Stacy Giardina BSN, RN Quality Department West Virginia University Medicine

1. Smoking Cessation Treatment Beginning During Inpatient Admission Using the Electronic Health Record Stacy Giardina BSN, RN Quality Department West Virginia University Medicine Authors: Samantha Minc, MD, MPH; Stacy Giardina BSN,RN; Jason Hwang, DO; Megan Lauris; Marc Phillips, PharmD, CPHQ; Rebekah Matuga, PharmD, CPHQ; Luke Marone MD

2. Disclosures • The authors of this project have no financial disclosures

4. US Preventative Services Task Force Guideline (2015) • The USPSTF recommends that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and providebehavioral interventions and US Food and Drug Administration (FDA) – approved pharmacotherapy for cessation to adults who use tobacco. (Grade A)

5. Tobacco Quitlines (TQL) • 1-800-QUITNOW • Provide counseling and support to quit • Provide information about medications and behavioral counseling • Convenient and free • Proactive coaching calls and unlimited reactive calls • 8 weeks of nicotine replacement therapy (NRT) – patches, gums, or lozenges

6. TQL + NRT triples the odds of smoking cessation success • Unassisted abstinence rates: 3-5% • Tobacco Quitline abstinence rates: 10% • Tobacco Quitline with NRT abstinence rates: 15%

7. Tobacco Cessation Quality Charter

8. EHR and Tobacco Cessation

9. How it Works • Upon admission, a best practice advisory (BPA) alert prompts the provider if patient has smoking history. Alert contains: • Order set for tobacco cessation counseling referral • Order set for IP nicotine replacement • Addition of tobacco use to problem list • Notification to PCP that referral was made • Patient can start cessation treatment during admission

10. Outcome measures • Primary Outcomes: • Referral utilization by providers • NRT utilization by providers • Pharmacotherapy utilization by providers • Secondary Outcomes: • Patient utilization of Quitline • Patient smoking cessation at 3 months, 6 months, 1 year

11. Results

12. In-roads to Quality Improvement • Organized group meetings to talk to all providers • Reception has been positive as all physicians and APPs see the importance of smoking cessation. • Utilization of BPA and order set to send in-box messages to PCP. • Systematic attempts to follow-up on patients. • Can be difficult → Lack of compliance

13. Challenges & Improvements • Nurses not required to record and/or update tobacco use in the patient’s history upon admission. • Held meetings with the nursing administration in order to make this a requirement and enforce it.

14. Challenges & Improvements • WV TQL requires a formal state-approved enrollment form be faxed to them upon referral. • Delays in patient enrollment • Unrealistic expectation upon providers • We removed this barrier to streamline the process of obtaining referral to TQL.

15. Challenges & Improvements • WV TQL required photo ID to be faxed to them in order to enroll patients before starting therapy. • Unrealistic expectation • The photo ID that are taken of patients when admitted to the hospital on EPIC now count.

16. Challenges & Improvements • WV TQL calls from an unidentified line for patient privacy • Some patients do not pick up the phone • When leaving voicemail, they do not directly identify themselves. • Patients do not get follow-up • Educated patients that a phone call is coming from an unidentified line.

17. Challenges & Improvements

18. Success Factors • Administrative support was instrumental in getting this project off the ground. • The WV Hospital Association Honor’s Program: • Highlighted increased access to tobacco cessation as a requirement for Honor Roll designation in 2018. • This provided administrative motivation to support the project. • Identification of a physician champion was critical at the early stages in order to vet the program and engage physicians as the project progressed.

19. Future Directions • The team is modifying the order set so this process can be rolled out to outpatient clinics. • To assess utilization the VQI data managers are adding #TQL to comments in VQI abstraction sheets to indicate that a patient was appropriately referred to the Tobacco Quit Line. • In the future the follow up modules will be used to assess for efficacy.

20. Conclusions • Tobacco use in the vascular surgery patient is prevalent and a preventable source of disease progression and complications. • Smoking cessation programs are shown to be more effective than nothing in aiding patients to quit. • EHR is an integral part of daily workflow and presents a unique opportunity to capture, enroll and help every patient seen by the vascular surgery service.

21. Thank You