Lessons learned about policymaking: Moving an emergency department-initiated screening protocol to systemwide input in the development and implementation process.

Emergency department (ED) utilization by cancer patients is greater than that of the general population and improving care coordination may not only enhance the quality of care but also decrease ED visits.1 Despite the benefits of the Affordable Care Act (ACA) and the expansion of Medicaid eligibility through the ACA, the current health care landscape can still be a particular challenge for cancer patients needing to access subspecialty and advanced diagnostic care and treatment.2 The role of ED in maximizing touch point opportunities for patients is expanding as “office-based physicians … [are] making growing use of EDs to perform complex workups and expedite non-elective admissions” due to patient's severity/complexity of illness, need for after-hours care, and access to sophisticated diagnostic equipment.3 There are increasing data suggesting that ED care coordination and treatment protocols can be effective in redirecting appropriate acute health care utilization.1, 4 One way to address the growing ED utilization by patients with severe illness and more complex health issues is to implement effective and efficient screening protocols. As EDs deal with time-sensitive conditions and provide acute care on a 24/7/365 days a year basis, time allocation is a primary marker of operational efficiency for diagnosis, management, and optimal patient flow. A recent survey of cancer survivors found that receiving a verbal explanation of follow-up care plans from a doctor/nurse/other health professional was associated with improved cancer survivor self-efficacy, and those with higher self-efficacy had an incrementally lower prevalence of ED visits (prevalence ratio 0.92, 95% confidence interval [CI] 0.88–0.97) and inpatient hospitalizations (prevalence ratio 0.94, 95% CI 0.89–0.99).5 Further, ED-initiated protocols focusing on adult frequent ED users have demonstrated improved delivery of care, substantial cost savings, and reduction in ED utilization by cutting down frequent and repeat visits.4 In 2019, Improving Cancer Survival and Reducing Treatment Variations with Protocols for Emergency Care (ICARE; https://clinicaltrials.gov/ct2/show/NCT04673890) was funded by the Centers for Disease Control and Prevention (CDC) to improve outcomes for cancer patients presenting to the ED through implementation and evaluation of ED-initiated, evidence-based screening protocols for deep vein thrombosis/pulmonary embolism (DVT/PE) and sepsis. Cancer patients are at increased risk of sepsis and DVT/PE, and these conditions remain leading causes of mortality among cancer patients.6, 7 We faced several challenges when trying to initiate new organizational policies that incorporate ED-initiated screening protocols designed to improve early detection and management of sepsis and lower-extremity DVT among patients with active cancer. Challenges also occurred in the implementation of an ED-based patient navigation protocol to support care coordination for cancer patients postdischarge. Implementation of these protocols in the ED and getting broader institutional support and buy-in from not only the clinical staff but also the ancillary services was difficult because of lack of familiarity with the overarching goals of the proposal and the protocols. Previous studies show that concerns about increase in workload and disruption in an already busy workflow can deter staff from being open to new policies, especially those that substantially increase their responsibilities.8 Our experience was that policies resulting in systems change become challenging to implement because of not only the acute, fast paced environment of the ED, but also the time sensitivity of illness, significant patient volumes, and the role of ED being at the forefront of any public health emergency. The logistic barriers due to the very nature of ED and the involvement of multiple moving parts makes system change harder. In addition, based on our experience we found policies entirely localized to ED are becoming rare as the complexity of patients seeking ED visits are increasing. Also, the start of the study coincided with the COVID-19 pandemic. Because of the pandemic, the research was temporarily paused for 6 months with ED access being limited to essential health care personnel only. This delayed every aspect of the study, including study recruitment, integrating patient navigation into cancer care, and creating and implementing new protocols for cancer care. Months of meetings (i.e., weekly meetings from February 2020 to April 2020, then paused due the pandemic until September, and later resumed as biweekly meetings until November 2020), both in-person and via video conferencing, with select, small groups of established collaborators proved to be insufficient to meet the objectives of widespread buy-in for the screening protocols. Following the delays resulting from the barriers in gathering widespread commitment and support, we changed our approach in January 2021 to a hybrid model that involved both a top-down (i.e., where the ED and external leadership including operations director, nurse manager, relevant external division/program directors are involved in policy development and implementation) and a grassroots approach (i.e., where ED physicians, mid-level providers and advanced practice providers, nurses and resident trainees have a say in policy development and implementation). By identifying existing institutional meetings where a diverse group of collaborators were gathered and including the policy development team and end-users, we were able to make significant progress. After the new approach was adopted, a total of only six meetings were needed between January 2021 and June 2021, with presentations to a protocol review committee (that had representation from many of the relevant collaborators), an anticoagulation quality improvement committee, and a resident house staff meeting. Moreover, due to the pandemic, pivot to virtual meetings helped us avoid traditional difficulties in scheduling in-person meetings and allowed us to expand our audience virtually and made it easier to get robust participation from relevant collaborators. It was important to go beyond the usual policy development engagement approach of starting with a limited working group of ED staff and administrators and instead cast a wider net of partners. Figure 1A presents our previous approach of policy implementation in the ED where the ED Policy Working Group is a smaller subset of the ED faculty and staff and there is no initial involvement of the partners external to ED. Alternatively, Figure 1B presents a revised approach, based on our experience and lessons learned in this project, which involves a wider net of interested partners who would be potentially impacted by changes in policies within ED. While policy development may be more effectively accomplished in a smaller working group, the policies implemented in ICARE project showed that a broader, more diverse set of partners are required to be engaged earlier. Waiting until the implementation phase to bring in the necessary partners can result in costly delays, confusion, push-back, and ineffective engagement. As we navigated the policy implementation barriers, we adapted our approach to include a more open, collaborative, and multidisciplinary policy working group. Our implementation of screening protocol to assess cancer patients at high risk for DVT/PE and sepsis was more effective with engagement and buy-in from not only ED providers, but also all providers potentially involved in the care of the patients after leaving the ED for continuity of care. EDs already have an active partnership with multidisciplinary clinical teams that have a seat at the table to garner widespread institutional support. In the ICARE project, the list of partners extended far beyond what was initially planned. In the case of the implementation of the ED-initiated screening protocols, the list of potential partners who would be affected by these protocols and whose participation can enhance the decision-making process included relevant clinical departments chief of service, division directors, program directors, resident physicians, hospital-related steering committees, diagnostics, and information technology services in addition to ED faculty and staff. Support from all layers likely to be affected by this policy was important as this ED-initiated policy would impact acute inpatient hospital stay. As new clinical evidence keeps emerging in the field of medical care, EDs may benefit from incorporating this evidence into potential new policies and/or to revise existing ones. There are certain policies and guidelines that are universally enforced across the ED, known as standards of care, nonetheless, each institution can overlay additional policies to further improve patient outcomes. To our knowledge, there is no clear consensus on what the optimal process of policy creation is for an ED, due to unique environment at each institution. Shaikh et al.9 have identified five steps in policymaking process in the ED, starting with identification of the problem, creating a policy team, constructing the policy, implementing, and monitoring it and actively addressing barriers to ED policymaking throughout the process. Certain challenges may continue even if the process at each institution becomes optimally streamlined. Bureaucracy (that leads to compartmentalization and fragmentation leading to slower adaptability) and limited resources may continue to be an ongoing challenge for institutions. System-level implementation of department-initiated protocols is an example of where thinking about the larger landscape of working partners/collaborators at the onset might make a significant difference in securing appropriate buy-in across the health care delivery environment. For cancer patients in particular, continued work in improving care and developing/implementing effective care protocols is important because cancer patients are a unique subset that face additional challenges related to fragmentation of care secondary to referral patterns for diagnosis, treatment, and follow-up care.10 Social determinants of health inequities contribute to health disparities, with worse cancer outcomes among groups that are marginalized.11 As cancer health disparities continue to widen,11 efforts to identify individuals at the highest risk for poor health outcomes in patients presenting to the ED are important. In summary, we learned the following lessons in addressing the barriers faced when implementing new policies in ED: (1) anticipate resistance from busy ED staff, administrators, and partners and plan to obtain their buy-in through education and training; engage and invest in educating and training ED staff and administrators from the outset through faculty meetings and staff huddles; (2) design new policies in a way that do not make extreme demands on staff time as well as offering staff the support and resources necessary to implement them; and (3) engage health care staff and administrators from across the hospital care system from the outset, including the policy development phase. The authors declare no potential conflict of interest.