Reducing preventable ED visits in patients with advanced NSCLC: Collective insights from three cancer centers.
Authors: Waugh Wendi , Das Devika Govind , Thomas Nancy N , Plotkin Elana , Salgia Ravi , Spira Alexander I. , Socinski Mark A. , Lee Percy , Smeltzer Matthew , Kim Joseph , Boehmer Leigh 
Published: September 2022

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Background: While many patients with advanced NSCLC have complex medical needs, emergency department (ED) visits may be preventable if clinicians predict, identify and treat symptoms early and deliver outpatient interventions. The Association of Community Cancer Centers (ACCC) evaluated how cancer centers participating in a multi-phase initiative found ways to reduce preventable ED visits in patients with advanced NSCLC. Methods: After holding QI workshops, ACCC followed-up with three centers located in AL, OK, and OH. These centers aimed to improve lung cancer symptom management, patient education, and care coordination related to the CMS Measure #OP-35 diagnoses: dehydration, diarrhea, emesis, nausea, pain, or pneumonia. Results: Patient Education and Reminders: Patients who undergo systemic treatment often need to be reminded to call their medical oncology team if they develop symptoms. Examples of effective practices include: a patient education and reminder campaign to “call-first” before visiting the ED; wallet cards with phone numbers; and ongoing reminders whenever patients come for infusion or clinician visits. Intensive Care Coordination: Some patients with advanced NSCLC may be “high risk” for ED utilization (eg, co-morbidities, social determinants, etc.). Intensive care coordination delivered by nurses may be directed specifically at these patients. Interventions may include scheduled phone calls and/or telehealth visits to assess symptoms and coordinate outpatient interventions. Immune-related Adverse Events (irAEs): Patients with advanced NSCLC may receive immune checkpoint inhibitors which may cause irAEs. Colitis may lead to dehydration, diarrhea, emesis, nausea; pneumonitis may be misdiagnosed as pneumonia. One center began using a patient symptom questionnaire delivered by a nurse navigator and managed 94% of irAE symptoms in the outpatient setting. Another center surveyed ED providers to assess gaps in identifying irAE symptoms an formed a multidisciplinary irAE work group to discuss patient management and facilitate increased awareness and early recognition. These efforts led to a series of education programs for ED staff. Early Palliative Care: Since early palliative care is associated with reduced ED utilization, one center streamlined palliative care referrals in the outpatient setting by developing an electronic pathway. 91% of patients with advanced cancer enrolled after initial consult; only 24% made an ED visit. Conclusions: While many ED visits are necessary, some may be preventable, especially if members of the multidisciplinary cancer care team risk-stratify patients, proactively identify and empower patients to “call first,” treat symptoms early, and provide early palliative care. The collective insights from these cancer centers provide guidance around sustainable strategies that can potentially reduce preventable ED visits.