Transcript Document

Opportunistic Intervention for Smoking Cessation
Among Hospitalized Smoker Patients in TTSH
Leong Y Y, Lathy P, Suvaseni K, Wang M, Jasemine, Mageswari, Norazalin, Chuang S H, Pek W Y
Nursing Service, Pharmacy Department, Respiratory Department
MISSION STATEMENT
At the end of 6 months, 90% of patients in Level 9
wards who accepted the option of intensive
counseling will be provided with bedside quit
smoking counseling within their stay in hospital.
PARETO CHART
Main Concerns
TEAM MEMBERS
Department
Nursing Service
Nursing Service
Level 9
Pharmacy
Respiratory
Ward 9D
Ward 9C
Ward 9B
Ward 9C
Accept bed side counseling
PSA to inform smoking
counselor of bedside
counseling session
Reject counseling
Counselor record details of
counseling session in
continuation notes , smoking
file & database.
PSA to obtain follow-up appt
/ patient informed
Counselor calls patient at 3,
6 & 12 month to give
support & assess quit rate.
COST AND EFFECT DIAGRAM
Patient
Environment
Work load
Process of referral is
busy
Don’t
need
Ignorance
assistance not clear
No time
of heath
Unable to locate
problem
Pt not around
smoking file
Too ill
Communicatio
Timeliness
Shortened LOS
transferred
n barrier
Weekend
“hard core
Procedure
Denial
No
counselor
smokers”
Patients
Rapid discharge
were not
Do it later
given full
Not familiar with
No orientation of program
counseling
procedure
Change of usual routine
Extra charting /additional work
Dr’s not re-enforcing
Forget to flag and
and not assisting with
Poor perception of program
refer New staff
referral
Process not
Resistance to
Least priority in acute setting
standardized
change
Nurse
Operation Issues
The causes of not being able to provide bedside quit
smoking counseling were poor perception, not
familiar with processes, less priority, no counselor
and work process not standardized.
0
Not familiar Less priorityNo counselor
Work
No follow up Timeliness
with
process not by nurse
procedure
standarized
Communicate and
create
awareness
through:
• Journal
Club
Presentation
• Posters
Audit 2
weekly
Standardize
workflow
process
Recognize
staff
commitment
through
incentives
Nominate
smoking
champions
Review
strategies
with staff
Listen to
feedback
Involve all
staff
90% of
patients who
agreed for
counseling will
be counseled
Engage
part time
smoking
cessation
nurse
Recognize
as a KAA
RESULTS
Through multiple PDSA cycles, we saw an
improvement in providing the counseling service
to smokers from 0% to 90%.
Percentage of Patients Counseled and
Quit Rate at 3 & 6 Months
18
100
16
90
80
14
70
12
60
10
50
8
40
6
Percentage
FLOW CHART OF PROCESS
1. Paste patient’s sticky labels into the smoking
cessation record sheet
2. Complete all columns in the record sheet.
3. Paste smoking sticker on IMR.
20
INTERVENTION
Number Referred
• In TTSH, we integrated smoking cessation
intervention into routine care in acute care setting
since 2004. However, only 30% of patients in level 9
receive this intervention from Jan to April 2008.
1. Provide strong and clear advice to quit.
2. Inform the availability of bedside smoking
cessation counseling.
3. Ask patient’s intent to have bedside
counseling session.
4. Provide smoking cessation pamphlets.
40
25.7
10
80
60
P D
A S
• Hospitalization is an ideal “window of opportunity” to
reach smokers at a time when they may be especially
receptive to smoking cessation interventions.
If YES
72.9
47.1
20
Poor
perception
EVIDENCE OF A PROBLEM WORTH SOLVING
• Cigarette smoking is the most prevalent health risk
behaviour. The mortality rate from smoking-related
disease in Singapore is 466 per 100,000 population.
“Do you smoke?” (Yes , No, UA)
61.4
30
91.5
82.9
0
Designation
ADN (Leader)
Senior Nurse Clinician
Unit Nurse Manager
Pharmacist
Consultant
RN
RN
EN
PSA
Nurse/HCA identifies smoker while doing
Nursing Assessment Record for all newly
admitted patient.
40
P D
A S
Name
Leong Yoke Yin
Lathy Prabhakaran
Suvaseni K
Chuang Shen Hui
Pek Wee Yang
Wang Min
Jasemine
Mageswari
Norazalin
100
Percentage
Number of Vote
50
30
4
20
2
10
0
0
Jan Feb Mar
08 08 08
Apr May Jun
08 08
08
Jul
08
Aug Sep Oct Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul08 08 08 08 08 09 09
09 09 09 09
09
Numbers Referred
% Counseled
Quit Rate 3 Month
Quit Rate 6 Month
PROBLEMS ENCOUNTERED
• New nurses were not familiar with the work process.
• Short of dedicated counselors
• Not all clinicians are actively motivating patient to see
the counselor
• Nurses find it difficult to motivate patients to see the
counselor.
STRATEGIES FOR SUSTAINING THE GAINS
• Audit and obtain staff feedback regularly
• Engage clinicians to participate in motivating and
referring patients
• Obtain funding for full-time smoking cessation counselor
to run the program
• Convert manual work process to electronic in future
• Spread across all wards in TTSH and all NHG hospitals
LESSONS LEARNED
• Patient focused care
• Leadership commitment and support from the stake
holders
• Multidisciplinary team work
• Effective communication and listening
• Upfront incentives and recognition
Acknowledgement: CNE Tan Si Ling