Shared learning database

Blackpool Teaching Hospitals
Published date:
January 2013

The implementation of a treatment service for patients offering 'bedside' advice, information and support to patients who use tobacco, putting in place the foundation blocks for achieving a long term quit. Timely stop smoking advice shortly after admission taps into a potential period of heightened motivation, encourages smokefree policy compliance and highlights any need for withdrawal management. The service refers all patients ready to stop smoking to the Community Stop Smoking Service (CSSS) at point of discharge.

Please note that this guidance was orginally submitted to demonstrate implementation of recommendations in NICE PH10 but is also relevant to PH48 Smoking cessation - acute, maternity and mental health services, which partially updates PH10.

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 patients, both planned and unplanned admissions, are screened for tobacco use to ensure that those patients who are identified as tobacco users receive timely withdrawal management, brief advice and referral to specialist support within the hospital setting.
- To increase the number of patients, who have been identified as tobacco users, receiving effective and timely stop smoking advice at the 'bedside'.
- To improve access to NRT products for patients to support patients experiencing withdrawal management.
- To support the Trust to achieve and maintain compliance with the organisational smokefree policy.
- To increase the number of patients being referred to their local stop smoking service on discharge and promote the support available to them after hospitalisation

Reasons for implementing your project

Blackpool has a high prevalence of smoking. 8000 people are currently suffering with a smoking related disease, 383 smokers die prematurely in Blackpool every year. It is estimated that 24,800 day-case and inpatients come through the hospital per year who are tobacco users and that 80 beds at any one time are taken up with smoking-related admissions.The Trust has a Public Health Strategy, which was developed in conjunction with partners including NHS Blackpool and NHS North Lancashire. Despite the high prevalence of smoking in Blackpool, the National Health Promotion in Hospitals audit 2009 had reported low levels of health education being delivered to patients. At the same time, the Trust was also failing to reach the Advancing Quality Pneumonia targets and so both audits, along with the lack of implementation of NICE guidance PH1 and PH10, had highlighted the need for intervention:
1. Staff training was recognised as key to the implementation of the intervention. As recommended in NICE guidance PH1 and PH10 that health care professionals should be trained to give brief advice on stopping tobacco use and additional specialised training should be provided for those working with specific groups for example those who are hospitalised. A Health Education Practitioner was recruited whose main focus would be on the development and delivery of brief intervention training for staff. 2. The need for a completely smokefree hospital site was also identified as necessary to support patients in remaining smokefree during their admission. The Trust committed to a completely smokefree site in 2007.

Patients are able to use their hospital stay as an opportunity to make a quit attempt. Therefore, a change was needed to ensure that patients were being correctly identified as tobacco users and were then receiving all the support needed to stay smokefree during their admission and encouragement to remain smokefree in the longer term.

Initially, in 2009, the Trust had made links with Blackpool Stop Smoking Service. The service provided a stop smoking specialist advisor who worked in the hospital 3 days per week. The advisor worked to Department of Health (DH) 4-week quit targets. It became clear that within the hospital setting it was difficult to work to a quit target and having a specialist advisor coming into the setting from an outside organisation was difficult.

For further context can be found in the supporting material

How did you implement the project

- NICE Guidance PH10, Recommendation 8 states that smoking cessation advice and support should be available in secondary care settings for everyone who smokes. Therefore we recruited two stop smoking specialist advisors who's role it is to visit the patient at the 'bedside' putting in place foundation blocks for achieving a long term quit. Online database refers patients to local community stop smoking services at discharge.
-Monthly staff 'brief intervention' training plus training delivered at ward level. Training delivered regularly to FY1 doctors and student nurses.
-Amendments made to admission documents to prompt screening for tobacco. This ensures that the project incorporates NICE guidance PH10, Recommendation 6 that health care professionals should identify and record the smoking and/or tobacco use status of all their patients. Work continues, in partnership with the I.T department, to ensure that a prompt to screen for tobacco use and act accordingly is incorporated into the new electronic system currently being installed. These documents have been added to the Trust's Nursing Care Indicators and Medical Care Indicators plans.
-For AQ Pneumonia - green stickers were used in all medical patient notes to prompt staff screen. See appendices.
-To ensure the project incorporated NICE guidance PH1 recommendations that practitioners with suitable training should offer a prescription of pharmacotherapy in line with NICE technology appraisal guidance number 39 and additional support a range of Nicotine Replacement Therapy (NRT) products were added to the formulary. This action also incorporated PH10 recommendation 4 that states that a combination of NRT should be offered to patients who show a high level of dependence on nicotine. Brief intervention training includes - discussing the options of NRT with the patient. Patients identified as smokers are treated for tobacco withdrawal through prescription of NRT.

Further detail on Methods and barriers can be found in the supporting material.

Key findings

Evaluation of the work to date has been through a range of methods.
- Referral data is collected monthly and uploaded onto the Trust internet under 'performance data' and includes:
- Number referred via e-referral system including by ward and named referrer.
- Number registered on QuitManager
- Number attending first appointment within community setting (data only available for Blackpool)
- Number smokefree at 4 weeks (data only available for Blackpool)
- Walking audits of the hospital site are conducted bi-monthly to monitor adherence with compliance to the smokefree policy. This information is uploaded onto the Trust internet under 'performance data'.
- Staff training figures are collected monthly for each ward and department areas. These figures are monitored and any areas poorly represented are encouraged to attend and offered additional ward based training.
- Evaluations are collected from staff on both the classroom based and ward based training. Referrals to the service has significantly increased since the change over to the new service model. (figures attached)
The AQ Pneumonia data has seen significant improvements as consistently more patients are being identified as smokers and are being given advice. This acheivement was recognised within the Trust as the AQ Pneumonia team recieved a 'Team of the Year' recognition award for the imrpovemnts that the team had achieved.
Funding has recently been secured to work in partnership with the University of Central Lancashire to recruit a research post to evaluate this service. More detailed data will be available within the next 12 months - with a focus on how the service has contributed to improved recovery and any reductions in length of stay.

Key learning points

- embedding a stop smoking service within the Trust has enabled the service to develop and has increased engagement with staff.
- removing the DH 4 week quit target enables the service to focus on building the foundations to a long term quit with patients rather than trying to focus on targets which are not appropriate to the secondary care setting.
-Implementing a smokefree policy and achieving compliance is vital to the success of any inpatient stop smoking service. This work goes hand in hand.
- staff attitudes, and their own relationship with tobacco, can be a huge barrier to the success of this type of service but the development of the staff responsibility campaign, to gain support from all staff in relation to the smokefree policy, has helped to overcome this.
- as it can be difficult to engage staff with the training, particularly with so many competing priorities in busy ward environment - it is important to offer as many options as possible and work with the ward managers to deliver training in the most flexible ways.
- Working closely with ward managers has been important to gain the support for the service. Basing the stop smoking advisors in 'key target areas' is helpful as a means to engaging staff and embedding the service within these areas. For example Acute Medical Unit and maternity.
- Executive sponsership of the service and the smokefree policy has been essential to the success.

Contact details

Rachel Swindells
Public Health Facilitator
Blackpool Teaching Hospitals

Secondary care
Is the example industry-sponsored in any way?