San Francisco General Hospital and

Trauma Center

COMMITTED TO A

TOBACCO FREE COMMUNITY

OUR CHARGE

To improve long-term tobacco cessation and clinical outcomes in high-risk patients following the transition from hospital to home.

SFGH BECOMES A SMOKE FREE CAMPUS IN 2008

Implemented and enforced policy that prohibited

smoking anywhere on the SFGH campus

(includes buildings,

grounds, parking lots and gardens).

Tobacco Free Community Initiative

Mission To unite all (from front line staff to physicians, nurses,

social workers, pharmacists, educators, IT, patients and their families) with the common goal of improving the health and well-being of tobacco users through expanded counseling sessions and wellness activities, improved access to pharmacotherapy and better communication between primary care providers, smoking cessation consultants, and underserved communities.

A COMPREHENSIVE APPROACH

EDUCATION/RESOURCES

POLICIES/COMMUNICATION OUTPATIENT/INPATIENT TREATMENT SERVICES

TOBACCO FREE

TOBACCO FREE COMMUNITY INITIATIVE

YEAR 1: Strategic Plan GOAL: advance tobacco cessation strategies for our hospitalized patients by upgrading existing guidelines, protocols, and staff education and training.

• STRATEGY 1- Ensure an accurate tobacco user identification system is established (inpatient/outpatient) • STRATEGY 2- Provide adequate training, resources, and feedback to ensure that healthcare providers consistently deliver effective treatments and appropriate referral • STRATEGY 3- Dedicate staff to provide tobacco cessation assessment, counseling and tobacco dependence treatment • STRATEGY 4- Promote hospital policies and outreach efforts that support and provide tobacco dependence services • STRATEGY 5- Ensure tobacco dependence treatments (both counseling and medication) identified as effective are provided in a timely manner for all patients identified as tobacco users.

Inpatient Tobacco Treatment Program

• Formed August 2011 • Membership includes

• 3 Inpatient Tobacco Treatment (ITT) Coordinators

• Staff from Inpatient nursing units, outpatient clinics, ED, wellness services, social services, BHC, RT, Medicine and Pharmacy and staff from the DPH Tobacco Free Project.

• Dedicated RN champions from inpatient nursing units

INPATIENT TOBACCO TREATMENT COORINDATORS

Goals include (1) identifying current smokers, (2) ensuring inpatients receive nicotine replacement therapy (NRT), assessing readiness to quit, and providing education, counseling and appropriate outpatient smoking cessation program referral at discharge for those who are ready to quit.

To reach trained coordinators for inpatient bedside

cessation counseling call 206-5861

Jo Anne Roy Oscar Cardenas Soledad Aquino

Inpatient Staff Training Program

Goal: ◦ Provide staff training to 100 nursing staff on nicotine

dependence and the SFGH inpatient tobacco assessment, treatment, referral protocol and procedures.

Process: ◦ Trained staff attending Med Surg Annual Updates. ◦ Included a baseline knowledge pretest.

By July 31,2012 ◦ 96 staff participated in training.

Next Steps ◦ Train night shift staff. ◦ Target more specialized training to key clinical staff

Jan 2012 the ITT Coordinator phone line was activated. Tobacco Cessation Staff Pocket Cards distributed

Hosted Annual Outreach Events

Patient enters Hospital & assessed for Tobacco Use at either

Emergency Department

Admission Process

Tobacco assessment completed by assigned nurse on the Unit -Documented in LCR

SMOKER

NRT ordered and started by PTs assigned RN

NON SMOKER

No Action Needed

(1) ITTC visits PT

(2) Assesses PT for NRT/ completes PI data tool

(3) Provides bedside counseling

(4) Prompts orders for NRT via provider with IP Pharmacy

OR

*ITTC schedules follow up with PT as appropriate

*Ensures PT is referred to appropriate OP services

*Ensures new patient packets and discharge packets include resources/ 1-800 No-BUTT

*Motivated patient receives direct referral to SFGH SSP (via e-referral, email or direct contact)

IP Intervention Completed

OP takes over

If NRT NOT Started/ PT PRIORITIZED

In Patient Flow Chart for Tobacco Assessment and Nicotine Withdrawal 2011-12

SMOKER

If PT high risk (core measures) PT PRIORITIZED

Inpatient Tobacco Treatment Coordinator Process Map

475 468

502

619 628 648

131

57

118

386

465 445

0 4 3

46 47 50

9 25

68

135 154

237

0

100

200

300

400

500

600

700

Q1 2011 (N=733)

Q2 2011 (N=753)

Q3 2011 (N=778)

Q4 2011 (N=619)

Q1 2012 (N=680)

Q2 2012 (N=648)

ITT Coordinator (s) Visits Total Pt Identified for Assessment

Pt seen by ITT Coordinator

Pt with Core Measure DX

Pt with Nicotine Patch Initial Visit

*From Q1-Q3 2011, smoking status was captured as a Yes/No field. For Q4 2011 and forward, patients are categorized as one of the following: Current every day smoker, Current some day smoker, Former smoker, Never smoker, Smoker, current status unknown, Unknown if ever smoked. The updated data collection process is designed to only capture current smokers. Total patients identified for assessment are limited to units 5A , 5C and 5D for Q1-3 in 2011AND 5A, 5C, 5D, 4B, 4D & 6A moving forward.

(30%)

(12%)

(24%)

(62%)

(74%) (69%)

NEW ITT program Started

733 753

778

619

680 648

320

416 391 387

467 471

118 103

120 133

95 115

0

100

200

300

400

500

600

700

800

900

Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012

Identified Smokers and Nicotine Replacement Therapy (NRT)

Total smokers ADB

Total NRT during hospitalization

Total NRT at discharge

*From Q1 - Q3 2011, smoking status was captured as a Yes/No field. For Q4 2011 and forward, patients are now categorized as one of the following: Current every day smoker, Current some day smoker, Former smoker, Never smoker, Smoker, current status unknown, Unknown if ever smoked. The updated data collection process is designed to only capture current smokers.

44%

55% 50% 63%

67% 73%

Outpatient Programs Include

DPH Stop Smoking Program SFGH Community Wellness Program ◦ Integrate healthy lifestyle services and resources with tobacco treatment services such as nutrition, physical activity, stress management, health education and other healthy lifestyle resources.

Tobacco Cessation Hotlines

Cumulative Data

Total Referrals: IP to OP service

N= 73 Gender

Male 53 Female 20

Connections made 47% of patients were unreachable This number includes patients 1. Without a phone. 2. Where their phone was

disconnected. 3. Where 3 calls/ and or emails

were attempted with no response, and

4. Those pts. Who reside in Residential Care (RC) facility/ Left message/ no phone access or HIPAA concerns cited by RC sites

Inpatient Transition to Outpatient Cessation Services upon Discharge

Method 1: Calculated based on all referrals received (N= 73) • 21% of patients reported they quit tobacco at some stage of the

process • 4% reported reduction in consumption by 6/30/12 _________________________________________________ Method 2: Calculated based on contact made with patients (N= 39) Patients were reached and did not refuse services 38% Quit 4% Reduced their tobacco consumption _________________________________________________ Results Include:

◦ Sustained quitting after hospitalization ◦ Quit through 1:1 counseling at Community Wellness Center ◦ Quit via group based intervention at SFGH

Outcomes

Accomplished 2011-12 GOALS 1. Assessed accuracy & process of our inpatient Tobacco User Identification System (RN Admission Database)- ongoing 2. Developed a performance improvement data tool to track and monitor program improvements (expanded indicators tracked) 3. Developed and implemented staff trainings around nicotine replacement therapy, and tobacco cessation, patient education and counseling. 4. Hired and trained Tobacco Treatment Coordinators to provide inpatient tobacco cessation assessments and counseling for hospitalized patients identified as tobacco users

Accomplished 2011-12 GOALS(cont.)

5. Established criteria for prioritizing ITT services for identified tobacco users admitted to hospital. 6. Increased the ordering of nicotine replacement therapy (NRT) to identified tobacco users in a timely manner. 7. Improved warm hand off from discharge to home through appropriate referrals to the DPH Tobacco Free Project and the SFGH Community Wellness Program.

Living Well Tobacco Counseling & Group Relapse Services at Community Wellness Center

◦ Holistic approach, complimentary medicine discussion and activities, demonstrations, and creative topics to assist people in sustaining a tobacco-free life. ◦ Seasoned counselors are

trained and experienced cessation providers ◦ Counselors are former smokers

with many years living as a non-smoker ◦ Process and outcome data

being collected

21

One on One Counseling Services

Description and Staffing: One to One Counseling available for 8 hours per

week in English and Spanish at Wellness Center. 2 smoking cessation counselors provide service. Procedures: Referral Source: E-referral, self referred, the ITT,

and walk – ins. Counselors made 3 attempts via telephone to

contact each patient referred.

One on One Counseling Outcome

192 patients who used tobacco were referred to this service. Contact made with 105 patients (55%) who scheduled an

appointment between March 1 and August 1. Seventy–five (75) patients (72%) attended at least 1

appointment. Eighteen (18) people attended two scheduled appointments 9 people attended 3 appointments. 4 people who attended a 4th appointment. High no-show rate Fifteen (15) people quit using tobacco (20%) quit rate (N=75) .

MR. P’s Wellness Story SMOKE FREE 7 MONTHS!!

Mr. P was visited by Soledad (ITT coordinator) when hospitalized earlier this year for the second time for viral meningitis. He was very sick and he told us, “I was at deaths door.” Mr. P said he was ready to quit, had tried numerous times in the past, but had never been able to stay quit. He told us if Soledad hadn't discussed with him all the resources available to help him quit, he probably would have gone right back to smoking when he was discharged and received his 2 weeks worth of NRT. Mr P. credits the entire process with saving his life including his one to one visit by Soledad on through to his contact with the outpatient program , attending the classes, doing the behavior based activities, and keeping his quit date.

Next Steps Assess future educational/training needs for ITT coordinators

and key program personnel based on data Assess accuracy of RN admission database and identify

areas for improvement of tobacco use for every patient admitted to the medical, surgical, and critical care units.

Expand criteria to prioritize high risk individuals (i.e. with asthma and COPD) who require bedside counseling.

Standardize protocol for consistent use of prescription

nicotine replacement therapy, bupropion, and varenicline (provide training for providers).

Ensure all patient education packets provided in ED,

admission, discharge and by ITT coordinators include updated, relevant tobacco cessation resources, which includes behavioral counseling.

Next steps Work with champion physicians and pharmacy to

develop standardized protocols to ensure that patient receives supply of nicotine patches upon discharge.

Ensure patient is plugged into primary care at

discharge through e-referral to outpatient smoking cessation program (with follow up plan).

Implement electronic documentation of

performance measures for individual counseling consistent with the performance measures used by group programs.

Increase outpatient clinic smoking cessation capacity through programs offered through the community wellness program.