Doerfler-Evans, Ruth E. RN, CNOR, OCN
The primary tenet of nurse navigation is patient-centered delivery of care with timely access. By using patient-centered communication skills (such as active listening), nurse navigators can make an intimate connection with their patients upon initial contact, which allows for a trusting relationship to develop. And specifically in oncology, nurse navigators play a critical role in both cancer screening and in coordination of services.
In thoracic oncology, the nurse navigator is the primary contact for patients as abnormal chest imaging is evaluated, chest CTs are ordered, and a diagnosis is made.1
Throughout the diagnosis, the thoracic nurse navigator's role requires scheduling appointments for initial physician consultations; requesting additional imaging studies; scheduling patients for procedures including surgical biopsy for diagnosis and staging; following up with the patient about pathology results; and directing the patient to the next provider most appropriate for the treatment needed (i.e., the thoracic surgeon, medical oncologist, and/or radiation oncologist).2
We set out to find whether a “gold standard” exists for timely throughput, from discovery of an abnormal CT finding (lung mass or nodule) to diagnosis and handoff for treatment. We conducted a literature search across multiple databases, including PubMed and Google Scholar, to identify if a recommended timeline existed for lung cancer diagnosis and treatment.
Lung cancer remains the leading cause of cancer death in men and women. It is expected to cause 159,260 deaths in 2014—27 percent of all cancer deaths for the year, according to the American Cancer Society's most recent projections.3 And between 2003 and 2009 (the most recent time period for which data are available), there was a 54 percent five-year survival rate when the disease was diagnosed at a localized stage, but only 15 percent of lung cancers were detected at this early stage.3
Prompt initiation of cancer treatment depends on the diagnostic confirmation of lung cancer tissue type and staging. Unlike the standard diagnostic set for patients with breast cancer that recommends a five-day breast lump discovery to treatment timeline, studies remain unclear as to whether timeliness of care in non-small-cell lung cancer (NSCLC) improves patient outcomes.4
Thirty studies met the inclusion criteria for our literature search and were reviewed. None demonstrated a consistent, standardized timeline for patients exhibiting an abnormal CT scan. Rather, the studies focused on unacceptable delays along this trajectory.
Based on the lack of evidence to guide standards for practice, we elected to evaluate the efficiency of our throughput for patients referred to our Interventional Pulmonology (IP) service who presented with abnormal chest CT scans and had a suspicious lung mass or nodule that required a tissue biopsy for diagnosis at Medstar Franklin Square Medical Center. Data were collected in real time.
Ten patients per month were randomly selected for an 11-month period, for a total of 110 patient records.
The nurse navigator recorded the date of the patient referral, date of surgical intervention with bronchoscopic biopsy, date the biopsy pathology results were shared with the patient, and the date of handoff of the patient to the next appropriate treatment discipline based on the pathology and staging reports.
Findings and Impact
The results demonstrated a mean of five days for patients to undergo their bronchoscopy procedure after the nurse navigator was accessed. Patients were notified of their pathology results within three days of their procedure date, and the total throughput from initial access to handoff to the next medical provider for treatment was a mean of eight days.
At our institution, the nurse navigator coordinates with the physician's office to schedule a patient's bronchoscopic procedure, helping to also schedule necessary consultation and biopsy. The navigator also coordinates the required preoperative testing, acting as the gatekeeper to quickly move patients through the system.
Following diagnosis, the navigator quickly refers the patient to the next provider for cancer treatment. By using a primary point person—the nurse navigator—to coordinate care services for each patient, the time to treatment (as well as anxiety for our lung cancer patients) is reduced.
When these results were disseminated at our Cancer Center Quality Improvement meeting, the membership was quite surprised to realize there were no national guidelines or recommendations addressing timely throughput for these patients. Furthermore, although no benchmarks exist, members were encouraged to learn about our program's results, which were similar to those identified in the literature for patients with breast cancer.
The literature as yet does not support a “gold standard” in timely throughput for patients requiring a tissue diagnosis for an abnormal chest CT scan. But, nurse navigators can decrease barriers to access to care and provide customized care delivery for our oncology patients.
Nurse navigators are also a resource for the patient having this devastating disease and are often a sounding board and “point person” in an often fragmented health care system. Nurse navigators play a pivotal role guiding patients through initial detection to diagnosis and treatment.
Our quality improvement study illustrates a method to establish guidelines that nurse navigators can use to measure their efficiency in providing timely care coordination for the newly diagnosed patient with lung cancer.
Although evidence is lacking about “gold standard” throughput measures, nurse navigators can be instrumental in quantifying care to develop future benchmarks.
RUTH E. DOERFLER-EVANS, RN, CNOR, OCN, is a nurse navigator at Medstar Franklin Square Medical Center in the Division of Interventional Pulmonology. She has 38 years of experience, working primarily in Perioperative and Oncology nursing and is certified in both nursing specialties.
1. Hunnibell L, et al. Foundations for Lung Nodule Management for Nurse Navigators. Clinical Journal of Oncology Nursing 2013; 17:525–531.
2. Case M. Oncology Nurse Navigator: Ensuring Safe Passage. Clinical Journal of Oncology Nursing 2011; 15:33–40.
3. Siegel R, et al. Cancer statistics, 2014. CA: A Cancer Journal for Clinicians 2014; 64:9–29.
4. Olsson JK. Timeliness of Care in Patients with Lung Cancer; A Systematic Review. Thorax 2009; 64:749–56.