Gasser Rudi

ENSH –Global
SMOKING – taking
action at every
opportunity
Dr Rudi Gasser, Coordinator
Victorian Network of Smokefree
Healthcare Services
Situation in Australia
Situation in Australia
Situation in Australia
Why take action?
• Smoking remains a leading cause of preventable illness and death
in Australia – Cancer Council-2011 – 8,114 lung cancer cases
• Smoking as an addiction is a medical co-morbidity – it can and
should be treated
• Seven out of 10 smokers want to quit – local and international
research
• Treating smokers reduces clinical risk, reduces complications and
hence the cost of providing medical care
• Treating smokers improves the quality of care – accreditation and
future KPI
• Hospital admission is a strong motivator for quitting
• $$$$
Why take action?
• “Health Services have important obligations in the struggle to
reduce the use of tobacco and it’s deleterious health effects.
• These obligations include not only a tobacco-free environment to
protect non-smokers but also the provision of active support for
smokers in their quitting process.
• This concerns patients as well as all categories of personnel.”
ENSH Global Network based on Framework Convention for Tobacco
Control
Smokefree Victoria- VNSHS
What did we achieve?
Total number of health services
30
25
20
Regional/Rural
15
Metropolitan
10
5
0
2011
2012
2013
2014
What did we achieve?
•
Joint forum with the Department of
Health – “Best Practice for Brief
Intervention” with Hayden McRobbie
(March 2014)
•
Workshop and member campaign for
World No Tobacco Day (May 2014)
•
Mental Health & Smoking Workshop at
Austin Health (June 2014)
•
Joint workshop with the Royal Australian
and New Zealand College of
Anaesthetists – “Smoking and Surgery”
with Ashley Webb (November 2014)
•
Involvement with the DH pilot project
“Supporting Patients to be Smokefree”
What did we achieve?
• Ongoing opportunities for
networking and information sharing
–
–
–
–
Bi-monthly teleconferences
LinkedIn
Website & shared resources
6 monthly newsletter
• Engagement with ENSH including
input into the review of the ENSH
standards
• Representation on the ENSH Board
• Representation at international
meeting and Gold Forum
Barwon Health Journey
SMOKING
BANS
CULTURAL
SHIFT
CULTURAL
SHIFT
INTEGRATION
INTO CLINICAL
CARE
Smoking is not
allowed here
We don’t expect
to be able to
smoke here and
we expect others
not to smoke
What else can
we do to reduce
the health impact
of smoking
Here, we address
smoking as a
routine aspect of
clinical care
We are
here and
moving on
Framework for Smokefree at
Barwon Health
• Ask about smoking at each client contact and provide
appropriate support by:
Clinical Care
• Building workforce capacity
• Establishing processes and systems to support consistency and
continuity of care
• Support staff who smoke by:
Staff Support
• Asking all new employees about smoking
• Establishing systems to support opportunistic discussion at
StaffCare visits
• Providing ongoing communication to encourage staff to quit
• Offering individual smoking cessation support
• Prevent exposure to ETS by:
Smokefree
environment
• Providing clear signage and pavement markings around facilities
• Providing supportive communication directed at clients, visitors
and staff
• Ensuring appropriate enforcement and accountability
Clinical Care
• Inpatient procedure for managing nicotine dependence has been
in place since 2009 but implementation has been limited. Action
to address this includes:
– Training to develop capacity
– Consultation to establish best mechanisms for routinely identifying
smokers – plan is to incorporate smoking into standard risk
assessment which is an electronic assessment administered by
nursing staff to all patients within 24 hours of admission
– Establishment of documentation to support management of smokers
– hard copy only at this stage.
– NRT on imprest and expertise within pharmacy
– Various areas working to address local needs e.g. Mental health,
pregnancy care, physiotherapy, information and access, rehabilitation
Beyond the inpatient setting
• “Be Smokefree” community based
clinics
• Trial of clinic-based smokefree
specialist within high risk pregnancy
care clinic
• Working with Medicare Local to
develop pathway for management of
nicotine dependence which includes
incorporation of smoking status into
referral templates
• Standard question for clients
accessing community based services
(centralised process)
Smoking & Surgery
• Smoking increases the risk of intra- and post operative
respiratory complications
• Increased risk of admission to ICU following general and
orthopaedic surgery
• Delayed wound healing, increased infections, dehiscence and
erosions.
• All these smoking associated complications are particularly
problematic after plastic & reconstructive surgery, orthopaedic
surgery, bowel surgery, dental surgery, microsurgery and organ
transplantation
Source: Scollo, MM and Winstanley, MH Tobacco in Australia Facts and Issues 4th edition Cancer Council Victoria 2012
Magnitude of impact of smoking on
perioperative outcomes
• retrospective review of data from more than 500 000 patients in the US
who had non-cardiac surgery.29, 30 Information on the 30-day period
following surgery was compared for 82 304 current smokers and 82 304
control patients. Current smokers were 40% more likely to die than never
smokers. Their risk of major morbidity also increased: the risk of
pneumonia doubled, the risk of unplanned intubation almost doubled,
and the odds of postoperative ventilation increased by 50%, cardiac arrest
by 60%, myocardial infarction by 80%, and stroke by 70%. The risk of
superficial and deep infections increased by 30% and 40%, respectively,
and sepsis, organ space infections and septic shock were 30% to 50%
more likely. The increased perioperative mortality and morbidity were
confined to patients who had smoked more than 11 pack-years.
What works, What doesn’t,
What next
What works
–
–
–
–
Organisational commitment
Clinical leadership and expectations
Relevance for patients and treatment providers
Focus on benefits and return for time spent
What doesn’t
– Punitive and disciplinary action leads to escalation
What next
–
–
–
–
–
–
Full implementation of ABCD
Closing the training gaps
Finally resolve the IT – electronic documentation issue
Explore “the teachable moments” for motivation
Consistent tailored advice to stop smoking and offer of appropriate help
4 R’s right place right time right procedure right preparation!
Start the conversation
http://starttheconversation.org.au/
A Smoker’s Journey