The Abramson Cancer Center’s nurse navigators can now help patients find their way to getting a diagnosis.
When a patient shows up to the Emergency Department (ED) with concerning symptoms – unexplained pain or swelling, perhaps – sometimes that is only the start of a longer journey marked with a big letter “C” for cancer. Patients who learn from their ED physician that their symptoms may be cancer now have more support for the next steps, thanks to a Penn Medicine initiative at two hospitals.
Not only is care easier for patients, but it’s easy for the ED provider to help them get the support they need. The ED provider simply completes a “Consult to Nurse Navigator” referral order for these patients in PennChart, Penn Medicine’s electronic health record. That order is automatically sent to an inbox shared by the Abramson Cancer Center’s (ACC’s) team of oncology nurse navigators. The navigator who focuses on the body site of the potential cancer – for example, lung or gastrointestinal – will then reach out to the patient within two to three days. “We tell patients, ‘The navigator will get you to where and what you need,’” said Keith Hemmert, MD, the ED medical director at the Hospital of the University of Pennsylvania (HUP).
A Guide to Get Evaluated for Cancer
Most patients come to a cancer diagnosis through the traditional route: They notice something concerning and visit their primary care doctor, or a troubling result shows up on labs or scans. But for some, the ED is their starting point. “Lung cancer, for example, doesn’t have many symptoms until it progresses,” explained oncology nurse navigator Megan Roy, MSN, RN, OCN; a patient who has lung cancer may present at the ED for shortness of breath, chest pain, severe back pain, or in rare instances coughing up blood. In other cases, patients visit the ED for something unrelated, and something shows up on their exam or scan that could be a sign of cancer.
Before the initiative started, patients who left the ED with a suspicion of cancer would go home with instructions to contact the oncology call center to make an appointment. But if the patient doesn’t have a confirmed cancer diagnosis, getting an appointment to see cancer specialists at HUP can be tricky. In a big academic medical center such as HUP, there are no general oncologists to work up a patient and get a diagnosis, noted Roy: “HUP’s oncologists are highly specialized. It is difficult to know who to see first, which makes scheduling appointments challenging.”
It was a frustrating situation for ED providers as well. “We didn’t have a good discharge pathway,” Hemmert said. Patients in this situation need additional testing which can’t be performed in the ED.
“Many patients aren’t sick enough to require admission to the hospital, but they’d return to the ED a week later, saying they couldn’t set up an appointment,” noted Hemmert. The ED providers didn’t want to admit patients to the hospital who didn’t truly need to be there.
When the ACC nurse navigators learned of this gap in care –nsometimes directly from patients they were able to meet with – they identified where they could intervene. The result was the new option in PennChart, built with ED leadership, where clinicians can refer patients to the oncology nurse navigators. It provides the patients with an immediate and personal connection with a trustworthy navigator who helps them get a diagnosis and treatment.
Easing Access to Cancer Treatment
The change in process has led to remarkable results. Since the start of the new referral program in May 2022, navigators have helped bring more than 175 ED patients into the treatment they need, efficiently and expeditiously. Consider the case of a patient seen in HUP’s ED early this year; the ED clinician sent a referral to the ONNs. Roy, who focuses on patients with lung cancer, contacted the patient the following day to get her care started. Three days later, the patient was seen by interventional pulmonology for a bronchoscopy to take a biopsy. The patient had a diagnosis two weeks later, and started treatment in early March. Now she’s on preventative treatment. “She had no idea she had lung cancer and five weeks later was already in curative treatment. It was found early enough,” marveled Roy.
But the road to treatment is not always straightforward for every patient, so navigators also help with other challenges along the way. People experience symptoms that feel like an emergency to them. Often, it’s pain, which can make waiting for the next available diagnostic appointment excruciating.
Roy recalled a patient who was discharged from the ED with suspected prostate cancer. Shannon Meier, MSN, BSN, RN, an oncology nurse navigator who works with genitourinary patients, got him scheduled with medical oncology for three weeks later. However, the patient had what were later found to be spine metastases which were very painful. “He was in agony,” Roy said.
Meier was able to get him an appointment at the Radiation Oncology Urgent Spine Clinic for pain. He was then admitted, received a diagnosis of multiple myeloma, and started on immediate treatment.
“We want to decrease the amount of burden on the patient, who already doesn’t feel well,” said oncology nurse navigator Trish Gambino, MSN, RN.
Sometimes, when a patient with cancer symptoms comes to the ED for care, it’s because they don’t have access to a primary care doctor who can help them with specialty care. But when the patient’s medical record says “no primary care physician,” that’s not always the case. After initially speaking with patients, especially those who have immigrated to this country, Gambino and other nurse navigators often discover that they do see a doctor in the community who may not necessarily be affiliated with Penn.
“I always call that person to touch base about the patient’s visit to the ED,” she said. “They know best how to make [the next steps in their care] work for a patient. We have to involve those who already know the patient and respect the community providers.”
Spreading the Word and Expanding the Strategy
The ACC nurse navigator program is working so well in the HUP ED that Hemmert is constantly talking it up: “Providers want this pathway. Once they use it, they don’t forget about it.” Indeed, it is part of the ED orientation for new physicians and is re-publicized among ED providers every few months. The program is now live at HUP, both in the Pavilion ED and at HUP–Cedar, and at Penn Presbyterian Medical Center (PPMC).
To further their outreach, the nurse navigators also educated employees in the oncology call center, making sure they refer these ED patients to the navigators. “Now they know the patient needs a nurse navigator to help,” Gambino said. “We can drill down to what’s going on with a patient and that comes from years of experience.”
The referral program also led to the opening in March of the Oncology Diagnostic Clinic at PPMC serving patients with a high suspicion of cancer – such as abnormal lab work or a tumor found in a scan – but no formal diagnosis. The oncologists order any further testing that’s needed to diagnose (or rule out) cancer and connect the patient to the right subspecialist for treatment.
One such patient came to the clinic after going to a non–Penn Medicine ED following a trauma. The hospital ordered CT scans to look for fractures or other internal injuries and found something surprising: a pancreatic mass.
Oncologists Christopher D’Avella, MD, and Christine Ciunci, MD, MSCE, run the new Oncology Diagnostic Clinic
“A lot of times when pancreatic cancer is discovered, it’s more advanced. In this case, it was an incidental finding,” said oncologist Christopher D’Avella, MD, who, with oncologist Christine Ciunci, MD, MSCE, runs the new Oncology Diagnostic Clinic.
“The question,” D’Avella posed, “then becomes: What does that patient do next?” In this case, the patient visited the new clinic where, “as oncologists, we know if someone comes in with a pancreatic mass, they’ll need blood work and testing for tumor markers. We’ll also check their liver and kidney function, and order an endoscopic ultrasound,” D’Avella said. “Because we have connections and relationships with providers across Penn Medicine, we can set that up within a reasonable amount of time to get the diagnosis.”
Clinic patients may be referred by a physician or self-refer, but must have a high suspicion of cancer: either abnormal findings in labs or imaging, or clinical symptoms. Patients initially speak with a new patient coordinator who collects information and helps them gather records. The clinic also provides access to experienced oncology nurse navigators who answer questions, offer guidance, and give emotional support.
Once a patient receives a diagnosis, they are referred to the appropriate subspecialist, such as hematologist Shivani Bakhshi, DO, seen at far right.
Roy, the oncology nurse navigator, said navigating an academic medical center, with its many moving parts, can be challenging, which is why the clinic is so important. D’Avella added that the clinic also helps improve health equity for patients from underserved populations who may lack a primary care doctor or the knowledge or experience to access care on their own.
When it’s up to the patient or their primary care doctor to figure out how to get a biopsy and any other tests they need, it can lead to delays in treatment, D’Avella said. “That’s the big advantage to this clinic. Patients with incidental findings or highly concerning symptoms [no longer] have to navigate the system by themselves to figure out how to get a diagnosis and facilitate care. We can use our expertise to essentially do that for them.”
Programs like these are part of Penn Medicine’s ongoing commitment to enhancing the patient experience and expanding services to meet the needs of the community.
Hemmert said that not only is the ED referral program a huge success, but it’s also a model for what the future of care could look like. “It’s an effective and reliable bridge between the ED and outpatient care – connecting patients who could be discharged to get appropriate patient care in a timely manner,” he said. “This is where we need to get to. But we need to think not just oncology but across the spectrum of all services we offer at Penn.”