Hamilton Health Sciences

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1 Hamiltn Health Sciences Psting Date: September, 2010 MANUAL Psting Histry Dates: Title: HHS Tbacc Cessatin Prgram Applies t: This plicy applies t all HHS staff, members f the medical, dental and midwifery staff, learners, hspital affiliates (including cntract and agency staff), students and residents wh prvide inpatient and utpatient care at Hamiltn Health Sciences. Hamiltn Health Sciences is cmmitted t prviding a safe, healthy and cmfrtable envirnment fr ur patients, staff, vlunteers, and all individuals wh enter ur premises. In accrdance with ur Missin "t prvide excellent health care fr the peple and cmmunities we serve" and the Strategic Gal "t have a healthy wrking envirnment", Hamiltn Health Sciences is a Smke-Free rganizatin. 1.0 Purpse Smking is Canada s leading cause f preventable disease, disability and death. Apprximately twenty percent f all patients admitted t hspital are smkers ( The majrity f smkers wh are hspitalized are addicted t nictine and will experience withdrawal symptms when they are unable t smke within the Smke-Free rganizatins. Smking cessatin is the single mst pwerful interventin in clinical practice t ffer large ptential benefits, which include enhanced quality and length f life and reduced risk f sudden cardiac death, mycardial infarctin, strke, cancers and chrnic lung disease (Pipe and Quinlan, 2007). Hspitalizatin prvides the pprtunity t systematically

2 identify and assist tbacc users in their desire t be tbacc-free as the hspitalizatin may prvide increased mtivatin fr the smker t make a quit attempt (Reid, R. et al.). "The Ottawa Mdel fr Smking Cessatin" has develped a systematic apprach t the identificatin and treatment f all tbacc used admitted t hspital which has been shwn t lead t an abslute 15% imprvement in the six mnth and ne year quit rate f hspitalized tbacc users (Reid, R et al). This mdel has been intrduced and implemented in ver 36 hspitals thrughut Canada. As Hamiltn Health Sciences becmes a Smke-Free Organizatin, this mdel will be implemented t ensure there is evidence-based apprach t identify and assist nictine-dependent patients admitted t ur rganizatin. Gals T discuss tbacc use and smking cessatin with every patient seen in utpatient clinics r admitted t hspital within Hamiltn Health Sciences using a 5A Mdel f Minimal Cntact Tbacc Interventin. 2.0 Equipment/Supplies Nne. 3.0 Plicy All patients at admissin r during clinic visit at Hamiltn Health Sciences will be screened fr tbacc use and dependency. Patients identified as using tbacc prducts within the last six mnths will be advised t stp and ffered educatin and cunseling n cessatin using the "5A Mdel f Minimal Cntact Tbacc Interventin: "Ask, Advise, Assess, Assist and Arrange". 4.0 Prcedure Healthcare staff will integrate the 5 A Mdel f Minimal Cntact Tbacc Interventin int rutine practice fr all admitted and clinic patients. 4.1 Inpatients: Admissin Tbacc Histry 1. The admitting nurse is respnsible fr screening newly admitted

3 patients fr tbacc use using Adult Tbacc Admissin Histry Frm, page 1 asking the fllwing ASK questins: Have yu used any frm f tbacc within the last 6 mnths? If the client answers N, n further actin is required. If the client answers Yes, the nurse will ask three additinal questins: 1. Have yu used any frm f tbacc in the last 7 day? If the answer is yes, the patient will be asked the amunt f cigarettes smked per day. If n, n further actin required. 2. Have yu tried t quit smking in the past? If yes, the patient will be asked t identify the methd used. 3. The patient will be asked if they wuld like help quitting smking r managing nictine withdrawal symptms while they are unable t smke in hspital. If, yes the nurse will Refer t Adult Tbacc Cessatin Admissin Histry fr Patients Wanting Assistance t cmplete 5 A Mdel interventin. If patients nt wanting t quit smking r managing nictine withdrawal symptms in hspital, the patient will be Advised that quitting smking is the best thing they can d fr their health, given Canadian Cancer Sciety Fr Smker s Wh D Nt Want t Quit resurce. Patients will be advised f HHS is a Smke-Free Hspital, that smking is nt allwed n HHS hspital sites and prperties and relevant aspects f the HHS Smke-Free and Tbacc-Free Plicy will be reviewed with patient and family. Patients will be ntified that if they change their mind and wuld like assistant t quit smking r manage their nictine withdrawal symptms during their stay, they shuld infrm their healthcare team. 2. Fr patients identified as smkers and wanting assistance quitting smking r managing nictine withdrawal symptms within hspital, nurses and ther healthcare prfessinals will use the 5 A Mdel t discuss patient's tbacc use and smking cessatin ptins t assist with quitting smking r managing nictine withdrawal symptms while in hspital by cmpleting page 2 - Adult Tbacc Cessatin Admissin Histry fr Patient's Requesting Assistance. ASK 3. The nurse will cmplete the questins n Page 2 t btain additinal tbacc histry and determine the patient's perceptin f hw imprtant it is t quit smking, hw cnfidence in ability t quit smking and readiness t make the change using the 5 pint scale. ADVISE

4 4. All healthcare prfessinals will advise their patients f the imprtance f quitting smking in a clear, strng, persnalized and nn-judgmental manner. ASSESS 5. The nurse will assess the patient s intentins t quit smking based n the Prchaska s Stages f Change. ASSIST 6. The nurse r ther healthcare prfessinal will prvide brief educatin and cunseling t supprt quit attempt r manage nictine withdrawal symptms in hspital. The nurse will prvide patients with educatinal materials frm Canadian Cancer Sciety and infrmatin n pharmactherapy ptins using the Patient Educatin Resurce "Medicatins t help yu quit smking". ARRANGE 7. Fr client s wishing pharmactherapy assistance, the nurse will cntact physician t arrange fr implementatin f Nictine Replacement Therapy PrePrinted Orders. 8. The nurse will discuss with the patient the ptins fr cmmunity tbacc cessatin fllw-up n discharge and determine patient's preference fr nging fllw-up. 9. Fr patient's wishing fllw-up thrugh the Smkers' Helpline Fax Referral prgram, the healthcare prfessinal in preparatin fr discharge will cmplete the Referral Frm including referring health prfessinal discipline, cntact infrmatin, patient/client cntact infrmatin, language preference f services, gender and fr female's nly if they are pregnant r gave birth in the past 6 mnths and best time fr Smkers' Helpline t cntact the persn and the written infrmed cnsent f the patient and fax the referral frm t Smkers' Helpline prir t discharge. 4.2 Outpatients: Health care prviders will ask all clients presenting fr an utpatient visit, if they have used any frm f tbacc within the last 6 mnths? If the client answers N, n further actin is required. If the client answers Yes, the nurse will ask three additinal questins: 1. Have yu used any frm f tbacc in the last 7 day? If the answer is yes, the patient will be asked the amunt f cigarettes smked per day. If n, n further actin required. 2. Have yu tried t quit smking in the past? If yes, the patient will be asked t identify the methd used. Clients identified as using tbacc prducts within the last six mnths will be advised t stp and ffered educatin and cunseling n cessatin using the "5A Mdel f Minimal Cntact Tbacc Interventin: "Ask, Assess, Advise, Assist and Arrange". 4.3 Prcedure fr Clients n Nictine Replacement Therapy

5 1. Nictine Replacement Therapy (NRT) can be prescribed fr patients wanting t quit smking r t manage nictine withdrawal symptms while in hspital. Please nte there are specific guidelines fr use f NRT in pregnant wmen and these are utlined with the rders. 2. A Pharmacist Cnsult is required fr patient's using ther frms f tbacc, fr NRT use in pediatric patients and fr ther tbacc cessatin pharmactherapy. 3. The Nictine Replacement Therapy (NRT) patch is rdered based n the number f cigarettes the patient smkes per day. It is recmmended that shrt acting NRT in the frm f gum, lzenge r inhaler are als rdered fr patients t manage breakthrugh cravings while n the patch. These prtcls are meant as a starting pint and shuld be titrated t manage the patient's nictine withdrawal symptms. It may be necessary fr the patient t remain n Nictine replacement therapy r at ne step fr lnger than utlined in the prtcl. 4. All patients prescribed NRT therapy will have the Withdrawal Scale assessed q shift. The nurse will ntify the physician is the patient experiences withdrawal symptms ranking 3 r 4 n withdrawal scale, despite NRT patch and shrt acting NRT use. 5. If patient's develp a skin rash r have a sensitivity t adhesive, the nurse will cntact the physician fr reassessment f rdered nictine replacement therapy use. 6. Prir t discharge frm hspital r transferred t the next level f care, the patient will be prvided with written instructins fr cntinued NRT use based n their treatment regime. 7. Upn discharge f patient t anther level f care r transfer t anther unit, the nurse will prvide infrmatin abut cntinued Nictine Replacement Therapy use t the next level f care n the transfer sheet r the unit t unit transfer f accuntability. 5.0 Dcumentatin 1. On admissin t hspital, nurses will cmplete the Adult Tbacc Cessatin Admissin Histry. 2. Fr utpatient clinics, the dcumentatin f the identificatin f smkers and implementatin f the 5 A Mdel f Minimal Cntact Tbacc Interventin will be incrprated int clinic dcumentatin. 3. Fr patients n Nictine Replacement Therapy, the Withdrawal Scale will be assessed every shift and dcumented in the same frm utilized by the unit t dcument vital signs, e.g. Unit Based Flwsheet, Vital Sign Recrd, Neurlgical Assessment Recrd, etc. 4. As part f the discharge planning prcess, the healthcare prfessinal will determine the patient's preference fr nging tbacc cessatin cmmunity fllw-up and cmplete the fllw-up preference in the "Arrange" sectin f the Adult Tbacc Cessatin Admissin Histry fr Patient's Requesting Assistance. 5. Fr patient's requesting Smkers' Helpline Fast Fax Referral, the health care prfessinals will dcument in the patient's chart that referral was faxed and place cmpleted the Smkers' Helpline Fax Referral Frm in chart. 6. Fr patients discharged n nictine replacement therapy, there will be dcumentatin f the educatin prvided t patients regarding the cntinued nictine replacement regime upn discharge.

6 6.0 Definitins Tbacc Prducts: include cigarettes, cigars, pipe tbacc, snuff, chewing tbacc, herbal cigarettes r cntraband tbacc prducts. 5 A Mdel f Minimal Cntact Tbacc Interventin: evidence-based apprach t tbacc interventin that is advcated in many clinical best practice guidelines that is designed t be implemented in less than three t five minutes. 5 A Mdel cnsists f Ask, Advise, Assess, Assist and Arrange. Ask: Tbacc use status ver the previus six mnths is identified and dcumented fr every patient during every admissin r clinic visit. Advise: Every tbacc user is advised f the imprtance f quitting smking in a clear, strng, persnalized and nn-judgmental manner. Assess: Every smker shuld be asked their intentins regarding quitting smking based n Prchaska's Stages f Change. Furthermre, the nictine withdrawal scale will be cmpleted fr all patients wishing pharmactherapy. Assist: Tbacc users are assisted with brief cunselling, educatin and pharmactherapy that is tailred t the patient's interest in quitting smking r managing nictine withdrawal symptms while in hspital. Arrange: Tbacc users are ffered fllw-up smking cessatin supprt upn discharge frm hspital t supprt quit attempt. Prchaska s Stages f Change: The prcess f quitting smking is nt always linear. There are fives stages f change that the patient may present with at the time f admissin. 1. Pre-Cntemplative: Nt ready t quit 2. Cntemplative: Thinking abut quitting 3. Preparatin: Ready t quit. 4. Actin: Persn has quit 5. Maintenance: Persn has been tbacc free fr six mnths Minnesta Nictine Withdrawal Scale: Validated self reprt scale that is utilized t evaluate the level f nictine withdrawal in admitted patients t use t titrate nictine replacement therapy. 7.0 Crss References

7 Hamiltn Health Sciences Smke-Free and Tbacc-Free Plicy, Hamiltn Health Sciences (2010) Adult Nictine Replacement Therapy (NRT) Order Set. Hamiltn Health Sciences (2010) Adult Tbacc Cessatin Admissin Histry. HHS Breathe Easy Electrnic Learning Mdules: 1) Intrductry Cncepts in Tbacc Cessatin; 2) Implementing Best Practices; and 3) Pharmactherapy. Hamiltn Health Sciences and St. Jseph's Healthcare Hamiltn (2009) Patient Educatin Resurce "Medicatins t help yu quit smking." Canadian Cancer Sciety Patient Educatin Resurces: Fr Smker's Wh Want t Quit, Fr Smker's Wh Dn't Want t Quit, The First Step t Help Smker's Quit, Smker's Helpline Infrmatin. Hamiltn Health Sciences Smkers' Helpline Fax Referral Frm, External References 1. Brant Cmmunity Healthcare System (July 2008)Tbacc Cessatin Supprt Prgram Plicy and Prcedure. 2. Canadian Cancer Sciety 3. Ontari Medical Assciatin (2008) Rethinking Stp-smking medicatins: Treatment myths and medical realities. Ontari Medical Review, 75(1): Pipe, A., Reid, R.D., Quinlan, B. (March 2007) Systematic Apprach t Smking Cessatin. Smking Cessatin Runds ( 1(1): Reid, R.D., Pipe, A., Quinlan, B., Slvinec, M., Kcurek, J., Riley, D.L., Papadakis, S. (May 2007), Smking Cessatin Runds ( 1(3): Registered Nurses Assciatin f Ontari Best Practice Guidelines (2007) Integrating Smking Cessatin int Daily Nursing Practice - Revised St. Jseph s Healthcare Hamiltn (March, 2010) Tbacc Free Plicy Tbacc Enhancement in Applied Cessatin Cunselling and Health The Ottawa Tbacc Research Unit, 9. University f Ottawa Heart Institute Mdel f Smking Cessatin Develped By/In Cnsultatin With HHS Smke Free Initiative - Medical Management Cmmittee

8 HHS Smke Free Initiative - Steering Cmmittee Hamiltn Public Health Canadian Cancer Sciety's Smkers' Helpline Prfessinal Advisry Cmmittee 11.0 Apprved By Medical Authrizing Cmmittee Keywrd Assignment Smking Cessatin Prtcl Tbacc Treatment Reprduced with permissin frm Hamiltn Health Sciences.

9 Regin f Waterl Public Health Plicy and Prcedure Manual Sectin #5 Plicy/Prc. #25 Effective Date: April 13, 2009 Revisin Date: February 15, 2011 Apprved by: Anne Schlrff, Directr, Central Resurces Minimal Cntact Interventin fr Tbacc Cessatin POLICY STATEMENT: All public health staff invlved in client assessment, either in persn r by telephne, frm the designated teams listed belw are required t query and dcument tbacc use using the minimal cntact interventin (MCI) fr tbacc cessatin fur A s: ASK, ADVISE, ASSIST, ARRANGE prtcl. This plicy sets ut the parameters f the 4 A s prtcl. OPERATING PRINCIPLES: Tbacc use is the number ne cause f preventable disease and death in Ontari, killing mre than 13,000 Ontarians every year. Tbacc-related diseases cst the Ontari ecnmy $1.6 billin fr health care annually, resulting in $4.4 billin in prductivity lsses and accunting fr at least 500,000 hspital days each year (Ontari Ministry f Health Prmtin, 2008). In Waterl Regin, 22 per cent f peple smke. Cigarette smking caused 15.9 per cent f all deaths in Waterl Regin between 2000 and 2004 and resulted in 31,193 years f ptential life lst prematurely. Expsure t secnd-hand smke resulted in an additinal 64 deaths during the same time perid. Tbacc prducts ther than cigarettes, including smkeless tbacc, are als linked t serius health effects (Regin f Waterl Public Health, 2009). As public health care prviders we can make a difference. Mre than half f smkers in Ontari want t quit smking in the next six

10 mnths and ne quarter indicated a serius intentin t quit within 30 days (Ontari Tbacc Research Unit, 2006). Evidence suggests the mst imprtant step in addressing tbacc use dependence is screening fr tbacc use and ffering minimal cntact interventin messages at every pprtunity t all peple wh use tbacc prducts. If substantial numbers f health care prviders implement minimal cntact interventins, there will be a significant reductin in the number f tbacc users, a decrease in related tbacc diseases, and a lwering f health care csts (Ontari Tbacc Research Unit, 2008). OPERATING DETAILS: The fllwing public health teams are required t have the 4 A s n their dcumentatin t ensure implementatin f the MCI prtcl with every client: Sexual Health and Harm Reductin Reprductive Health Dental Health Vaccine Preventable Disease - Travel Clinic nly Infectius Disease and Tuberculsis Cntrl Assessment Service Crdinatin (Nrth and Suth) Other relevant teams/divisins nt currently invlved in client assessment, either in persn r by telephne, will be infrmed f this plicy, but are nt required t query and dcument tbacc use using the fur A s prtcl. These teams/divisins include: Child and Family Health Prmtin team Cnsultatin and Skill Develpment (CSD) team Healthy Living, Planning and Prmtin Divisin Health Prtectin and Investigatin Divisin

11 PROCEDURES: Training Champins frm each team, trained by the Tbacc and Cancer Preventin lead public health nurse, will prvide training t new staff and nging supprt t existing staff within their teams. Advisry Cmmittee A Minimal Cntact Interventin plicy advisry cmmittee cnsisting f ne representative frm the abve listed teams as well as a representative frm the Tbacc and Cancer Preventin team will meet n an annual basis t review the plicy and t prvide n-ging supprt and training t the MCI team champins. Refer t the MCI Plicy Advisry Cmmittee terms f reference DOCS_ADMIN-# TERMS OF REFERENCE MCI WORKING GROUP Prtcl Evaluatin Prtcl implementatin cmpliance data has been cllected fr each prgram in cllabratin with the Tbacc and Cancer Preventin planner and reprted back t the MCI plicy advisry cmmittee t infrm nging training needs and supprt. Supprt resurces ARRANGE stage Each prgram is required t stck the supprt resurce required fr MCI prtcl implementatin which is a business card prduced by the Tbacc and Cancer Preventin team. This business card has the Smkers Helpline cntact infrmatin n ne side and the Regin f Waterl Public Health s Tbacc Infrmatin Line n the ther side. Each public health client wh agrees t receive infrmatin in the ARRANGE stage f the prtcl is t be given this business card. Regin f Waterl Public Health Tbacc Infrmatin Line Smkers Helpline tll-free, ne-t-ne telephne supprt line and nline prgram, , The design, revisins and reprinting f this business card are the respnsibility f the Tbacc and Cancer Preventin lead public health nurse. Each team will be prvided with a supply f these cards. T restck the cards cntact the Tbacc and Cancer Preventin lead public health nurse.

12 Smkers Helpline Fax Referral Prgram - ARRANGE Stage Regin f Waterl Public Health has partnered with the Canadian Cancer Sciety s Smkers Helpline t ffer the fax referral prgram. All teams will receive training n the fax referral prgram prir t cmmencing the fax referral prgram with clients. After initial training has been cmpleted, Champins frm each team, trained by the Tbacc and Cancer Preventin Prgrams lead public health nurse, will prvide training t new staff and nging supprt t existing staff within their teams. At the ARRANGE stage f the prtcl, staff will cntinue t ffer the Regin f Waterl Public Health Tbacc Infrmatin Line/Smkers Helpline business card t interested clients. In additin t ffering the business card, staff will als ask clients if they wuld like t have Smkers Helpline call them directly. If the client expresses interest in receiving a direct call frm Smkers Helpline, then the staff persn is t initiate the fax referral prgram. The staff persn will verbally cmplete the Smkers Helpline Fax Referral frm with the client (DOCS#931589). The staff persn will add the client s infrmatin t the frm based n the client s respnses. The client has the right t refuse t answer any questins n the frm. Hwever, in rder fr Smkers Helpline t cntact the client they require the client s name and phne number and the referring staff persn s name, designatin and cntact infrmatin. The staff persn must btain express verbal cnsent frm the client by reading ut the ntice f purpse statement at the bttm f the fax frm (written cnsent is nt required) prir t faxing the frm t Smkers Helpline. I (Health Care Prviders name) affirm that I have btained cnsent frm the client t fax this frm t Smkers Helpline (SHL) t facilitate direct cntact n this referral s that SHL can cntact the referred individual regarding his r her attempt t quit smking. I have explained the purpse f the disclsure f the infrmatin t the client, and have advised the client that SHL may use the infrmatin t cmmunicate directly with the referring health care prvider. I infrmed the client that SHL will keep all infrmatin cnfidential and will nly use it fr the purpse f administering the fax referral prgram. A valid cnsent under the Persnal Health Infrmatin Prtectin Act (PHIPA) stipulates that the cnsent must meet fur cnditins: 1. The cnsent must be f the individual wh relates t the persnal health infrmatin

13 2. The cnsent must be knwledgeable 3. The cnsent must relate t the infrmatin; and 4. The cnsent must nt be btained thrugh deceptin r cercin Fr mre infrmatin n cnsent requirements under PHIPA refer t plicy #4/sectin#13 Cnsent Requirements fr Handling f Persnal Health Infrmatin DOCS# If the staff persn has btained a valid verbal cnsent frm the client, the staff persn signs their name (health care prvider s name), designatin and dates the fax frm in the space prvided. When the staff persn is face-t-face with the client, the staff persn is t prvide the client with the pst card Yur healthcare prvider has referred yu t: Smkers Helpline. We ll be giving yu a call sn. If the staff persn is nt face-t-face with the client (e.g. n the phne), remind the client verbally that Smkers Helpline will be calling them in the next cuple f days t assist them with making a persnalized quit plan, cping with cravings, withdrawal and stress; quit tips and aids, and cmmunity resurces. The cmpleted fax frm is then faxed t Smkers Helpline within 48 hurs (2 business days) where pssible. A cpy f the fax frm is kept with the client recrd. The pst card resurce has been created by Smkers Helpline and is a requirement f the fax referral prgram partnership. Fr a supply f the pst card, cntact the Tbacc and Cancer Preventin lead public health nurse. GUIDELINES: Registered Nurses Assciatin f Ontari Best Practice Guideline Integrating Smking Cessatin int Daily Nursing Practice. March Retrieved April 16 th, 2008 frm SEE ALSO: Ontari Ministry f Health Prmtin. Creating a Smke-free Ontari. Retrieved April 16, 2008 frm Regin f Waterl Public Health. (2009, May). Building Healthy and Supprtive Cmmunities: Tbacc use and it s cnsequences in Waterl Regin. Waterl, ON: Authr. Ontari Tbacc Research Unit (2008). Update Health prfessinals advice n smking cessatin in Ontari: Retrieved April 16, 2008 frm