced advanced-practice providers (nurse practitioners and physician assistants) and a nursing team cross-trained in oncology and critical care. The Medical Oncology ICU team works in close collaboration with the Cleveland Clinic Lymphoma, Myeloma, Leukemia, Bone Marrow Transplant and Solid Tumor Oncology inpatient services as well as Infectious Disease, Nephrology, Palliative Care Medicine and other specialty consulting services as needed.

Organizational factors improve outcomes

Recent studies demonstrated reduced ICU length of stay among centers with greater experience providing cancer-specific treatment within the ICU, standardized practices and interprofessional care delivery models.4,5,6 Whereas, delayed ICU admission due to uncertainty of therapeutic benefit in the setting of limited ICU experience and poor communication between intensivist and oncologist have been shown to be associated with poor outcomes including increased duration of ICU and hospital lengths of stay.7,8 Additionally, increased medication regimen complexity is associated with an increased risk of medication errors and mortality.9 Pharmacy interventions have been associated with a reduction in adverse events, medication errors, and resource utilization.10

This dedicated ICU team aims to address these issues by facilitating effective collaboration and communication between ICU and oncology teams, standardizing interdisciplinary ICU workflow, and implementing protocols and best practices. The Medical Oncology ICU conducts a daily team huddle which allows for care coordination of our ICU patients, and identification of patients admitted in regular floor oncology services who are at risk for decompensation and may need early ICU evaluation.

References

1. Puxty K, McLoone P, Quasim T, Sloan B, Kinsella J, Morrison DS. Risk of Critical Illness Among Patients With Solid Cancers: A Population-Based Observational Study. JAMA Oncol. 2015;1:1078–1085
2. Zampieri, Fernando G., et al. “Trends in clinical profiles, organ support use and outcomes of patients with cancer requiring unplanned ICU admission: a multicenter cohort study.” Intensive Care Med. 2012;47(2):170-179.
3. Wallace, Susannah K., et al. “Two decades of ICU utilization and hospital outcomes in a comprehensive cancer center.” Crit Care Med. 2016;5:926-933
4. Biard, Lucie, et al. “Center effects in hospital mortality of critically ill patients with hematologic malignancies.” Crit Care Med. 2019;47(6):809-816.
5. Dumas, Guillaume, et al. “Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure.” J Crit Care. 2019;23(1):1-10.
6. Soares M, Bozza FA, Azevedo LCP, et al. Effects of Organizational Characteristics on Outcomes and Resource Use in Patients with Cancer Admitted to Intensive Care Units.J Clin Oncol. 2016;34:3315-24. 10.1200/JCO.2016.66.9549
7. van der Zee EN, Benoit DD, Hazenbroek M,et al. Outcome of cancer patients considered for intensive care unit admission in two university hospitals in the Netherlands: the danger of delayed ICU admissions and off-hour triage decisions. Ann Intensive Care. 2021; 11(1):125.
8. Hampshire, Peter A., et al. “Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis Who of the ICNARC Case Mix Programme Database.” J Crit Care. 2009;13: 1-17.
9. Sikora A, Ayyala D, Rech MA, et al. Impact of pharmacists to improve patient care in the critically ill: a large multicenter analysis using meaningful metrics with the medication regimen complexity-ICU (MRC-ICU). Crit Care Med. 2022; 50(9):1318-1328.
10. Rech MA, Gurnani P, Peppard WJ, et al. Pharmacist avoidance or reduction in medical costs in critically ill adults: PHARM-CRIT study. Crit Care Explor. 2021; 3(12):e0594.