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

Funding information Improving Cancer Survival and Reducing Treatment Variations with Protocols for Emergency Care (ICARE) was funded by the Centers for Disease Control and Prevention (CDC) through the Centers for Research and Demonstration for Health Promotion and Disease Prevention University of Illinois 6 U48DP006392-01- 01 ILLINOIS PRC CORE + SIP19- 007. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry

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://clini caltr ials.gov/ct2/show/NCT04 673890) 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 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  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.

CO N FLI C T O F I NTE R E S T
The authors declare no potential conflict of interest.