Download Stopping Smoking before Surgery

Stop Smoking for
Safer Surgery:
The politics of
making a change
Dr. John Oyston
Assistant Professor
University of Toronto
Department of Anesthesia
CAS Meeting, Toronto
25th June 2011
Disclosure: Patient information
materials published by Johnson &
Johnson and Pfizer
There is a HUGE opportunity here:
If we could get patients to stop smoking before
surgery we could:
1) Decrease perioperative complications
2) Improve surgical outcome
3) Reduce health care costs
4) Save lives
5) Make our lives easier
6) Increase the status of anesthesiologists
But it’s a new ball game
We are used to making changes in our
own practice, or working with the OR
Committee.
Stopping Smoking for Safer Surgery
requires working on a larger scale.
Need to educate patients, GPs,
surgeons, other anesthesiologists,
administrators, journalists and politicians.
• Smoking is a major problem in the operating
room, in recovery and postoperatively.
…and the #1 cause of preventable deaths in
Canada.
• Upcoming surgery is a “teachable moment” for
smoking cessation.
– Vulnerability
– Interaction with health care
– Deadline
• Anesthesiologists are supposed to ensure
patients are as fit as possible for surgery.
• We should at least “Ask, Advise & Refer”.
2006 – First SSfSS Web Site
Media Coverage
• 2007 Worked with hospital media relations
– Local coverage, CTV
• 2008 Worked with Ontario’s Anesthesiologists,
Developed a poster and a new web site
– CBC Radio
Metro Morning
– CBC TV
– Many local media
– Canadian Chinese
media
2009
• Worked with OMA
– Presentation at OMA Anesthesia Meeting
– Coverage in Ontario Medical Review
– Globe and Mail
– “Action Plan” for
hospital CEOs
– Quit Cards
Quit Card
Available by emailing John Oyston at [email protected]
2010
–The Scarborough Hospital became
Smoke Free
–OMA Smoking and Surgery
brochure
–CAS became involved
The Scarborough Hospital goes
Smoke Free (Feb 1st 2010)
SMOKING IS NOT ALLOWED ANYWHERE ON
HOSPITAL PROPERTY
• YOU KNOW
– You are not allowed to
smoke here
• YOU KNOW
– Smoking makes it harder
for your body to heal
• YOU KNOW
– You should stop smoking
• WE KNOW
– It’s hard to stop smoking
• WE KNOW
– You have tried to quit
before
• WE KNOW
– Ways to help you quit for
good this time
Speak to your nurse or call extension
#XXXX for help to stop smoking now!
What next?
Ottawa Model for Smoking Cessation
Accreditation
Health Ministry
Canadian Journal of Anesthesia
New posters
The “Quit Quarter”
Legal situation
Ottawa Model for Smoking Cessation
The current model applies to inpatients only.
Needs to be extended to preoperative patients!
• An independent not-for-profit organization
• Evidence-based, focussed on patient safety
and organizational excellence
• 600 surveyors ensure proper policies in place
in 1000 health service organizations across
Canada and world wide
• Now becoming interested in smoking policies!
Accreditation “Wish List”
1) SMOKE-FREE HOSPITALS
No smoking anywhere on hospital property, across the country.
2) ELECTIVE PATIENTS INFORMED
Hospital admission packages should include a statement that smoking is
not permitted on hospital property.
The reasons should be explained.
Patients should be encouraged to quit before admission.
3) NICOTINE REPLACEMENT THERAPY (NRT)
NRT should be freely available to all patients who wish to use it.
4) FOLLOW UP
Patients should be encouraged to remain smoke-free after discharge.
This could be delegated to other organizations e.g. using the OMA “Quit
Connection” or referral to the Smokers’ Helpline.
5) STAFF
Staff should be encouraged to quit smoking.
Employee benefit packages should include smoking cessation therapy.
Ontario Ministry of Health
• Becoming very involved with
managing wait list issues.
• Moving away from a free-for-all
where surgeons book whatever they
feel like doing to a real computerized
health care system.
Recommendation
• All smokers must receive education
about risks of perioperative smoking
and advice about how to quit.
• Elective surgery scheduled no sooner
than six weeks after patient gets
education and advice.
Editorial
The Role of
Anesthesiologists
in Promoting
Smoking
Cessation
September 2011
New posters
• Being produced by Pfizer under an
unrestricted educational grant.
• Will be distributed to preadmission clinics,
surgeons offices and GPs in Ontario, Fall 2011.
• Very limited number of prototype posters
available from Pfizer booth.
Hypothetical legal case
Mary S consulted her family physician about a breast lump.
Mastectomy for Ca by General Surgeon.
Referred to Plastic Surgeon for elective TRAM flap reconstruction.
Seen by the anesthesiologist in the Preadmission Clinic.
“20 pack-year smoking history”
“Mild-moderate COPD, with occ. use of Salbutamol inhaler”
“Well healed mastectomy scar, chest sounds clear”
“Generally healthy, ASA 2, fit for OR”
Anesthesia induced. Uneventful routine anesthesia and surgery.
Episode of coughing and hypoxia in PACU -> small haematoma, drained
under local.
Flap became necrotic, had to be revised.
Multiple surgical procedures to cover deficit.
Low grade infection requiring antibiotics.
Period in isolation as drug resistant organisms cultured.
Prolonged hospital stay, with loss of income.
Poor cosmetic result, painful scar.
Patient sued both the surgeons, both the anesthesiologists and her family
physician, claiming that they were all negligent in failing to advise her about
the risks of perioperative smoking and assist her in quitting before elective
surgery.
Who, if anyone, was guilty of negligence?
1) Her Family Physician who did not advise her
to stop smoking before either operation.
Press
A for Guilty,
B for Not guilty,
C for Don’t know
Who, if anyone, was guilty of negligence?
2) The General Surgeon knew she smoked and
referred her for major elective plastic surgical
procedure, but did not advise preoperative
smoking cessation.
Press
A for Guilty,
B for Not guilty,
C for Don’t know
Who, if anyone, was guilty of negligence?
3) The Plastic Surgeon talked about the risks of
surgery, (including postoperative respiratory
complications, of wound infection and of flap
necrosis) but did not mention that all these
risks could be reduced by stopping smoking.
Press
A for Guilty,
B for Not guilty,
C for Don’t know
Who, if anyone, was guilty of negligence?
4) The Consulting Anesthesiologist was
supposed to ensure she was optimised for
surgery but did nothing about her smoking, a
recognized and treatable risk factor.
Press
A for Guilty,
B for Not guilty,
C for Don’t know
Who, if anyone, was guilty of negligence?
5) The anesthesiologist on the day of surgery
who found out she had smoked in the car on
the way to the hospital. Nevertheless he went
ahead with the case in spite of the increased
risk.
Press
A for Guilty,
B for Not guilty,
C for Don’t know
THE VERDICT:
PHYSICIAN
Family Physician
General Surgeon
Plastic Surgeon
Consulting
anesthesiologist
Anesthesiologist
on day of surgery
GUILTY VOTES
www.stopsmokingforsafersurgery.ca
[email protected]
PRETEST
When you see smokers in the pre-admission clinic,
do you usually:
• A) Not take a smoking history
• B) Take a smoking history but not advise them to
quit preoperatively
• C) Advise them to quit but not offer assistance
such as printed material or a referral
• D) Advise them to quit and offer assistance such
as printed material or a referral
POST-TEST
Next time you see smokers in the pre-admission
clinic, will you:
• A) Not take a smoking history
• B) Take a smoking history but not advise them to
quit preoperatively
• C) Advise them to quit but not offer assistance
such as printed material or a referral
• D) Advise them to quit and offer assistance such
as printed material or a referral