The work described here was presented at the Pharmacy Together 2019 conference.
Smoking is a risky, costly behaviour. Cessation as ‘treatment’ can lead to lower drug doses, fewer complications and re-admissions, higher survival rates, better wound healing and decreased infections.
However, persuading smokers to abstain is challenging. Nearly half a million smokers are admitted to secondary care every year. Acute admissions units (AMUs) are high patient turnover areas, presenting an ideal opportunity to treat and provide behavioural support to smokers. We sought to improve the smoking cessation model in the acute admissions unit at University College London Hospital.
We found that one part-time smoking cessation advisor was in post to support cessation. Local data showed low rates of nicotine replacement therapy prescribing and community cessation referrals, indicating that in-patients were receiving sub-optimal care and smoking CQUIN targets were unmet.
Root cause analysis and data review mainly identified the ‘lone professional’ approach to be ineffective, and that staff feedback identified a lack of awareness of good cessation practice.
A quality improvement approach was therefore adopted to develop a more collective cessation model. Proposals included:
- Joint pharmacy/smoking advisor working
- Further stakeholder engagement
- Identification of smoking champions
- Improved training to increase referrals and prescribing
- Health promotion with other AMU disciplines
From January 2019, pharmacist involvement in the project led to a structured Plan-Do-Study-Act cycle to test the interventions by:
- Establishing champions promoting cessation (January)
- Launching a newly developed visual prescribing guide (February)
- Monthly training (optimal prescription and administration of NRT products, ‘Very Brief Advice’)
- Monthly project review (pharmacist and smoking advisor)
Our objective was to achieve a 25 percent increase in the number of cessation referrals and NRT prescriptions within three months.
Electronic in-patient prescriptions, smoking referrals and training feedback forms were collated and reviewed to monitor progress. By March 2019 the new model had resulted in a 325 percent increase in smoking referrals. The number of prescriptions created, and patients prescribed NRT had increased by over 200 percent – a marked improvement from 2018 data.
The number of prescriptions created, and patients prescribed NRT increased by over 200 percent
Cessation prescribing and referral rates increased, contributing to patient wellbeing and achieving CQUIN targets. However, the quality was not assessed, and we were unable to identify which single intervention caused the effect. Doctors and pharmacy staff reported increased empowerment to discuss cessation during consultations, initiate NRT and make onward referrals, all of which may have increased cessation rates.
A multi-disciplinary quality improvement approach is key to enable patients to quit smoking. Through smoking champions, frequent training and more collaborative working, staff can support patients to be healthier.
The project was undertaken pre-implementation of organisation wide electronic health records which presented challenges for modifying the approach and future improvement. During the study, it became apparent that certain cohorts may require tailored treatment or specialist input. Ongoing training and surveillance, engagement of outstanding disciplines and roll-out to other wards is planned. Our project follows national guidance, encouraging patients to quit smoking, demonstrating a model that is effective in acute care.
Dr Naseem Mushtaq, University College Hospital, London.
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.