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Shared learning database

Bolton Council & Bolton NHS Foundation Trust
Published date:
July 2014

To ensure hospital inpatients who smoke are identified and subsequently routinely offered advice and support regarding smoking cessation. That inpatients are offered evidence based approaches to quitting or temporary abstinence. This specifically supports guidance set out in PH48 Smoking Cessation in Acute, Maternity & Mental Health Settings but also cuts across several other NICE guidance including: PH1; PH 10; PH 26; PH 14 PH45 PH 48.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

To ensure hospital inpatients are routinely offered advice and support regarding smoking cessation. The main objective was to create a pathway that was not too onerous to learn and practice and one which has the backing and belief of the individuals delivering it i.e. healthcare staff. The pathway needed to be available to patients 24 hours per day every day of the year. The pathway should ensure the delivery of evidence based interventions and support including the best use of all available pharmacological products. The pathway should also ensure that the potential for patients to fall through gaps for follow up support are minimised.

Reasons for implementing your project

Initially there was a fragmented, ad hoc and non-standardised approach to identifying smokers and offering advice and support within the hospital setting. A small irregular trickle of patients were referred to Stop Smoking Service each week but these were often difficult to contact. A hospital deals with a large number of people each year from a variety of backgrounds, but high numbers from deprived areas with high smoking rates. We estimated that the average local smoking prevalence was at the time about 26%. Given that people who smoke tend to present more often to hospital with illness the population of smokers within a hospital could eaily be double the local number. These people have varying heath needs and attendance at hospital is part of an attempt to address such illness. As such they can be more open to interventions concerning their health than in their usual routines. It was an obvious gap in overall community-wide service provision if the hospital was a place which was unable to advise or support people adequately to attempt to quit or abstain from smoking. Also, it was considered to be a public health failing that a large and health-promoting environment was not extensively used to promote and support the significant health benefits of smoking cessation. In addition to this, it was also known that some staff smoke and this may also be tackled within a framework of hospital based smoking cessation interventions. The development of a smokefree site policy also required that as much help as possible was available to inpatients to help them attempt to remain smokefree whilst on the site.

How did you implement the project

1. Training for staff regularly delivered and referral process made apparent and available. This quickly increased referrals to the local Stop Smoking Service.
2. Staff also seemed to be making quit attempts that they may not otherwise have considered.
3. Outpatient referral capacity was quickly improved but inpatient access to smoking cessation support was not initially available. The Level II pathway offers an adequate level of support to inpatients who cannot access community based services whilst admitted. Patients admitted to hospital for a variety of reasons, are now routinely offered advice and support to stop smoking or abstain.
4. The hospital is increasingly working with the Local Authority on public health and increasingly taking a role in delivering public health and health promotion practices alongside its usual secondary care role.
5. The practice also provides practical support in implementing a smoke free hospital site policy. As this pathway utilizes existing hospital staff, costs were minimal other than the time spent in training. Given that a patient who stops smoking is often discharged sooner and less likely to be re-admitted it is likely to be a cost effective practice to implement.

Key findings

Hospital staff were and still are, regularly consulted for their input on smoking cessation practices from the design of forms and training, to training delivery approaches, update planning and delivery. Each training session delivered is evaluated to seek indication if the training meets their needs and expectations.
The number of referrals at Level I are recorded when received at the Stop Smoking Service. Level II referrals again are all recorded at the Stop Smoking Service and within hospital patient case notes. Data from pharmacy also alerts us to where stop smoking pharamacology has been prescribed which can be matched against referrals to see which patients have not been offered behavioural support through the pathway. Costs of hospital practices involving supply of NRT have been obtained from pharmacy purchase and dispensing records.
Actual costs are difficult to determine but a recent evaluation put pharmacology costs at approximately £3000-£5000 per year for about 250 patients put on a supported quit attempt. There are approximately 25 referrals into the Stop Smoking service each month. These are from a fairly restricted number of but high priority aras such as cardiology and respiratory. The overall quit rate of the Level II referred paitients is about 40-45%. Given the cost effectiveness data provided by NICE this looks to offer a very cost effective service.
Verbal feedback from patients themselves has on the whole been very positive and they view the practices as being of value and important to them.

Key learning points

1. Smoking cessation interventions should be available at ALL times and not just office hours.
2. Put in place safeguards against smoking cessation pharmacotherapies being prescribed independently of some behavioural support as this does not follow the evidence base and will not be cost effective.
3. Dedicated training is required to equip hospital staff with the skills, knowledge and confidence to intervene in patients smoking (Such training is unlikely to be appropriately delivered in less than three hours).
4. Buy-in from senior management and pharmacy will ease implementation of a pathway as these can be significant barriers otherwise.
There are many known learning points and many still emerging, there is an additional document uploaded with this preliminary explanation which offers a more descriptive methodology of the level II pathway itself.

Contact details

Gary Bickerstaffe
Programme Manager Public Health
Bolton Council & Bolton NHS Foundation Trust

Is the example industry-sponsored in any way?

Some of the staff Level II training sessions and clinical staff update sessions received sponsorship from pharmaceutical companies. This usually involved supplying refreshments and product information on training and pharmacology update sessions.