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