Provision of smoking care in NSW hospitals: opportunities for further enhancement

A considerable proportion of hospitalised patients are smokers (19–38%), and of this group, up to two-thirds are nicotine dependent.^1–5 Smoking is banned in all buildings and grounds of the more than 200 NSW Health hospitals, with few exemptions.⁶ Hence, a significant proportion of the hospital population is likely to require assistance to cope with nicotine withdrawal.^7–10 Support for quitting is also important, as 25% of patients report that they are ready to quit smoking and a further 45% are contemplating quitting.^1,9 Despite this, the Australian health-care system appears to have regarded smoking as a lifestyle choice, rather than a medical condition to be treated.⁵

Hospital smoking care can be separated into two aspects. First, smoking care can support patients willing to use the hospital contact to commence a permanent quit attempt.^10,11 Second, for patients unwilling to quit, smoking care can support temporary abstinence during the inpatient stay, provide patients with an opportunity to trial smoking cessation and prompt a future permanent quit attempt.^12,13 Australia currently lacks a national guideline regarding hospital smoking care.⁵ However, in 2002, in recognition of the need for an evidence-based protocol for the treatment of inpatients who are smokers, the NSW Department of Health released the Guide for the Management of Nicotine Dependent Inpatients (the Guide).¹¹ The Guide was sent to Chief Executive Officers of each NSW area health service for distribution to hospitals and training divisions. Although the focus of the Guide was the management of the inpatient stay, it also provided recommendations for smoking-cessation care. The Guide’s recommendations were compatible with several international smoking-cessation care guidelines and are summarised in Box 1.^12–16

At the time of the Guide’s release, a cross-sectional survey of senior managers representing 169 (82%) NSW public hospitals sought to determine the level of smoking care routinely provided to inpatients.¹⁷ Approximately two-thirds of managers (68%) reported most inpatients (80% or more) were informed of the smoke-free site policy. Eighty per cent of managers reported that most inpatients had their smoking status recorded in patient medical records. Only 1 to 8% of respondents reported that most patients were provided nicotine replacement therapy (NRT) or provided discharge-related care (Table 1).

Table 1.  Proportion of NSW public hospitals providing smoking care (n = 169) reported by a survey of senior hospital managers at the time of the release of the Guide for the Management of Nicotine Dependent Inpatients

A more robustly evaluated study investigated levels of smoking care provided to 617 nicotine-dependent patients discharged from four regional hospitals 6 to 18 months after the release of the Guide (unpublished data). Patient telephone surveys and audits of medical notes assessed receipt of 11 smoking care practices. The patient survey demonstrated that although the majority (79%) of patients were asked about their smoking status, only 47% were advised they should quit smoking and 8% were provided with NRT during their stay (Table 2). Discharge-related smoking care was the least provided smoking care element (1 to 7% of patients). The audit of medical notes demonstrated a similar pattern of smoking care delivery.

Table 2.  Proportion of patients provided with smoking care (11 smoking-care practices) in four regional NSW hospitals.^a Results of a survey of nicotine-dependent patients and audits of their medical records following the release of the Guide for the Management of Nicotine Dependent Inpatients

The senior hospital manager survey suggested that levels of smoking-care provision were generally low at the time of the Guide’s release, and the later patient survey and notes audit study demonstrated that the dissemination of the Guide had not achieved high levels of smoking care in the hospitals involved. Both studies suggested that a minority of patients were routinely provided smoking care sufficient to assist with a smoking-cessation attempt or to manage nicotine-withdrawal symptoms. This pattern of high levels of smoking status assessment and lower levels of other elements of smoking-care provision is similar to that found in overseas studies.^18–24 The results suggest that the assessment of smoking status is conducted more as an administrative task, rather than to trigger appropriate care.

Poor levels of smoking care may be a result of the unique hospital setting barriers to the provision of such care.²⁵ Suggested barriers include: a lack of role delineation regarding who should provide each aspect of smoking care; limited opportunities for follow-up; underutilised referral to quit smoking services; and organisational barriers related to hospital systems not being geared toward preventive care.²⁵

The dissemination of the Guide was an important step towards increasing hospital smoking care. However, the Guide’s distribution was through relatively passive means. At the time of the Guide’s release, no support was provided to area health services to aid its adoption. The clinical practice change literature suggests that passive distribution of guidelines is not likely to be effective, and intensive dissemination methods are required to significantly impact on care provision.^26–30 This suggestion is supported by the continuing low levels of smoking-care provision in countries that have previously released smoking-cessation care guidelines.^{18,23,31–36}

Guidance regarding the most effective strategies to increase smoking care potentially comes from several sources, including evidence from literature reviews, evidence from well designed individual studies and comments from experts in the field. Currently, there is no review that specifically examines the effectiveness of strategies designed to increase smoking care in hospitals. Reviews of clinical practice change generally have demonstrated that strategies such as educational outreach visits, reminders, interactive educational meetings and multi-faceted interventions are effective.^26–30,37

Several individual controlled studies have examined the effect of an intervention on levels of hospital smoking-care delivery.^21,38–48 Most studies employed multiple intervention strategies.^{21,38,40–43,45,46,48} The capacity of this evidence base to guide health care providers is restricted because the majority of studies were: undertaken before the release of smoking-care guidelines; conducted in the USA; addressed single units within a hospital or patient groups with a single diagnosis; and reported on a limited range of smoking care practices (few reported on the provision of NRT and post-discharge cessation assistance).^5,21,38–48 Such studies reported variable intervention effectiveness, with the majority finding at least one positive outcome.

Since the Guide’s release, one published Australian study has addressed intervention effectiveness in increasing hospital smoking care.⁴⁸ A randomised controlled trial examined the effect of an intervention on the provision of smoking-cessation care in a pre-surgical clinic of a major teaching hospital in NSW (control n = 86, intervention n = 124 patients). Intervention strategies included:

• identification of opinion leaders

• establishment of local consensus regarding smoking-care delivery

• computerised support systems to prompt, facilitate and provide elements of cessation care

• tailored self-help material for patients

• staff training

• monitoring and feedback of care provision performance.

That study demonstrated large increases (up to 89%) in a range of care elements over the trial’s 6 month duration including NRT provision.⁴⁸

Although there is some deficiency in the evidence base, particularly that regarding hospital-wide smoking care across multiple facilities, commentators have provided guidance for how hospital administrators can increase smoking-care delivery. These recommendations include: strong management support; systematic identification and recording of smoking status; tracking systems to ensure smoking-care follow-up; provision of education and resources to staff; feedback on care delivery performance; identification of health professionals to deliver care; inclusion of nicotine dependence pharmacotherapy on formularies; and smoke-free site compliance.^12,13,49

Subsequent to the release of the Guide, NSW Health has implemented a range of statewide strategies, in accordance with the available evidence and recommendations, to support hospital smoking care provision. These include:

• Quitline fax referral forms. Clinicians can complete a fax referral form to refer a patient to a free call-back service from the NSW Quitline.⁵⁰

• Accredited smoking-cessation competency training. As part of the national Population Health Training Package, competency standards and learning and assessment materials were developed. A 20-hour pilot training course was delivered via videoconference to more than 300 clinicians at 27 sites in 2007.

• Smoke-free policy. The NSW Health’s mandatory ‘Progression of the NSW Health Smoke Free Workplace Policy 2005’ requires all Area Health Services to progress towards smoke-free campuses.

• Research funding. The NSW Health Promotion Demonstration Grants Scheme funded a study to investigate whether a multi-strategic intervention increased hospital-wide smoking-care provision in two regional hospitals compared with matched controls.

• Clinician and patient smoking-cessation resources. Non-hospital specific resources, such as the guideline, Let’s take a moment, quit smoking brief intervention: a guide for all health professionals, and a DVD, Health Smart – Nicotine Replacement Therapy, are available.⁵¹

• Smoking-cessation forums. Non-hospital specific forums have been convened to assist information sharing, dissemination and advocacy of smoking care (e.g. the Tobacco Control Network (TOBNET) and a smoking-cessation listserve).

The NSW Department of Health has planned several additional activities to further enhance smoking care. These include: a recommendation for systematic collection of hospital patient smoking-status data; encouragement of each area health service to collect data on the provision of smoking-cessation care and smoking-cessation outcomes; statewide standing orders for hospital nurse-initiated NRT provision; and integration of referral to the NSW Health Quitline into hospital discharge plans.⁸

It is not yet known if significant improvements in smoking-care delivery have occurred in response to the initiatives outlined above. However, based on available evidence and recommendations, several additional strategies may further enhance the delivery of smoking care. These include:

• Supportive systems to prompt and facilitate smoking care. As demonstrated by the Wolfenden et al. study, strategies that more directly address local systems and procedures of care delivery may produce higher levels of smoking care provision.^48,52–55 The planned initiatives regarding performance monitoring of the recording of smoking status and area health service encouragement to collect data on the provision of smoking care are important. However, to prompt and sustain large scale changes in smoking-care provision, statewide systems including a range of mandated smoking care fields in medical records, linked to automated prompts and Quitline referral, are required.^{12,54,56–58} Existing information technology presents a barrier to the achievement of such a system; however, the planned introduction of electronic medical records may facilitate this in the future.^56,57

• Compliance monitoring and reporting. Currently hospitals are not accountable for the levels of smoking care provided to patients. Increased engagement from hospital leaders may be enhanced if smoking care delivery becomes a reportable requirement for hospital accreditation, similar to US models.^57,59 This strategy is supported by the National Tobacco Strategy 2004–2009, which calls for the identification and treatment of smokers to be a performance indicator for Australian hospitals.⁸ The routine or regular collection of data describing a range of smoking care practices will also help gauge the impact of implemented initiatives. Compliance monitoring would need to address the potential difficulties in routinely collecting smoking-care data across the diverse hospital medical record systems that currently exist across NSW Health. Recently the NSW Hospital manager survey of smoking-care provision was repeated. Although data are not yet available, the results will provide some insight into the impact of the current initiatives on the delivery of smoking care.

• Smoking-cessation training. It is unlikely that all clinicians will undertake the 20-hour accredited training course made available by the NSW Department of Health or self-educate using existing resources. It is also unlikely that adequate numbers of smoking-cessation counsellors will be provided to each NSW hospital. As it is recommended that all clinicians possess the necessary skills to identify, provide brief advice and refer to ongoing cessation assistance, mandatory routine training similar to infection control training could be considered for all clinical staff.⁴⁹

The initiatives and activities undertaken by NSW Health to date have supported the provision of smoking care to hospitalised patients. However, further initiatives may be required to ensure every patient has the opportunity to be offered this care. Continuing strong leadership and systems-level change at the state level will be required if the maxim ‘prevention is everyone’s business’ is to become a reality with regard to the delivery of hospital smoking care.