It’s time we made smoking
history.
6. A Case Example
New England Medical Center
Cathy Milch, MD
Co-Presenters: Amy Simon, MD
Susan Campbell, PhD
Tufts-New England Medical Center
Tobacco Cessation Initiative
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Tobacco Cessation Initiative (TCI)
Team Members
• Project Manager: Susan Campbell PhD, RN, Quality Improvement
• Co-Chair: Amy Simon MD, Director, Asthma Center
• Co-Chair: Catherine Milch MD, Internist, Dept. of Medicine
• Director of Nursing: Pat Noga RN, BSN, MBA, Clinical Director of Nursing and Patient Care Services
• Nursing Education: Anita Huse RN, MSN, Ed.D
• Consultant: John Nickrosz BA, MA, Interpreter Services Consultant
• Consultant: Davidson Hamer MD, Chair, CAP
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Outline: Cessation Initiative (TCI)
Evolution of Initiative Goals Planning and Development Implementation and Roll-out Current Status Estimated Benefit Future Direction Lessons Learned
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Evolution of the TCI
Outgrowth of JCAHO Core Measures (CAP, CHF) and Medicaid C.C. Quality Improvement projects:
Required screening for smoking Outcome measure: % provision cessation
counseling
• Eligible patients located throughout 2 institutions
•Core measures not being met: no data available for reporting
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Evolution of the TCI
ProblemHow to identify smokers to measure provision of cessation counseling for
eligible patients?
Solution Broad-based effort needed: Expand
initiative throughout hospital
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Evolution of the TCI
• Clinicians: All patients must benefit • Hospital leadership: Screening not enough,
must provide cessation assistance• QI team: Assess for all types of tobacco use
Tapped latent feelings“Our long-overdue responsibility”
From Focused QI Project to Hospital-wide Initiative: How did it happen?
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Planning and Development
Occurred in stages driven by:
• Desire to implement evidence-based “best practice”
• Institutional capabilities and available resources
• New ideas • Solutions to barriers
“Think big, start small”
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Planning and Development: Initial Steps
Secured executive hospital leadership support (medical and nursing)
Formed multi-disciplinary team Included leaders in JCAHO and QI projects Physician leaders Nursing and education leaders Interpreter Services
Identified unit-based nurse champions
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Planning and Development:Goals
• Assess every patient for tobacco use
• Document tobacco use status
• Advise tobacco users to quit
• Offer in-hospital cessation assistance
• Sustain motivation to quit after discharge
Make it easy and acceptable for
patients and clinicians!
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Planning and Development: How to Achieve Goals?
Screening for tobacco use• To be done for every patient on
admission/ outpatient visit• Developed standardized form and
protocol (the Tobacco Use Questionnaire)
• Modified for inpatient and outpatient use • Translated into 8 foreign languages
TOBACCO USE QUESTIONNAIRE
Smoking harms the heart, lungs, and the blood. Heart attack, lung disease, and cancer are more common in people who smoke. Heart and lung disease are made worse by smoking. Use of other tobacco products can also cause cancer. People in the home or community can be harmed by breathing the smoke of others. No one should smoke. Quitting smoking and the use of other tobacco products can improve health.
******************************************************************************************
1a) Have you smoked cigarettes in the last twelve months? Yes No 1b) Have you used other tobacco products in the last twelve months? Yes Cigars Pipe Chewing tobacco Snuff No If “yes” to question 1a or 1b, continue questionnaire: 2. Have you tried to stop? Yes No 3. Would you like to receive some information about health benefits of stopping tobacco use, as well as ways to stop? Yes No 4. Do you want to speak to your doctor or nurse about ways to quit or problems you had with quitting? Yes No 5. There is a free program that can help you stop using tobacco. It involves telephone counseling. Would you like to participate? Yes No
CLINICIAN SECTION: Cessation Strategies Patient will try: NRT Wellbutrin Counseling Other ________________________ none __________________________________ _______Clinician/Interpreter Signature Date__________________________________Name and Title Form # (Sept, 03 Outpatient) 2003 New England Medical Center Hospitals, Inc.; All Rights Reserved.
COPY 1 – MEDICAL RECORD COPY2 - PATIENT
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Planning and Development: How to Achieve Goals?
Cessation Assistance TUQ provides education at screening TUQ prompts patients to consider
assistance Patient educational materials available
in each unit Monthly CE sessions for RNS and MDs Referral to free outpatient cessation
service: Quitworks
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Planning and Development: Incorporation of Quitworks
Modification of Quitworks enrollment form:
• Enhance ease of use for hospital staff• Identify referring hospital• Identify patient’s PCP or Specialist • Enable Quitworks staff to follow-up with PCP directly, not hospital
• Ensure HIPAA compliance
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Implementation: Steps
• Developed protocol for use of forms• Trained Tobacco Treatment Specialist • Provided specialized training for Interpreters • Developed and held monthly CE sessions• Recruited additional clinical leaders • Piloted forms and process on 2 nursing units • Created institutional website
REVISED, REVISED, REVISED
ADMITTING RN GIVES TUQ TO PATIENT AT INTAKE
SMOKER NON-SMOKER
EDUCATION PROVIDEDRN REVIEWS DESIRE TO QUIT,
RECEIVE CESSATION HELP, AND/OR QUITWORKS REFERRAL
EDUCATION PROVIDEDTUQ COMPLETE
AND FILED
TUQ FILED PROVIDE BROCHURES, NRT,QUITWORKS REFERRAL
NO YES
INTERPRETER
MD
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Implementation: Process Problems and Solutions
Problem: Adoption of new forms Unit-level differences
Solutions: One page simplified protocol Unit champions to teach and encourage Elicit feedback to identify barriers Modify for local adaptation Regular communication and interaction
with nursing leadership and staff
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Implementation: Process Problems and Solutions
Problem: Patient too sick Solution:
Screen for tobacco use/cessation prior to discharge
Involve discharge planning
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Implementation: Process Problems and Solutions, cont.
Problem: How to inform physician?Solution:
Prominent placement/flag TUQ in chart
Primary nurse to communicate with MD
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Implementation: Process Problems and Solutions
Problem: No budget
Solutions: Rely on unpaid efforts of Core Team and
Nursing Request limited funds from institution Solicit pharmaceutical companies Involve Development Office
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Implementation: Process Problems and Solutions
Problem: How to maintain momentum?
Solutions: Dedicated volunteer team Elicit support from executive leadership Regular meetings and communication Recruit new members Publicity, outreach, new approaches Form external
collaborations/partnerships
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Implementation: Pharmacological Therapy Issues
• Not all products on hospital formulary
• Limited member benefits for NRT
• NRT started during inpatient stay may not
be covered after discharge
• Medicaid does not cover NRT
• In-hospital NRT use: Data indicate safety,
but clinician doubt high and Rx low
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Implementation: Extension to Outpatient Units
More decentralized, so requires: Buy-in from division chiefs and clinic
managers Emphasis on cost-savings/work
reduction Clinic-individualized process Easy access to forms (institutional
intranet)
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Current Status
Pilot roll-out: 50% of smokers accepted Quitworks referral
TUQ in use in 5 inpatient units All forms on website CE sessions (% impact):
RNs: 10% Attendings: 7% (PCPs: 80%) Medical residents: 65%
Quitworks referrals (6/2 – 10/31): 57
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Characteristics of T-NEMC Patients Accepting Quitworks ReferralN=22
Female: 45% Age, mean (range):~50 (19-77) Smoking Status: 18% quit Stage of Change (only non-quitters)
Contemplation: 39% Preparation: 61%
Services Accepted Info packet: 100% Local tx program: 72% ACS warm transfer completed: 33% Q-tips: 28%
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Estimated Benefit of TCI
16,000 inpatients/yr x 5 min/ TUQ = 1,333 additional RN hrs. (0.6FTE)
4,000/yr inpatient smokers (25%) x 10 min/counseling = 667 additional RN hrs.
If 50% enroll Quitworks* = 2,000/yr. 200 additional pts/year will quit200 additional pts/year will quit (10%**) 1,333 + 667 RN hrs / 200 quitters =
10 RN hrs / quitter = “A Shift to Quit” *Based on pilot data
**Double baseline rate
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Estimated Benefit of TCI
33% of smokers die prematurely due to tobacco
Projected estimated future benefit: - - 6767 (33%x200) (33%x200) T-NEMC patients/yr will notpatients/yr will not diedie premature smoking related deaths! - Estimated cost: 2,000 additional RN hours
Estimated Cost/Benefit: 30 RN hours per life saved
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Future Plans
• Hospital Tobacco Cessation policy
• Institutional Cessation Program
• Employee Health screening and cessation program
• Employee non-tobacco-user benefit
• Community Outreach/Cessation Programs
• Internal collaborations (Nephrology)
• External grant funding
• External collaborations and partnerships
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T-NEMC Lessons Learned
Secure executive leadership support early Find dedicated personnel to lead and
implement To date: ~1,000 hrs. unpaid + 600 hrs. paid
Recruit new volunteers continuously Use personal connections Search multiple funding sources: community
initiatives, pharmaceutical, etc. Survey, monitor, revise, revise, compromise
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Bottom Line
Realize it requires a great deal of effort by a few but the rewards are enormous: Patient health Clinician fulfillment Institutional reputation Community benefit
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Thank You
The Tufts-NEMC Tobacco Cessation
Initiative Team