Background
Abnormal findings unrelated to the indications for testing are occasionally identified in studies performed on patients presenting to the emergency department (ED). The literature denotes these findings as incidental and represents an important discovery requiring an oncologist's further investigation. When there are gaps in health care options, people tend to rely on the emergency department as their only resource, leading to a consistent rise in its usage. An estimated one-third to one-half of emergency visits are considered non-urgent and add to overcrowding and longer wait times.
Common obstacles that increase emergency department utilization are 1) lack of primary care providers, 2) financial difficulties, and 3) lack of comprehensive care outside the emergency department. While the patient benefits from the emergency department's one-stop approach for a rapid diagnosis and testing of a simple bronchitis condition, the care gap widens for vulnerable populations when the chest x-ray identifies a suspicious finding requiring further diagnostics. Vulnerable communities with undocumented, uninsured, or underinsured people often wait to follow up outside the emergency visit due to a lack of insurance, clear directions on the next steps, or understanding the importance of follow-up. It can be challenging for patients to know what to do next and navigate practical obstacles after leaving the emergency department. This can lead to some patients falling out of the loop and not receiving the necessary care.
Objective
Various institutional barriers contribute to the care gap, including the absence of standardized referral flow to oncology within the organization, the emergency department's unawareness of internal referral resources, and the patient's lack of knowledge and resources to complete the next steps. Some obstacles faced by the patient included language barriers, lack of insurance, transportation issues, distrust, and fear of pursuing additional diagnostic follow-up.
A well-established protocol has been put in place to guarantee impartiality and equity for those emergency department patients who are diagnosed with incidental findings and potentially unforeseen cancer, and it involves referring them to the Oncology Access Center. This process utilizes ambulatory navigators to connect patients with follow-up care, guiding them through the next steps.
Results
Within the first 60 days, 27 patients were transitioned to the Fast Track to Oncology program for incidental findings. Of the patients, 22% were Hispanic, and 18% reported Spanish as their primary language. A staggering 37% of individuals had either inadequate insurance or insufficient coverage. The Equity Patient Navigators are experts in streamlining the Charity Care application process, leading to significantly shorter wait times for patients seeking care. This has resulted in an impressive 54% of patients being able to consult with an oncologist within a mere three days. Nearly half of the referrals (48%) required the intervention of a navigator to ensure prompt assistance and avoid the need for patients to revisit the emergency department. The follow-up visit rate has significantly improved thanks to the navigators who worked with patients. Amazingly, 92% of the referrals completed their oncology consultation. This positive outcome is a testament to the importance of supporting patients during their cancer journey.
Conclusion
In March 2023, our system standardized and implemented the emergency department workflow throughout the organization to improve communication and collaboration between vulnerable populations experiencing incidental findings that need follow-up. Following standardized protocols when there is an unexpected finding can reduce the number of return visits to the emergency department. This also helps improve communication, timeliness, and the number of completed ambulatory visits.
Efficient navigation can overcome obstacles such as transportation and the cumbersome application process for charity care. Using Equity Patient Navigation for practical problems, health care can be delivered in a timely manner, and access to financial and supportive services can be increased.
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Authors: Jeanne Silva, MSN RN-BC, CMSRN, CN-BN. RWJBarnabas Health and Rutgers Cancer Institute of New Jersey; Portia Lagmay-Fuentes, APN, RWJBarnabas Health and Rutgers Cancer Institute of New Jersey; Avni Patel, MSN RN. RWJBarnabas Health and Rutgers Cancer Institute of New Jersey; Amanda Gaughran, BSN, RN, RWJBarnabas Health and Rutgers Cancer Institute of New Jersey; Odalys Ferguson, MPH, Rutgers Cancer Institute of New Jersey
This project was supported, in part, by a grant from the Merck Foundation
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