Audit Number: 5802 Smoking Audit V11 06/03/2018

Local Clinical Audit: Smoking Cessation in Secondary Care

Topic: Smoking cessation provision in respiratory wards at Southampton General Hospital Audit goals and objectives: The primary aim of the audit will be to identify smoking prevalence in a respiratory inpatient population and evaluate smoking cessation advice, prescriptions for smoking cessation products, and referrals to local smoking cessation services for this population. Secondary aims will assess staff training levels and stock of smoking cessation products in the clinical areas, the main hospital pharmacy and onsite independent pharmacist. Staff involved: Dr Zoe Pond Consultant in Respiratory Medicine Dr Lisa Ballard CPsychol Post-Doctoral Research Fellow and Health Psychologist Emma Ray BSc MRes Research Fellow and Respiratory Nurse Specialist Nisha Sharma BSc MSc Behaviour Change Specialist and Trainee Health Psychologist Helen Kruk MSc CLAHRC Respiratory Nurse Specialist and Project Manager Kate Gillett BSc Research Fellow and Respiratory Nurse Specialist

1. Background and rational: Smoking is the most preventable cause of premature death in the United Kingdom and is responsible for the deaths of approximately 96,000 people every year (1). Smokers have a higher risk of developing chronic diseases including heart disease, lung disease and a range of cancers (1). The inhalation of tobacco smoke is directly linked to the development of Chronic Obstructive Pulmonary Disease (COPD) in susceptible individuals. COPD is a disease of the lungs that causes irreversible damage to the airways leading to persistent symptoms and poor quality of life. The prognosis for these patients is poor in the longer term if they continue to smoke (2). Stopping smoking has the potential to reduce the risk of further lung function decline and may improve the effectiveness of treatment in patients with COPD (2). Findings from economic analyses from the UK and elsewhere confirm that smoking cessation interventions, including pharmacotherapy, are among the most cost-effective health care interventions available, leading to fewer bed days, reduced hospital readmission rates and increased survival rates (3). The benefits of intensive behavioral support programmes (see appendix 1) that begin in hospital, carry on well after discharge and promote smoking cessation regardless of diagnosis (4). Health care settings provide a unique opportunity for NHS staff to broach smoking cessation with their patients and the offer them support to quit (5). However, to be able to sensitively discuss these issues and provide support for stopping smoking health care workers require training and education. In 2009/2010 an audit of smoking cessation provision was conducted on the Acute Medical Unit (AMU) at Southampton General Hospital (6). 185 patients were included in the audit which found that only 30% of smokers were provided with smoking cessation advice and only 7% referred to the Quitters service. Moreover, the prevalence of smokers on the unit

Audit Number: 5802 Smoking Audit V11 06/03/2018

was higher (28%) compared to that of the national average (21%). The audit concluded that there was a need to educate staff and increase awareness of smoking cessation advice, referrals and nicotine replacement therapy (NRT) to achieve the targets set by NICE. Current NICE Guidance (3) advises that every secondary care patient should be:

Asked if they smoke

Informed that the secondary care environment is smokefree

Advised to stop smoking completely

Assisted in receiving licenced nicotine containing products or other pharmacotherapies immediately

Assisted in receiving intensive behavioural support to stop smoking and, if the patient agrees, referral to the local NHS Stop Smoking Service.

Expected outcomes of the audit This audit will help inform to what extent the Hospital Trust are meeting the NICE guidance and will make comparisons to the previous smoking cessation audit possible. If any shortcomings are identified, the Hospital Trust can work directly with the audit team to put a plan in of action place. Improvements may results in a reduction of direct and indirect health care costs in terms of fewer bed days, fewer unplanned, quicker recovery for patients, less complications, lower rates of surgical site infections for example. The Hospital Trust is currently a ‘core’ smokefree site, and therefore the audit will reflect this position. A ‘core’ smokefree site means that smoking zones are available on the perimeter of the hospital boundary outside the smokefree core. The only smoking on site is permitted in the designated limited smoking shelters that comply with legislative requirements. The purpose of these shelters is to ensure a core smoke free site which can provide a sensible option for those who wish to smoke to do so, at appropriate locations on the perimeter of the site, as the Trust had seen an increasing number of breaches of the smoke free policy by individuals on site, particularly around our main entrance (7). The benefits to the NHS This proposal fits in with the Trust’s Commissioning for Quality and Innovation (CQUIN) strategy for 2018 – 2019 (8) to support people to change their behavior to reduce the risk to their health from alcohol and tobacco. It also fits with the aims and objectives of the NHS Southampton City CCG two year operational plan (2017-2019) (9):

to identify and target people who smoke with a long term condition

to support with the outcomes of reducing the number of residents who smoke in the City

to develop integrated models which places care and expertise in the most appropriate setting. The other two most common long term conditions this approach will impact on is for those with Diabetes and COPD.

Continue to review and make recommendation to reduce NEL admissions for those with long term conditions, particularly where resource use is high, including COPD and other respiratory conditions, and those with Diabetes complications

Audit Number: 5802 Smoking Audit V11 06/03/2018

Primary outcomes The primary outcomes for this audit will include the number and proportion of patients:

a) with a documented smoking history in their hospital notes b) who smoke compared to those who do not smoke c) who had a conversation with a health care practitioner about their smoking d) who were informed to only smoke in the designated smoking areas available on

the perimeter hospital site e) who were advised to stop smoking completely f) who smoke that are referred onto an evidence based smoking cessation service g) who smoke who received behavioural support with pharmacotherapy from an

evidence-based smoking cessation service Secondary outcomes The secondary outcomes for this audit will include the number and proportion of patients:

a) of times a patient states that a healthcare professional has had a conversation with a carer, relative or friend to only smoke in the designated smoking areas available on the hospital site

b) of times a patient states that a healthcare professional has had a conversation with a carer, relative or friend about stopping smoking

c) of health care practitioners who have received smoking cessation training d) of smoking cessation products available on the clinical area, in the main hospital

pharmacy and in the on-site pharmacy retail outlet.

2. Methods The purpose and scope of the audit has been discussed with each nursing team lead in each clinical area proposed, in order to gain their approval for us to conduct the audit. Participants

Patients on respiratory wards D5, D6, and HDU

Staff working in these clinical areas

Main hospital pharmacy and onsite pharmacy retail outlet Eligibility

Exclusion Inclusion

cognitive impairment, language barriers, terminal illness and being significantly clinically unwell where it would be deemed inappropriate to approach the patient (all indicated by a member of ward staff at the start of the day prior to the audit taking place)

any patient not meeting the exclusion criteria

Duration of audit Data collection: 1st March 2018 to 30th June 2018 Data Analysis: 1st July to 30th September Dissemination: 1st September onwards

Audit Number: 5802 Smoking Audit V11 06/03/2018

Recruitment a) Patient notes (see appendix 2)

All available notes from each ward will be audited over a period of one day per week, over a maximum period of six weeks (3 days total on each ward)

b) Patients (see appendix 3) It is possible that the recording of smoking status in the patient notes may not be reliable; therefore all patients that meet the inclusion criteria (as determined by a member of ward staff) will be approached and asked if they are a current smoker. Verbal consent will be taken from patients who are identified as being a current smoker and agree to take part in the audit. If patients do not want to consent to the audit they will be assured this will not affect their care.

c) Staff (see appendix 4) Staff working in the clinical area on the last day of the audit will be asked whether they have had any smoking cessation training.

d) Pharmacy (see appendix 5) The clinical areas, the main hospital pharmacy and on-site pharmacy retail outlet will be asked to comment on what range of products are in stock available to prescribe or purchase by patients.

3. Data generation

Data will be collected using a paper survey. All patient identifiable data will remain confidential and will not be shared with any third parties in-line with Trust guidelines and Information Governance protocol. Data will also be stored in a locked cabinet in a secure location on the hospital site. Descriptive statistics will be used to describe the population in terms of mean (SD), percentages and totals.

4. Safety and ethical considerations For some patients, being a smoker and not being able to give up can be a distressing issue. Fortunately two members of the audit team (LB and NS) are trained specialist smoking cessation advisors, and ER, KG and HK have also completed a level 2 smoking cessation course and can offer support and advice to minimise distress. Potentially it may be inappropriate to approach some patients during the audit, as they may be too unwell or have cognitive issues for example. At the beginning of the day, and prior to starting the audit in the clinical areas, the audit team will ask the ward team leader which patients it would be inappropriate to approach about the audit. This information will be collected, documented and reported on (see Appendix 7 for data collection worksheet). The time of day the audit is conducted on the clinical area may also make it difficult to approach particular patients, if they are having investigations for example. In this instance the audit team will aim to survey these patients at a later time, on the same day if convenient. However, the audit will generally take place in the afternoon, outside of rest times because it is generally quieter then, patients should be more available and the ward rounds usually take place in the morning.

Audit Number: 5802 Smoking Audit V11 06/03/2018

If patients do not want to consent to the audit, their wishes will be respected and they will be assured this will not affect their care. All audit staff have up-to-date Good Clinical Practice training. The patient and public involvement group at CLAHRC Wessex have reviewed and approved the questions that will be asked to smokers approached in the audit. Their views were sought in order to ensure the questions were understandable, pertinent and were not likely to cause distress.

5. Dissemination of findings and publication The findings from the audit will be shared with the relevant departments at the hospital Trust as well as CLAHRC Wessex. We also aim to publish the findings in a journal that has an interest in clinical audits, respiratory disease and/or smoking cessation and to present our findings at the next British Thoracic Society Conference. Social media may also be used to publicise the results. Abbreviations CLAHRC Wessex – Collaborations for Leadership for Applied Health Research and Care Wessex References 1. Action on smoking and health (2016) Smoking Statistics. Available from:

http://ash.org.uk/category/information-and-resources/fact-sheets/. (Accessed 6th November 2017).

2. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017. Available from: http://goldcopd.org.

3. National Institute for Health and Care Excellence (2013) Smoking cessation in secondary care: acute, maternity and mental health services. Available from: https://www.nice.org.uk/guidance/ph48. (Accessed 6th November 2017).

4. Rigotti, N.A., Clair, C., Munafò, M.R. and Stead, L.F. (2012) Interventions for smoking cessation in hospitalised patients. Cochrane Database of Systematic Reviews. 5, pp. 1-86.

5. Warner DO. Helping surgical patients quit smoking: Why, When, and How. Medical Intelligence 2005; 101:481-487.

6. Harrison, R., Preston, P., Bucur, C. and Fletcher, S.V. (2012) Smoking prevalence and

smoking cessation amongst acute medical admissions. Thorax. 67(2), pp. A153-A154. 7. University Hospital Southampton Foundation Trust (Feb 2016) Smoking Policy. 8. Commissioning for Quality and Innovation (CQUIN) Guidance for 2017-2019 (2016).

Available from https://www.england.nhs.uk/wp-content/uploads/2016/11/cquin-2017-19-guidance.pdf (Accessed 9th November 2017).

9. NHS Southampton City CCG Two Year Operational Plan (2017-19). Making Southampton a healthy city for all an supporting delivery of the Hampshire & Isle of Wight Sustainability & Transformation Plan (STP). Available from

Audit Number: 5802 Smoking Audit V11 06/03/2018

http://www.southamptoncityccg.nhs.uk/documents?search-media=operational+ (Accessed 9th November 2017).

Appendix 1

Definition of Behavioural Support and Pharmacotherapy Behavioural support This can be individual behavioural therapy or group behaviour therapy. NICE guideline PH10 states that individual behavioural therapy involves scheduled face-to-face meetings between someone who smokes and a practitioner from the smoking cessation service trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy. NICE guideline PH10 states that group behaviour therapy involves scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy. Pharmacotherapy Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion. NICE guideline PH10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement. NICE guideline PH26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women. A summary of further considerations relating to pharmacotherapy is provided in quality statement 4.

Audit Number: 5802 Smoking Audit V11 06/03/2018

Appendix 2 Notes Check

Please circle and tick as appropriate

Ward: Date: __ __/__ __/__ __ __ __

Smoker? Yes / No

Hospital Number: Patient Initials:

Bed: Bay:

Question Answer

1 a. Is smoking status recorded?

b. if patient refused, has this been recorded

Yes / No Yes / No / NA

2 If recently stopped smoking, has quit date been recorded? Yes / No / NA

3 How long after admission was smoking status discussed/recorded? Date of admission: __ __/__ __/__ __ __ __ Date recorded: __ __/__ __/__ __ __ __

Immediately 24 hours 2 days 3 days 4 days 5 days + Other patient was too ill on admission Date missing

4 Has any further discussion documented in the notes? Yes / No / NA

5

If yes, what was discussed?

Tick if recorded below

The Trust is a core smoke free site and smoking is only permitted in the designated smoking areas

Stop smoking completely

Advised that support is available

If patient declined support, support was offered on other occasions

Behavioural support on the ward was offered

Behavioural support on the ward was arranged

The patient was referred to the local smoking cessation service (Southampton Healthy Living)?

The patient was offered licensed nicotine-containing products or other pharmacotherapies

The patient received licensed nicotine-containing products or other pharmacotherapies

Discussion with carers, family, other household members and hospital visitors about secondhand smoke or stopping smoking themselves

Other discussion, please detail:

Audit Number: 5802 Smoking Audit V11 06/03/2018

Appendix 3

Patient Survey

Please circle as appropriate

Ward:

Date:

__ __/__ __/__ __ __ __

Hospital Number: Patient Initials:

Bed: Bay:

Question Answer

1 Do you smoke? No ► skip to question 8

Yes ► continue to question 2

Recently quit (<1 month) ►

continue to question 2

1

Has anyone working at the hospital, like a nurse, doctor,

pharmacist or health care assistant spoken to you about

smoking since you have been in hospital?

Yes / No

State who............................

If yes:

2 Did they advise that the Trust is a core smokefree site and

that smoking is only permitted in the designated smoking

areas?

Yes / No

3 Did they encourage you to stop smoking completely? Yes / No

4 Did they offer you a product, like nicotine patches for

example, to help you quit?

Yes / No

If yes:

5 What products did they offer you? Free text

6 What products did you receive? Free text

7 Did they offer to refer you for further support to stop

smoking with the smoking cessation services?

In house

Local SSS

None

8 Did staff in the hospital inform your relatives, carers or

friends that the Trust is a core smokefree site and that

smoking is only permitted in the designated smoking

areas?

Yes / No / NA

9 Did staff in the hospital give information to your relatives,

carers or friends about the local stop smoking service?

Yes / No /NA

Audit Number: 5802 Smoking Audit V11 06/03/2018

10 Any other comments:

Appendix 4

Staff Survey

Ward: Date: __ __/__ __/__ __ __ __ Are you a health care practitioner? The respiratory research team at UHS are conducting a smoking audit on some of the wards. As part of this audit we would like to know whether staff members have completed any smoking cessation training. Please would you indicate below what training you may have completed. Many Thanks

Please tick

Initials Online Face to face Other (please comment)

Audit Number: 5802 Smoking Audit V11 06/03/2018

Appendix 5 Pharmacy/ward survey

Hospital pharmacy Onsite pharmacy retail outlet Ward If ward, which ward Date: __ __/__ __/__ __ __ __

The respiratory research team at UHS are conducting a smoking audit in the hospital. As part of this audit we would like to know what products are available in the wards and on the hospital pharmacy to support patients to stop smoking. Please would you indicate what products you stock by ticking the appropriate box. Many Thanks

Yes No

Nicotine trans-dermal patches

Nicotine mouth spray

Nicotine inhalator

Nicotine gum

Nicotine lozenge

Nicotine microtab

Nicotine nasal spray

Bupropion (Zyban)

Varenicline (Champix)

E-cigarettes

Additional comments:

Audit Number: 5802 Smoking Audit V11 06/03/2018

Appendix 6

Audit standards

Guidelines: PH48: Smoking: acute, maternity and mental health services (3)

Recommendation 2. Identify people who smoke and offer help to stop

Who should take action

Health and social care practitioners in acute, maternity and mental health services, including community services, drug and alcohol services, outpatients and pre-admission clinics. Health and social care practitioners responsible for the care of people after compulsory admission to hospital under the Mental Health Act. Stop smoking advisors and health and social care practitioners trained to provide intensive stop smoking support.

Overview of Standards Target % Clinical Exceptions

Inpatient During the first face-to-face contact, ask everyone if they smoke or have recently stopped smoking. Record smoking status and the date they stopped, if applicable, in the person's records (preferably computer-based) and any hand-held notes.

100% If a person is unable to or does not want to talk about smoking, note this in their records and ask about their smoking status at the first available opportunity.

Advise everyone who smokes that secondary care settings are smokefree, and they must therefore abstain from smoking while admitted to or using secondary care services. Record discussion in the person’s records.

100%

Encourage everyone who smokes to stop smoking completely. Explain that help is available, and if necessary provide immediate access to licensed nicotine-containing products or other pharmacotherapies, if appropriate. Record discussion in the person’s records.

100% If a person declines help to stop smoking, leave the offer open. At subsequent contacts, offer the support again.

Offer and, if the person agrees, arrange for them to receive intensive behavioural support,

100%

Audit Number: 5802 Smoking Audit V11 06/03/2018

either during their current outpatient visit or during their inpatient stay. Record discussion in the person’s records.

Recommendation 2. Identify people who smoke and offer help to stop

Provide immediate support if necessary, and otherwise within 24 hours of admission. Record discussion in the person’s records.

100%

Provide support (delivered in the setting) as often and for as long as needed during admission. Record discussion in the person’s records.

100%

Offer weekly sessions, preferably face-to-face, for a minimum of 4 weeks after discharge. If it is not possible to provide this support after discharge, arrange a referral to a local stop smoking service. Record discussion in the person’s records.

100%

Recommendation 5. Provide information and advice for carers, family, other household

members and hospital visitors

Who should take action

Health and social care practitioners in acute, maternity and mental health services.

Stop smoking advisers.

Overview of Standards Target % Clinical Exceptions

During contact with partners, parents, other household members and carers of people using acute, maternity and mental health services:

provide clear information and advice about the risks of smoking and secondhand smoke

advise them not to smoke near the patient, pregnant woman, mother or child; this includes not smoking in the house or private vehicle

offer people who want to stop or reduce smoking a referral to a hospital or local stop smoking service, as appropriate.

100%

Provide information and take the opportunity to explain to visitors that smoking is not allowed on the premises.

100%

Provide information and take the opportunity to provide advice to visitors about the benefits

100%

Audit Number: 5802 Smoking Audit V11 06/03/2018

of stopping smoking and how to contact local stop smoking services

Recommendation 8. Make stop smoking pharmacotherapies available in hospital

Who should take action Hospital pharmacists and managers.

Overview of Standards Target % Clinical Exceptions

Ensure hospital pharmacies stock varenicline, bupropion and a range of licensed nicotine-containing products (including transdermal patches and a range of fast-acting products) for patients and staff

100%

Ensure people using secondary care have access to stop smoking pharmacotherapies at all times

100%

Ensure a range of licensed nicotine-containing products are available for sale in hospital to visitors and staff.

100%

Audit Number: 5802 Smoking Audit V11 06/03/2018

Appendix 7

General

Ward: Date: __ __/__ __/__ __ __ __

1. Ask ward staff before commencing the audit if there are any patients for whom it would not be appropriate to be approached regarding participation.

Patient Name Bed Bay Reason

2. Also record any patients who can be approached, but there are special

considerations for.

Patient Name Bed Bay Reason

Audit Number: 5802 Smoking Audit V11 06/03/2018