The Road to an Evidence-Based In-Patient Tobacco Cessation Program at Georgetown University Hospital

Mary Beth Ginn, RN, BSN, CCRN Georgetown University School of Nursing and Health Studies

WHY Offer an In-Patient Tobacco Cessation

Program

THE COSTS Tobacco use costs $53$73 billion per year in medical bills

(Morrell, Cohen, Bacchi &West, 2005)

WHY Offer an In-Patient Tobacco Cessation

Program
THE DEATHS 440,000 deaths per year 32% are attributable to smoking-related cardiovascular disease 28% are attributable to smoking-related lung cancer 23% to respiratory diseases
(Centers for Disease Control, 2005)

WHY Offer an In-Patient Tobacco Cessation

Program
Studies have shown that hospitalization with a smoking-related illness increases the likelihood that a patient will be receptive to health messages regarding smoking cessation

(Hennrikus et al, 2005).

In-patient smoking cessation interventions can increase quit rates to as high as 74%

(Ong et al, 2005).

WHY? The 2004 CMS and JCAHO Mandates Say to DO IT

Community Acquired PNA Core Measures
Initial antibiotic within 4 hours of arrival O2 assessment Pneumococcal vaccine assessment Blood culture prior to first antibiotic Appropriate initial antibiotic selection Influenza vaccine Adult smoking cessation/counselling advice

Heart Failure Core Measures

Left-ventricular assessment ACE-I or ARB Discharge instructions Adult smoking cessation/counselling advice

Acute MI Core Measures

ASA at arrival and prescribed at discharge ACE-I and ARB Beta Blocker on admission and prescribed at discharge Thrombolytic agent within 30minutes of admission PCI within 120 minutes of admission Adult smoking cessation/counselling advice

Adapted from CMS HQA Hospital Quality Measures: 2004-2007

Keys to a Successful Evidence-Based In-Patient Tobacco Cessation Program

In-patient advice, education and behavioral counseling Nicotine Replacement Therapy Post-discharge follow-up
(Wolfenden, Campbell, Walsh & Wiggers, 2003)

Georgetown University Hospitals (GUH) Tobacco Cessation Performance Measures

% of Identified Smokers Given Smoking Cessation Advice

120 % Given Smoking Cessation Advice 100 80 60 40 20 0 Q3/03 Q4/03 Q1/04 Q2/04 Q3/04 Q4/04 Q1/05 Q2/05 Quarter CAP CHF

AMI Omitted R/T WHC Referral

Georgetown University Hospitals (GUH) Tobacco Cessation Performance Measures

% of PNA Patients Advised at GUH

43%

GUH RESULTS = BELOW NATIONAL BENCHMARK By 80%

Georgetown University Hospitals (GUH) Tobacco Cessation Performance Measures

% of HF Patients Advised at GUH

50%

GUH RESULTS = BELOW NATIONAL BENCHMARK By 80%

Bridging the Gap for Quality Improvement

Ammendment of nursing admission database to assess smoking status as well as readiness to quit. Solution Includes prompt to initiate smoking cessation orders on all identified smokers and those who have recently quit. Creation of tobacco cessation orders to be completed for all identified smokers. Includes medical and nursing orders for NRT, education and outpatient counseling referral

Key Factors Influencing Poor Performance: Under-assessment of smoking status

Poor documentation

Solution

Physician/Nurse knowledge gaps

Solution

Education initiated with nursing and medical staff through multiple channels including: nurse managers, clinical educators, chief residents, pulmonary and cardiology fellows, hospitalists

Key Players to Champion the GUH Tobacco Cessation Protocol

Donna Sanford, RN

Dr ODonnell and Dr OBrien, Pulmonary

Gail Thurkauf, RN, Case Manager

Chief Resident George Kluchnik, MD MultiDisciplinary Team Public Relations

Geoff Cox, Pharm D

Brendan Furlong, MD, ER

Nurse Managers

Hospital Practice Council

Richard Morrissey, MD, Cardiology

The Roll Out of the Hospital-wide Tobacco Cessation Protocol

April

May

June

July

Data collection Idea-generating meetings with nursing, medical and pharmacy staff Creation/revision of protocol

Pharmacy and Therapeutics Committee Approval Patient Care Services/Nursing Approval Forms Committee process begins Revisions to admission database

Hospital Practice Council creation and approval of standard of care for tobacco cessation Selection of patient education materials

Forms Committee Approval of Tobacco Orders! Hospital-wide announcements introducing protocol Tobacco protocol up and running effective JULY 15th!

Hospital-wide Publicity and Education about the Tobacco Cessation Protocol

Physician Training:
New Resident Orientation In-services with cardiology and pulmonary fellows Incorporation of TCOs in monthly ward orientation for residents Medical Bulletin announcement Individual in-services with attending physicians as appropriate

Nurse Training:
Announcement/ presentation at PCS managers meeting In-services with nursing units Creation and distribution of nursing self-learning packet Involvement of Hospital Practice Council to create nursing standard of care for tobacco cessation

Announcement was also made through the hospital-wide Monday Memo

Reading the Sign Posts Along the Road

Victories:

Strong hospital support of nurse-driven protocols Tremendous support from nursing staff, pharmacy director Geoff Cox and chief of cardiology Dr Richard Morrissey Research support and JCAHO teeth facilitated smooth approval process

Reading the Sign Posts Along the Road

Challenges:

Patient Care ALWAYS the PRIORITY Delays associated with summer vacations, edits to protocol Politics associated with revising hospital forms and asking nursing to undertake more initiatives

Next Steps
Three month postimplementation review Amendment of the physician admission intake packet to include assessment of readiness to quit and a prompt to initiate the tobacco cessation protocol. Presentation of protocol and tobacco cessation counseling tactics during Grand Rounds.

Next Steps
The Tobacco Cessation Network: Television Channel Respiratory Therapy Involvement On-Going Intensive Physician and Nursing Training In-Patient Group Counseling and Post-discharge Follow-up

A Special Thanks.
Janie Heath- for her guidance and for being the brainchild of this project!! Dr Geoff Cox- for his enthusiasm and support of nursing Dr Richard Morrissey- for his support Dr Sharon OBrien and Dr Anne ODonnell- for their editorial support Gail Thurkauf and Donna Sanford- my data gurus! The P&T and Forms Committee- there would not be a protocol without your approval Cristie Namata- to whom I am passing the tobacco torch- good luck!