When people go to an emergency room after being injured, suspicious images may show up on their imaging scans that are unrelated to their injuries but may be indicative of cancer. A team at Vanderbilt University Medical Center recently established a better process for ensuring these patients receive follow-up diagnostic care, an initiative that is already receiving national recognition.
Members of the team are giving overviews of that process to the Oncology Nursing Society Congress meeting April 20-29 and to the Association of Community Cancer Centers annual business summit March 1-5.
The new, expedited process establishes a streamlined system and clearly defined chain of responsibility for following up on these incidental findings. It utilizes eStar, VUMC’s Epic-based software, to send automatic alerts when patients are identified who need the diagnostic care.
“The patients are who ultimately benefit from this,” said Tyler Barrett, MD, MSCI, medical director of the Vanderbilt University Adult Hospital Emergency Department. “It really started from us identifying a need many years ago and figuring out a way to handle the follow-up for these patients with incidental findings. It has gone through multiple iterations, and we’ve ultimately landed on a simple, efficient and reliable process.”
The system meets patients’ needs by matching them with the person who can best handle their cases. If the patient is visiting Nashville, an Emergency Department case manager routes that person to a cancer center where they live.
“Before, if a patient came to the Emergency Department and had an unrelated incidental finding, it was the responsibility of the ED or the patient to reach out and find the appropriate provider follow-up,” said Katharine “Katie” Klar, RN, who supervises the V-ISTA team (Vanderbilt-Ingram Service for Timely Access).
“Occasionally, I would get a message basket from an ED doctor that was just sent to the general oncology basket, but the workflow was not well-defined. Once the new process was started, the ED doctor or other provider could just put in a referral order. It comes straight to a work queue that I monitor.”
From the time the new system was implemented in early May through the end of November, 703 patients with incidental findings had completed diagnostic appointments at Vanderbilt-Ingram Cancer Center (VICC). Without the streamlined process, many of these patients may not have received diagnostic care. In most cases, the incidental findings are not cancer, Klar said. The image may be a benign cyst or a lesion on the lung from a past infection. But a scan can also indicate something more serious.
“Time to treatment matters with cancer patients,” Klar said. “If you have to wait three weeks for an appointment or you go home and put it on the backburner, that could matter. I had a patient who popped up on my work queue, and this patient had a pancreatic mass with liver lesions. I knew it was critical to get that patient in. I contacted one of our oncologists who gave me an overbook for the next day. That patient started chemotherapy one week to the day later. That’s how quickly we were able to move.”
Clinicians with both the Emergency Department and VICC recognized the need to improve the system. Nick Garland, MS, an administrative fellow embedded within VICC, was given the task of shepherding the initiative by Anna Rodriguez, MSN, MHA, the former associate nursing officer for VICC. Garland met with her and other leaders from both departments as well as representatives of Information Technology.
“We brainstormed for ideas — what we thought the ideal process would be like, what the goals were and the next steps,” Garland said. “I acted as a liaison between all these groups to connect all the dots and envision what the process would look like from an operational perspective.”
Klar will present VUMC’s system for handing incidental findings to the Oncology Nursing Society annual meeting, while Garland will speak about it at the Association of Community Cancer Centers business summit.
Discussions are underway on how VUMC can share the system with other hospitals that utilize Epic-based software. Additionally, members of the team are working to set up a similar system to better expedite follow-up diagnostic care for patients with incidental findings in settings outside of the Emergency Department.
“By first identifying this area of need in disposition of care in the ED and then integrating a joint plan with the VICC team, this important new algorithmic and clear process provides a huge service for patients with many possible cancers and, importantly, other health-related issues,” said Sam Chang, MD, MBA, the Patricia and Rodes Hart Professor of Urologic Surgery, VICC Chief Surgical Officer and its physician lead for the initiative.
Other members of the team responsible for the improved system include Ian Jones, MD; Stephan Russ, MD; Emergency Department nurse case managers Jan Dahlke, RN, and Penny Lancaster, RN; Emergency Department social worker Larry Prisco, MSW, LCSW; Health Information Technology senior application analysts Lisa Nilson, and Julie Ervin, RN, MSN; VICC nurse navigators Nikkie Baldi, MS, RN, and Amy Hayes, RN, OCN; Travis Osterman, DO, MS; VICC business analyst, Jon Stein, MBA; the eStar ASAP team and the clinicians of the Emergency Department.
