Transcript The gap between what we know and what we do is lethal”

An Approach to Improving
NRT Use in the Hospital
• Nicotine Replacement Therapy (NRT) reduces
nicotine withdrawal symptoms and increases
cessation rates
• NRT, along with good instructions, should be
available to in-patients who are current smokers
• BUT DOES THIS HAPPEN?
Vignettes
Three patients admitted to hospital for
illnesses worsened by their current smoking.
1. TIA  carotid endarterectomy
2. PVD  femoral-popliteal bypass graft
anxiety  Psychiatry consult
3. Angina  attempted cardiac catheterization
agitation  LP, CT, Neuro consult
A Health Care Facility Goes Smoke-Free
Objectives
• Provide all patients who use tobacco with
optimal NRT if not contraindicated
• Provide good instruction on the use of NRT to
these patients (AND to physicians and nurses)
• Connect patients who want to quit with
cessation resources in the hospital and in the
community
Continuous Quality Improvement Model
What did we learn?
What next?
Gather data
and observe
Determine causes
Act
Plan
Study
Do
Develop a remedy
Carry out the
change
The PDSA Cycle
Inpatient Protocol for Nicotine Withdrawal
Patients who are current smokers at the time of hospital admission may experience nicotine withdrawal
symptoms during hospitalization. These symptoms can include:
In alliance with
The University of Vermont
Nicotine Withdrawal Order Form
Addressograph Please
Date: _____/_____/_____
Time: __________
Allergies / Substances to be Avoided: ______________________________________________________



craving for nicotine
irritability, frustration or anger
anxiety and restlessness

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
diff iculty concentrating
increased appetite and weight gain
insomnia
Nicotine withdrawal should be considered as a possible cause of agitation. Compared to cigarettes,
nicotine replacement therapy (NRT) provides a safer and more manageable form of nicotine with lower
nicotine blood levels. The toxicity of a cigarette is always greater than NRT .
RELATIVE CONTRAINDICATIONS: Pregnancy, immediate post MI period, life-threatening
arrhythmias, unstable angina, temporal mandibular joint syndrome (gum).
Adverse Effects, Cautions and Instructions on Use of Nicotine Replacement Therapy
Circle one choice below
Type of NRT
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
AS NEEDED NICOTINE REPLACEMENT THERAPY: Recommended as initial therapy in patients
able to use these medications.
All forms of NRT
a) Nicotine Gum 2mg
1 piece q1-2 hr prn x 42 days (patient smokes < 25 cigarettes/day)
b) Nicotine Gum 4mg
1 piece q1-2 hr prn x 42 days (patient smokes > 25 cigarettes/day)



OR
AS NEEDED NICOTINE REPLACEMENT THERAPY: If unable to use gum or nicotine gum trial
failure.
 (in patient’s med drawer)
c) Nicotine Inhaler
4mg (1 cartridge) q2 hr prn x 42 days  (at bedside for self administration)
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Nicotine Gum
Cautions
Concomitant tobacco use
Less than 18 years old
Active coronary artery disease including immediate post MI period,
unstable angina
Life threatening arrhythmias
Pregnancy/nursing
Stopping smoking can increase blood levels of medications (e.g.
Theophylline, clozapine) Check with pharmacy
Adverse Effects
Jaw pain
Dyspepsia, nausea
Caution if TMJ
syndrome or poor
dentition
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OR
TRANSDERMAL PATCH: Recommended if:

Patient unable to use prn medications

Patient prefers continuous therapy to frequent doses of prn medication

Desires to begin cessation treatment
d) Nicotine Patch 21mg
patch apply qd x 42 days (patient smoked > 10 cigarettes a day)
e) Nicotine Patch 14mg
patch apply qd x 42 days (patient smoked < 10 cigarettes a day)
AND
 Patient Education Booklet for Tobacco cessation to patient
Should patient desire to continue smoking cessation treatment upon discharge, prescriptions must be written and
patient instructed to fill the prescriptions with an outpatient pharmacy. Arrange follow-up of smo king cessation
attemp t with primary care physician. Can suggest patient contact Q uit Line at 1-877-YES QUIT
(1-877-937-7848) available fr ee to residents of V ermo nt.
See reverse side for details on adverse effects and instructions on use.
Pager: _________________
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
Nicotine Inhaler
Transdermal
Nicotine Patch
Local irritation in mouth
and throat
Caution if history of
asthma
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Skin sensitivity
Sleep disturbance
(remove at night)
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Instructions
Chew slowly
Once tingling sensation felt, park
gum in between cheek and gum
Chew again when tingling goes
away
No acidic beverages immediately
before or after use
Place plug in two-piece inhaler
Pt. inhales on mouthpiece as
desired. One plug provides 80
inhalations
Use 6 to 16 plugs/day
No acidic beverages immediately
before or after use
Apply to area of skin without hair
If problems with sleep disturbance,
remove at night and replace in
morning
Resources for Tobacco Ce ssation Service s
Signature: _________________________________ __________________
Ve rmon t Q u itl i ne 1-877 YES QUIT (1-877-937-7848)
Printed Name: ________________________________
____________
Patien t Education Booklet for Tobacco C essation available on Nursing Unit
Timeline
Monthly Pharmacy Orders for NRT
FAHC goes
Smoke Free
Cmt
mtg
• Nicotine inhaler
• Standard order form
Chart
Review (Dec)
July
Aug
Sept
2001
Oct
Nov
Dec
Jan
2002
Feb
Monthly NRT Orders
(Pts on NRT/1000 discharges)
140
120
Form
Available
100
80
60
40
20
0
Nov- Dec- Jan- Feb- M ar- Apr- M Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- M ar00 00 01 01 01 01 ay- 01 01 01 01 01 01 01 02 02 02
01
Identification of Tobacco Users
“Are you using any tobacco products currently?”
• Registered as Y (yes)
173 (12%)
• Registered as U (unknown) 319 (22%)
• Registered as N (no)
940 (66%)
1,432 *
* Patients admitted as “IP” type and > 9 yrs old, not on
Psychiatry or Rehab
Chart Review of Current Smokers
• Order form on chart?
0 of 23 ( 0%)
• Any order for NRT?
5 of 18 (28%)
• Tobacco Counseling documented?
1 of 23 ( 4%)
Status of Forms on Floors
• 2 stations
In order form rack near secretary
• 2 stations
In file cabinet next to secretary
• 1 station
In pt information rack in room
away from secretary
• 1 station
In back room in an unmarked stack
of forms on top of a phone book
• 2 stations
Could not find
Chart Reviews After Presentations
20 charts of pts registered as “using Tob” admitted 4/1-4/15
Dec
0%
• Order forms on chart?
0 of 17 ( 0%)
• Any order for NRT?
3 of 10 (30%) 28%
• Any documentation of counseling? 5 of 17 (29%)
4%
• Intervention: standard order forms
• Small improvements observed with intervention
• Adherence significantly higher WHEN standard
order forms were in the chart
• BUT, standard order forms in only 24-27% of
charts
JAMA 2002; 287(10): 1269
NEJM 2001; 345: 965
Intervention
60
% of hospitalizations 50
during which eligible
40
patients were ordered
therapy
30
Control
* p < 0.001
*
*
*
*
20
10
0
Pneumo Vac
Influenza Vac Aspirin at D/C
SQ Heparin
Lessons Learned
• Knowledge
• Systems changes must be combined
with orientations with all staff - not
just with managers
• Positive
Attitudes
• Attitudes about “yet another form”
can be negative
• Systems that • Getting order forms into charts is
difficult; working with unit
enable
secretaries is very important
Acknowledgements
• Leadership
–
–
–
–
Thad Krupka
John Brumsted, MD
Maureen Loeffler
Skip Novak
• FAHC Tobacco Programs
– Evelyn Sikorski
– Bette Diette, RN
– Rachel Smith, MSA
• Order Form
– John Hughes, MD
– Laura Solomon, PhD
– Gary Greiner, Pharm D
• Measurement
–
–
–
–
Mike Nix
Anna Noonan
Lisa Bell
Kathleen Weidman
• Nursing, other Personnel
– Richard Watters
– Shannon Lonergan