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An Approach to Improving NRT Use in the Hospital • Nicotine Replacement Therapy (NRT) reduces nicotine withdrawal symptoms and increases cessation rates • NRT, along with good instructions, should be available to in-patients who are current smokers • BUT DOES THIS HAPPEN? Vignettes Three patients admitted to hospital for illnesses worsened by their current smoking. 1. TIA carotid endarterectomy 2. PVD femoral-popliteal bypass graft anxiety Psychiatry consult 3. Angina attempted cardiac catheterization agitation LP, CT, Neuro consult A Health Care Facility Goes Smoke-Free Objectives • Provide all patients who use tobacco with optimal NRT if not contraindicated • Provide good instruction on the use of NRT to these patients (AND to physicians and nurses) • Connect patients who want to quit with cessation resources in the hospital and in the community Continuous Quality Improvement Model What did we learn? What next? Gather data and observe Determine causes Act Plan Study Do Develop a remedy Carry out the change The PDSA Cycle Inpatient Protocol for Nicotine Withdrawal Patients who are current smokers at the time of hospital admission may experience nicotine withdrawal symptoms during hospitalization. These symptoms can include: In alliance with The University of Vermont Nicotine Withdrawal Order Form Addressograph Please Date: _____/_____/_____ Time: __________ Allergies / Substances to be Avoided: ______________________________________________________ craving for nicotine irritability, frustration or anger anxiety and restlessness difficulty concentrating increased appetite and weight gain insomnia Nicotine withdrawal should be considered as a possible cause of agitation. Com pared to cigarettes, nicotine replacement therapy (NRT) provides a safer and more manageable form of nicotine with lower nicotine blood levels. The toxicity of a cigarette is always greater than NRT. RELAT IVE CONT RAINDICATIONS : Pregnancy, immediate post MI period, life-threatening arrhythmias, unstable angina, temporal mandibul ar joint syndrome (gum). Adverse Effects, Cautions and Instructions on Use of Nicotine Replacement Th erapy Circle one choice below Type of NRT AS NEE DED NICOTINE REPL ACEMENT THER APY: Recommended as initial therapy in patients able to use these medications. All forms of NRT a) Nicotine Gu m 2mg 1 piece q1-2 hr prn x 42 days (patient smokes < 25 cigarettes/day) b) Nicotine Gu m 4mg 1 piece q1-2 hr prn x 42 days (patient smokes > 25 cigarettes/day) OR AS NEE DED NICOTINE REPL ACEMENT THER APY: If unable to use gum or nicotine gum trial failure. (in patient’s med drawer) c) Nicotine Inhaler 4mg (1 cartridge) q2 hr prn x 42 days (at bedside for self administration) Nicotine Gu m Cautions Concomitant tobacco use Less than 18 years old Active coronary artery disease including imm ediate post MI period, unstable an gina Life threatening arrhythmias Pregnancy/nursing Stopping smoking can increase blood levels of medications (e.g. Theophylline, clozapine) Check with pharmacy Adverse Effects Jaw pain Dyspepsia, nausea Caution if TMJ syndrome or poor dentition OR TRANSDERMAL PATCH : Recommended if: Patient unable to use prn medications Patient prefers continuous therapy to frequent doses of prn medication Desires to begin cessation treatment d) Nicotine Patch 21mg patch apply qd x 42 days (patient smoked > 10 cigarettes a day) e) Nicotine Patch 14mg patch apply qd x 42 days (patient smoked < 10 cigarettes a day) AND Patient Edu cation Booklet for Tobacco cessation to patient Should patient desire to continue smoking cessation treatment upon discharge, prescriptions must be written and patient instructed to fill the prescriptions with an outpatient pharmacy. Arrange follow-up of smoking cessation attemp t with primary care physician. Can suggest patient contact Quit Line at 1-877-YES QUIT (1-877-937-7848) available free to residents of Vermo nt. See reverse side for details on adverse effects and instructions on use. Pager: _________________ Nicotine Inhaler Transdermal Nicotine Patch Local irritation in mouth and throat Caution if history of asthma Skin sensitivity Sleep disturbance (remove at night) Instructions Chew slowly Once tingling sensation felt, park gum in between cheek and gum Chew again when tingling goes away No acidic beverages immediately before or after use Place plug in two-piece inhaler Pt. inhales on mouthpiece as desired. One plug provides 80 inhalations Use 6 to 16 plugs/day No acidic beverages immediately before or after use Apply to area of skin without hair If problems with sleep disturbance, remove at night and replace in morning Resource s for Tobacco Cessation Services Signature: ________________________________ ___________________ Vermont Quitline 1-877 YES QUIT (1-877-937 -7848) Printed Name: ____________________________________________ Patient Education Booklet for To bacco Cessation ava il able on Nursing Un it Timeline Monthly Pharmacy Orders for NRT FAHC goes Smoke Free Cmt mtg • Nicotine inhaler • Standard order form Chart Review (Dec) July Aug Sept 2001 Oct Nov Dec Jan 2002 Feb Monthly NRT Orders (Pts on NRT/1000 discharges) 140 120 Form Available 100 80 60 40 20 0 Nov- Dec- Jan- Feb- Mar- Apr- M Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar00 00 01 01 01 01 ay- 01 01 01 01 01 01 01 02 02 02 01 Identification of Tobacco Users “Are you using any tobacco products currently?” • Registered as Y (yes) 173 (12%) • Registered as U (unknown) 319 (22%) • Registered as N (no) 940 (66%) 1,432 * * Patients admitted as “IP” type and > 9 yrs old, not on Psychiatry or Rehab Chart Review of Current Smokers • Order form on chart? 0 of 23 ( 0%) • Any order for NRT? 5 of 18 (28%) • Tobacco Counseling documented? 1 of 23 ( 4%) Status of Forms on Floors • 2 stations In order form rack near secretary • 2 stations In file cabinet next to secretary • 1 station In pt information rack in room away from secretary • 1 station In back room in an unmarked stack of forms on top of a phone book • 2 stations Could not find Chart Reviews After Presentations 20 charts of pts registered as “using Tob” admitted 4/1-4/15 Dec 0% • Order forms on chart? 0 of 17 ( 0%) • Any order for NRT? 3 of 10 (30%) 28% • Any documentation of counseling? 5 of 17 (29%) 4% • Intervention: standard order forms • Small improvements observed with intervention • Adherence significantly higher WHEN standard order forms were in the chart • BUT, standard order forms in only 24-27% of charts JAMA 2002; 287(10): 1269 NEJM 2001; 345: 965 Intervention 60 % of hospitalizations 50 during which eligible 40 patients were ordered therapy 30 Control * p < 0.001 * * * * 20 10 0 Pneumo Vac Influenza Vac Aspirin at D/C SQ Heparin Lessons Learned • Knowledge • Systems changes must be combined with orientations with all staff - not just with managers • Positive Attitudes • Attitudes about “yet another form” can be negative • Systems that • Getting order forms into charts is difficult; working with unit enable secretaries is very important Acknowledgements • Leadership – – – – Thad Krupka John Brumsted, MD Maureen Loeffler Skip Novak • FAHC Tobacco Programs – Evelyn Sikorski – Bette Diette, RN – Rachel Smith, MSA • Order Form – John Hughes, MD – Laura Solomon, PhD – Gary Greiner, Pharm D • Measurement – – – – Mike Nix Anna Noonan Lisa Bell Kathleen Weidman • Nursing, other Personnel – Richard Watters – Shannon Lonergan