Navigating care to reduce emergency room (ER) visits in cancer patients using opioids.

Abstract

e18265 Background: Pain is the most frequent and one of the most important cancer related symptom with significant impact in quality of life. It is also the most frequent reason (27% of visits) for a patient to go to an ER and 53% can be prevented with adequate care (Panattoni, JCO 35, 2017 suppl; abstr 6505). Methods: In 2015 IOV developed a patient centered Navigation System based on Kanban (board and visual signals - KNS) for managing treatment plan of our patients that was very successful. In 2016 with support of an educational grant from QTP-ASCO we extended this system to manage pain and other cancer or treatment related symptoms. This study addresses only pain management and ER visits between dec16 and dec18 for a total of 187 patients using opioids. We measured the proportional reduction of ER visits related to pain to the total ER visits in three successive periods: development of the NKS (dec15-jul16), pilot phase (aug16-oct17) and as an adopted best practice (oct17-dec18). The pain KNS comprises a set of standardized procedures and successive checks for patients using opioids based on three procedures: (a) standardized prescription and use of analgesics using WHO’s Pain Ladder; (b) standardized follow up in 24 and 48 hours, 1, 2 and 4 weeks; and (c) manage side effects of opioids or other emerging problem (constipation, confusion, etc). Any patient initiating opioid use is included in the KNS until opioid is discontinued. Once pain is adequately controlled, the frequency of checks become wider up to once a month if no toxicity is identified. Any new condition will restart the 24-48 hours loop. The KNS is managed by oncology nurses using phone or video calls, messaging, and appointments; Mon-Sat from 6AM to 10PM. Results: The KNS managed a median of 132 patients per month during 29 months (aug16 to dec18). Pain represented 20% of ER visits (33.65 UCL and 6.7 LCL); in pilot phase 15% of ER visits (27.34 UCL and 3.70 LCL); and now 4% of ER visits ( 8.46 UCL and 0 LCL), an 80% reduction in pain related ER visits. ER visits represents patients with uncontrolled pain and not effectively managed by the KNS. Conclusions: The development of a simple visual system to manage cancer patients with pain resulted in 80% reduction of ER visits and adequate pain control in our practice.