University of Texas Health - San Antonio

Emergent Breast Abnormality Care & Evaluation (EmBrACE)

Project Lead:  Tatiana Emanuel, PA-C  

Project AIM(s): Formally evaluate and refine a novel pathway aimed at decreasing hospital admissions and time to definitive diagnosis by 50%, for unfunded and underserved patients presenting to the emergency department with a breast abnormality, through strategic partnerships and the utilization of hospital affiliated clinics.

Narrative Description

The journey of the patient starts when she presents to the ED with a complaint of breast abnormality. Evaluation in the emergency department would include a physical examination and use of a standardized “Breast Mass” order set. The breast mass order set includes an ultrasound, basic labs, and an automatic consult to case management. If the patient has any EmBrACE exclusion criteria, they will be admitted to surgical oncology for management. If the patient meets EmBrACE inclusion criteria they will be discharged home with antibiotics (if warranted) and scheduled for follow up within 24-48 hours at the UHS affiliated Ambulatory Connection Clinic (AMC). Case management has institutional approval to schedule unfunded EmBrACE patients, for follow-up appointments. Emergency providers and case manager will email the team lead the patient’s current contact information. The project lead will serve as a navigator during the initial phase of the patients evaluation. During the initial follow-up appointment, the patient will be evaluated by the provider and scheduled for a mammogram and breast US/biopsy (if needed). Also, during that initial appointment the patient will undergo screening for funding options. Funding options include grants, Medicare/Medicaid, or CareLink (financial assistance program). The Medicaid for Breast and Cervical Cancer Program is another source of funding that offers breast cancer screening and treatment to low-income, uninsured women. If the patient has private insurance, they will be connected with a provider in their network. During the second appointment, the provider will review the imaging and/or biopsy results. At this point, if indicated, the patient will be turn over to the breast clinic and/or surgical oncology. The goal is to complete the second appointment in less than one week from the initial emergency encounter. Decreasing the time-to-diagnosis and treatment improves survivability and quality of life. Stable patients with breast abnormalities will be preferentially treated in an area that has full-time advanced practice providers and not affected by resident rotations. Less provider variation will help with pathway compliance. All breast mass admissions will reviewed for appropriateness. Individualized feedback and performance improvement letters will be provided to providers for non-compliance with the pathway.

We were able to streamline the discharge process by making “Smart Sets” in the EMR. This took out any variation in practice, preventing over/under ordering. Standardized discharge instruction improved communication to the patients. We were able to complete the education campaign and it has continued. There were presentations at staff meetings, resident conference, and “just-in-time” teaching at the bedside. We were able to analyze the data to learn more about the number of patients and the outcomes.

  • 30/200 patients were positive for cancer (15% for all commers. 25% if you only include only those who followed up)
  • Found a 30% no show rate to follow-up appointments
  • ED encounter to Specialist was an average of 25 days for the cancer cohort
  • 26% were funded at the time of initial evolution. Post-intervention 67% were aligned with some form of funding
  • We also found that the highest rate of patients, presenting ED with a breast abnormality, came from lower income zip code.

We realized the standardizing a process that links non-emergent but high-risk patients to timely follow-up is key. One barrier to this is funding. Connecting the patients with a breast abnormality to a financial councilor has been successful in finding fund sources. Guaranteeing follow-up though hospital affiliated clinics has prevented hospital admissions and we were still able to provide timely care. We found a 30% no-show rate for the clinic. We have kicked off a new project to screen for barriers that would prevent a patient from follow-up. This is done before discharge and resources are provided (social worker, bus passes, information on community resources, and access to DxQI Seed Grant Final Project Report financial counselor). We were able to align funding to a large percentage of these patients. Not only did this increase access to cancer care, but this also increased access to primary care. We also found that the highest rate of patients, presenting ED with a breast abnormality, came from lower income zip code.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Failure to access the health care system or engage in the diagnostic process
  • Failure in information gathering
  • Failure in information integration
  • Failure in information interpretation
  • Failure to establish an explanation (diagnosis)
  • Failure to communicate the explanation to the patient

Root causes/causative factors addressed by the intervention

  • Patient-clinician interaction (includes patient and family engagement)
  • Workflow (includes testing, follow-up, and referrals)
  •  Diagnostic patient safety culture  

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)
  • Emergency department
  • Radiology/imaging