HEART Protocol Leads to Reduction in ED Visits After Chemoradiation
Using risk assessment and nurse education in the High ED/Admission Risk Therapy (HEART) protocol reduced ED visits by 18% after chemoradiation treatment.
The HEART protocol reduced emergency department visits post chemoradiation and increased nurse knowledge and confidence.
Implementation of a High ED/Admission Risk Therapy (HEART) team protocol led to fewer emergency department (ED) visits, according to a quality improvement project that was presented at the 50th Annual ONS Congress.
“This structured approach ensures timely and effective care,” Yun Jeong Seo, DNP, MSN, APRN, FNP-C, a nurse practitioner at Mount Sinai West, said during her presentation. “…This approach aligns well with the [Centers for Medicare & Medicaid Services (CMS)] quality goals and can serve as a model for other cancer institutions aiming to enhance patients’ outcomes proactively with team-based care.”
In particular, the HEART protocol led to an 18% overall reduction in ED visit rates following its implementation (pre-HEART protocol, 39%; post-HEART protocol at 6 months, 25%; post-HEART protocol at 12 months, 21%).
Further, pre- and post-training surveys of the HEART protocol showed that nurse knowledge and confidence in managing human-related complications improved from a score of 14 to 21.2 (P < .001).
HEART Protocol Objectives
The HEART protocol—which included nurses, nurse practitioners, attending physicians, and support staff such as social workers and dieticians—aimed to reduce ED visits at the institution by at least 10%.
The first objective of the HEART protocol was to generate specific guidelines to improve early detection of risk factors of unplanned ED visits in adult patients receiving chemoradiation.
The team implemented an evidence-based HEART protocol by developing a high-risk nursing assessment checklist, starting from the first day of chemoradiation treatment and then bi-weekly throughout treatment.
The checklist is designed to assess key risk factors—such as heart rate and vital signs, eating habits, activity, radiation-related adverse effects, test results, and sepsis risk—at levels of mild, moderate or severe.
Depending on the severity of the assessed risk factors, patients either continued on treatment (mild), were referred to the HEART team (moderate) of multidisciplinary care providers, or were transferred to the ED regardless of order from their treating physician (severe).
The protocol also instituted multidisciplinary team building, as well as a weekly nurse practitioner-led symptom management clinic.
“The checklist supported nurses in identifying early warning signs and the nurse practitioner clinic ensured primary intervention,” Seo said. “Together, this chart did help us prevent complications, avoid treatment delays, and reduce ED visits.”
The second objective of the HEART protocol was to have ongoing nurse education of high-risk patient assessment and symptom management.
With this, the team held 2 educational sessions on evidence-based high-risk patient early detection and symptom management, as well as continuous point-of-care coaching and teach-back methodology.
“Education was a critical factor in protocol success,” Seo said.
Need for Prevention of ED Visits
“Despite advances in treatment, emergency department visits related to treatment side effects are rising by about 11% annually,” Seo said. “Over 70% of these diseases are preventable.”
Seo noted that in 2022, the CMS monitored ED visits and hospital admissions among patients with cancer, to reduce unnecessary acute care use and improve quality of care. In turn, they identified 10 preventable encounters: anemia, nausea, vomiting, dehydration, neutropenia, diarrhea, pain, pneumonia, fever, and sepsis.
“CMS encourages proactive symptom management. Our team saw this as an opportunity to act early and support patients before [symptoms escalate],” Seo said.
Upon evaluation, the team discovered that, in 2022, 39% of patients were sent to the Mount Sinai West ED while on treatment or within 30 days of completion of chemoradiation as a result of diarrhea, pain, nausea/vomiting, dehydration, fever, neutropenia, urinary tract infection, deep vein thrombosis, and altered mental status.
“Many of these issues could have been managed earlier in outpatient care setting. This is clearly highlighting the need for a proactive, multidisciplinary approach to address this,” Seo explained.
Reference
- Seo YJ. Optimizing High-Risk Adult Oncology Care: The HEART Team Protocol© for Reducing ED Visits and Hospital Admissions. Presented at: 50th Annual ONS Congress; April 9-13, 2025; Denver, Colorado.
