The Butt Stop Here

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• The Butt Stop Here
• Implementation of a Minimal Contact Smoking
  Cessation Program at an Acute Care Facility in
  Ontario, based on the Ottawa Model
• Dianne Pletz RN BScN
• Tammy Tebbutt RN MN APN

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Smoking Cessation
The single most powerful preventive intervention
in clinical practice.
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Epidemiology

• Tobacco use is the leading preventable cause of
  death and disease killing 16,000 Ontarians each
  year and costing the Ontario healthcare system
  over 1.7 billion dollars annually (Ontario
  Ministry of Health Promotion, 2006).
• We can make a difference, the majority of smokers
  want to quit and are making quit attempts. In
  2006, 47.7 of Canadians made at least one quit
  attempt (CTUMS, 2006).

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Smoke Free Ontario

• The need for integrated and comprehensive tobacco
  cessation programs and services has increased in
  order to support smokers who have been influenced
  by the introduction of the Smoke Free Ontario Act
  on May 31, 2006 which prohibits smoking in
  enclosed workplaces and enclosed public spaces.

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Systematic Approaches to Smoking Cessation

• The importance of smoking cessation cannot be
  overemphasized
• The application of a simple systematic approach
  to the identification and counseling of all
  smoking patients can dramatically improve the
  rates of cessation in virtually any practice
  setting.
• Pipe, A., Reid, R., Quinlan, B. (2007).
  Systematic approaches to smoking cessation.
  Smoking Cessation Rounds, 1(1).

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Smoking cessation is the single most powerful
intervention in clinical practice to offer large
potential benefits which include enhanced quality
and length of life and a reduction in sudden
cardiac death and myocardial infarction. Dr.
Andrew Pipe, Bonnie Quinlan, Dr. Robert Reid
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Objectives

• Review the process of adopting a gold standard
  Minimal Contact Intervention (MCI), Smoking
  Cessation Program (The Ottawa Model) that is
  evidence-based and cost-effective
• Present the projects relevance to the WWLHIN
  Integrated Health Service Plan (IHSP)
• Review the inter-agency collaboration
• Review MCI in the acute care setting
• Review the implementation of the Program
  innovation
• Evaluate successes and challenges, lessons
  learned

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Why adopt a Smoking Cessation Program?

• Safer Health Care Now/Quality Healthcare Network
  Acute Myocardial evidence based interventions
  include smoking cessation
• Collaborative review with three local acute care
  facilities smoking cessation not done well
  (similar to QHN data)
• Local Health Integration Network Service Plan
• Smoke Free Ontario Act
• Risk factor for chronic disease COPD
• National Conference, Canadian Council for Tobacco
  Control information presented and available
• Experts Dr. Andrew Pipe, Dr. Selby, Dr. Paul
  McDonald

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Background Information SaferHealthCareNow

• Smoking Cessation is one of the
• six key interventions for reliable, evidence
  based care for Acute Myocardial Infarction (AMI)
• Smoking cessation counselling
• Serotonin uptake inhibitor
• Nicotine Replacement
• Referral to Cardiac Rehab Program

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Waterloo Wellington Local Health Integration
Network (WWLHIN)
WWLHIN MISSION Inspiring people to improve
quality of life now and in the future
through collaborative relationships and health
system integration.
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WWLHIN Action Plans
Improve Accessibility to Health Services
Improve the Health of the Population
Promote access to appropriate services
Promote healthy Living choices
Improve timeliness of service delivery
Ensure availability of appropriate services
Increase capacity of programs that enhance an
individuals health status
Facilitate coordinated preventative care
services

• Goals
• Improve access to health services as
  reflective of
• community needs
• Reduce wait times for acute care and long
• term care services

• Goals
• Increase availability of programs that enhance an
  individuals health
• Increase community awareness and participation
  in preventative practices and behaviours

WWLHIN MISSION Inspiring people to improve
quality of life now and in the future through
collaborative relationships and health system
integration

Build Community Capacity to Achieve a Sustainable
Health System
Enhance System Effectiveness
Increase Health Human Resources
Enhance system performance management funding
models
Improve coordination integration of services
programs
Enhance user-friendliness of the system
Ensure best practices for operational processes
clinical practice
Build an information technology foundation
Build Partnerships alliances

• Goals
• Ease of use of the health care system
• Increase ability to identify and apply
  well-researched methods and tools to health
  system planning and service delivery

• Goals
• Build partnerships and alliances to enhance
  community capacity
• Measure and report on system wide achievements
  within the health system
• Utilize technology to ensure people have the
  right information in the right place at the right
  time
• Stable healthcare workforce
• Transparent and accountable health system

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Environmental ScanNeeds Assessment

• Smoking prevalence (lack of documentation)
• Policies in existence (dont address NRT)
• Smoking cessation (need for coordinated program)
• Create an institutional implementation plan
  taking into account resources, policies and
  identification of champions and leaders
• (The Ottawa Model Workplan)

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The Process

• St. Marys General hospital in collaboration with
  Grand River Hospital spear-headed a project to
  create a hospital-based program to help
  hospitalized patients quit smoking and stay smoke
  free.
• Goals Develop practice competencies for staff
• Develop a documentation system to
  capture
• tobacco use
• Identify cessation support resources
  for
• patients
• Establish cessation support and
  education for employees, physicians and
  volunteers
• Establish a cost effective, sustainable,
  transferable program

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WWLHIN (boundary) Model

• Based on the Ottawa Model, our hospital-based
• Smoking Cessation Program
• Identifies smokers on admission
• Provides MCI stop-smoking counseling
• Provides medication during hospitalization
• Links the patient back to community resources
• Provides follow-up after discharge from hospital.
  
• Links with The Ottawa Heart Institute and The
  University of Waterloo to evaluate quit attempts
• Addresses employee cessation needs
• The program provides a simple method to intervene
  with smokers as a part of routine care.

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Collaborations
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What did we develop?

• Organizational Policy and Program Outline
• Employee Health menu of services available
• Patient Education Canadian Cancer Society,
  simple quick tips
• Staff Education PowerPoint presentation, DVD,
  Self-learning package
• Preprinted order current Nicotine Replacement
  Therapy included is the patch, will update as
  information becomes available, Zyban is on
  formulary
• Documentation screen and volunteer consent
• Poster summary and advertisements

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Volunteer Program Patient Follow-up

• Collaboration with the University of Waterloo
  Dr. Paul McDonald
• Computer Automated Telephone Interview
• Consent to contact the patient obtained during
  stay
• Contacted post discharge day 30 and day 180
• Program evaluation and smoking behaviour
  questions
• Goal to review quit attempts

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What exactly is Minimal Contact Intervention?
(MCI)

• MCI is brief personal contact to discuss smoking
  with a client, lasting approximately 1-3 minutes
• Any health care professional
• Telephone help lines (brief counselling,
  provision of information, advice, support,
  answers to questions, mail out of materials)

MCI (1-3 minute duration) to all tobacco users,
decreases the proportion of people smoking by
approximately 2 percent per year (RNAO, 2003).
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RNAO Best Practice Guidelines

• Integrating Smoking Cessation into Daily
• Nursing Practice, 2003.
• Recommendation 1 Nurses implement
• minimal smoking cessation intervention
• using the Ask, Advise, Assist, Arrange
• protocol with all clients

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MCI - Steps To Take - 4 As

• ASK about tobacco use with all clients (e.g..
  non-smoker, smoker, ex-smoker) and assess
  readiness to quit
• ADVISE every tobacco user of the importance of
  quitting
• ASSIST by providing minimal intervention
• ARRANGE follow-up or referral

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Ask

• Ask every patient about tobacco use
• Do you use tobacco products of any kind?
• Have you used tobacco products in the last 6
  months?
• Mark all records with tobacco use status
• as a reminder to follow up with each contact
• If the answer is yes, move on to ADVISE

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Advise

• Advise every patient who uses tobacco products to
  quit
• As your nurse, I would strongly advise you to
  quit smoking. It is the single most effective
  thing you can do to improve your health and well
  being
• I am concerned about your smoking (relate to
  health status and risk)
• Ask Are you interested in stopping smoking in
  the next six months?
• Depending on the clients answer, that will
  assist you in determining their readiness to
  quit, or the stage of change they are at

Stages of Change Unaware and unimpressed (not
thinking about quitting) Precontemplation Yes
but..(considering quitting within 6 months)
Contemplation Planning and decision making -
ready to make a try Preparation Doing
it! Action Prochaska, J. DiClemente, C.
(1983). Stages and processes of self-change in
smoking Toward an integrative model of change.
Journal of Consulting and Clinical Psychology,
51, 390-395.
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Assist and Arrange

• Assist
• Assisting clients with smoking cessation can be
  correlated to the Stages of Change model.
• Arrange
• Arrange to follow-up with the client, and/or
  arrange to have them access additional community
  resources. All patients are given information on
  Smokers helpline and available websites.

Every patient who smokes is encouraged to call
Smokers Helpline or access Smokers Helpline
online Every patient who smokes is asked to
consent to be contacted at 30 and 180 days post
discharge to determine how effective they thought
the program was and to ask about their smoking
status.
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RNAO Tobacco Free in 1 to 3
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Pharmacotherapy for smoking cessation
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Project Summary

• A process in place to help hospitalized smokers
  quit and stay smoke-free.
• The hospital-based program identifies smokers on
  admission, provides stop-smoking counseling and
  medication during hospitalization, links the
  patient back to community resources, and provides
  follow-up after discharge from hospital.
• The Ottawa model which was used at SMGH offers a
  simple method to intervene with smokers as part
  of routine care as advocated by RNAO BPG.
• The project is expanding to other acute care
  facilities within the LHIN, and hopefully
  processes will be adopted to include all
  hospitals in the region.

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What Worked Well

• Collaborative effort with ongoing networking and
  expansion to support all agencies
• Beg, borrow and steal shamelessly! PTCC, Canadian
  Cancer Society, The Ottawa Model
• Utilization of the skills, excitement, career
  building opportunities
• Education established by experts TEACH Program

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What needs more work

• Ongoing monitoring, review of documentation,
  constant feedback
• Ongoing enforcement of the by-law patients who
  choose to continue to smoke and their families
• Development of a Smoking Cessation Advisory
  Committee for the WWLHIN currently under
  development

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What we would suggest

• Late Career Initiative Program for Registered
  Nurses over the age of 55 excellent opportunity
  for staff to get involved
• Committed Committee!!? no one person can do this
  alone, Champions for each area who can help staff
  determine how best to use the program in their
  area and be responsible for providing feedback

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Evaluation

• Baseline smoking prevalence The Ottawa Heart
  Institute
• Quit attempts The University of Waterloo
• Documentation review
• WWLHIN advisory committee

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Systematic Approaches to Smoking Cessation
No other clinical intervention can produce a
reduction in predictable morbidity and premature
mortality that can equal smoking cessation.

• Smoking cessation is where the greatest payoff
  can be realized.
• Pipe, A., Reid, R., Quinlan, B. (2007).
  Systematic approaches to smoking cessation.
  Smoking Cessation Rounds, 1(1).

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Smoking Cessation
The single most powerful preventive intervention
in clinical practice.
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