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									                           Opportunistic Intervention for Smoking Cessation
                             Among Hospitalized Smoker Patients in TTSH
                       Leong Y Y, Lathy P, Suvaseni K, Wang M, Jasemine, Mageswari, Norazalin, Chuang S H, Pek W Y
                                                                   Nursing Service, Pharmacy Department, Respiratory Department

                MISSION STATEMENT                                                                                                                                          PARETO CHART
At the end of 6 months, 90% of patients in Level 9                                                                                                                               Main Concerns
wards who accepted the option of intensive                                                                                                     50                                                                                              100

                                                                                                                              Number of Vote
counseling will be provided with bedside quit                                                                                                  40                                                           82.9           91.5                80

smoking counseling within their stay in hospital.                                                                                                                                      61.4
                                                                                                                                               30                                                                                              60
                                                                                                                                               20                      47.1                                                                    40

                                  TEAM MEMBERS                                                                                                 10
                                                                                                                                                          25.7                                                                                 20
                                                                                                                                                       Poor      Not familiar Less priorityNo counselor    Work     No follow up Timeliness

Name                              Designation                          Department                                                                   perception       with
                                                                                                                                                                                                        process not by nurse

Leong Yoke Yin                    ADN (Leader)                         Nursing Service
Lathy Prabhakaran                 Senior Nurse Clinician               Nursing Service                                                                                    INTERVENTION
Suvaseni K                        Unit Nurse Manager                   Level 9
Chuang Shen Hui                   Pharmacist                           Pharmacy                                                                                                                                                                 90% of
                                                                                                                                                                                                                                              patients who
Pek Wee Yang                      Consultant                           Respiratory                                                                                               A S
                                                                                                                                                                                                                                              agreed for
Wang Min                          RN                                   Ward 9D                                                                                                   P D                                                          counseling will

                                                                                                                                                         A S
                                                                                                                                                         P D
                                                                                                                                                                                                                                              be counseled
Jasemine                          RN                                   Ward 9C                                                                                                                    Review
                                                                                                                                                                                                                      Involve all
Mageswari                         EN                                   Ward 9B                                                                                              Audit 2               strategies          Engage
                                                                                                                                                      Standardize           weekly                with staff          part time
Norazalin                         PSA                                  Ward 9C                                         Communi-                       workflow              Recognize             Listen to           smoking
                                                                                                                       cate and                       process               staff                 feedback            cessation
                                                                                                                       create                                                                                         nurse
    EVIDENCE OF A PROBLEM WORTH SOLVING                                                                                awareness
                                                                                                                       through:                                             incentives
• Cigarette smoking is the most prevalent health risk                                                                  • Journal
 behaviour. The mortality rate from smoking-related                                                                    Club
                                                                                                                       Presentation                   as a KAA
 disease in Singapore is 466 per 100,000 population.                                                                   • Posters

• Hospitalization is an ideal “window of opportunity” to                                                                                                                           RESULTS
 reach smokers at a time when they may be especially                                                        Through multiple PDSA cycles, we saw an
 receptive to smoking cessation interventions.                                                              improvement in providing the counseling service
• In TTSH, we integrated smoking cessation                                                                  to smokers from 0% to 90%.
 intervention into routine care in acute care setting                                                                                                      Percentage of Patients Counseled and
 since 2004. However, only 30% of patients in level 9                                                                                                            Quit Rate at 3 & 6 Months
 receive this intervention from Jan to April 2008.
                                                                                                                       18                                                                                                                                         100

                                                                                                                       16                                                                                                                                         90

                       FLOW CHART OF PROCESS
                                                                                                     Number Referred


 Nurse/HCA identifies smoker while doing                                                                               10
                                                               Accept bed side counseling                                                                                                                                                                         50
 Nursing Assessment Record for all newly                                                                               8
 admitted patient.                                                                                                                                                                                                                                                40

 “Do you smoke?” (Yes , No, UA)                                     PSA to inform smoking                              6
                                                                     counselor of bedside                              4
                            If YES                                    counseling session                                                                                                                                                                          20

 1. Provide strong and clear advice to quit.                                                                           2                                                                                                                                          10
 2. Inform the availability of bedside smoking                    Counselor record details of                          0                                                                                                                                          0
    cessation counseling.                                           counseling session in                                   Jan Feb Mar                Apr May Jun         Jul   Aug Sep Oct Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-
 3. Ask patient’s intent to have bedside                         continuation notes , smoking                                08 08 08                  08 08    08         08     08 08 08 08 08 09 09            09 09 09 09         09
    counseling session.                                                file & database.
 4. Provide smoking cessation pamphlets.                                                                                                                                Numbers Referred               % Counseled
                                                                                                                                                                        Quit Rate 3 Month              Quit Rate 6 Month
                                                                 PSA to obtain follow-up appt
 1. Paste patient’s sticky labels into the smoking                    / patient informed
   cessation record sheet
 2. Complete all columns in the record sheet.                                                                                                              PROBLEMS ENCOUNTERED
 3. Paste smoking sticker on IMR.                                 Counselor calls patient at 3,
                                                                     6 & 12 month to give            • New nurses were not familiar with the work process.
                                                                   support & assess quit rate.
                Reject counseling                                                                    • Short of dedicated counselors
                                                                                                     • Not all clinicians are actively motivating patient to see
                      COST AND EFFECT DIAGRAM                                                          the counselor
                                                                                                     • Nurses find it difficult to motivate patients to see the
        Patient                                    Environment                                         counselor.
                   Don’t need Process of referral is             busy Work load
  of heath          assistance not clear                                       No time                                       STRATEGIES FOR SUSTAINING THE GAINS
  problem                               Unable to locate
                                                                     Pt not around
                        Too ill         smoking file                                                 • Audit and obtain staff feedback regularly
                           Timeliness      Shortened LOS                           transferred
        n barrier
                            “hard core
                                                                         Procedure                   • Engage clinicians to participate in motivating and
             Denial             smokers”   No counselor
                                                         Rapid discharge          Patients             referring patients
                                                            Do it later
                                                                                  were not
                                                                                  given full
                                                                                                     • Obtain funding for full-time smoking cessation counselor
                                          Not familiar with
 No orientation of program                    procedure                           counseling           to run the program
Change of usual routine            Extra charting /additional work           Dr’s not re-enforcing   • Convert manual work process to electronic in future
Forget to flag and                                                          and not assisting with
refer New staff                   Poor perception of program                         referral        • Spread across all wards in TTSH and all NHG hospitals
  Resistance to                                                         Process not
  change                       Least priority in acute setting          standardized                                                                                  LESSONS LEARNED
              Nurse                            Operation Issues
                                                                                                     • Patient focused care
                                                                                                     • Leadership commitment and support from the stake
The causes of not being able to provide bedside quit                                                   holders
smoking counseling were poor perception, not                                                         • Multidisciplinary team work
familiar with processes, less priority, no counselor                                                 • Effective communication and listening
and work process not standardized.                                                                   • Upfront incentives and recognition

                                                                                                                                                                                                 Acknowledgement: CNE Tan Si Ling

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