WHO-CC Copenhagen would like to thank

1. WHO-CC Copenhagen would like to thank The Minister of Health RajkoOstojić, Dr. Antoinette Kaic-Rak, Head of WHO Country Office, Prof.MirnaŠitum, Head City of Zagreb Health Authority, Prof.DavorMiličić, Dean Medical School University of Zagreb, Prof.MirnaŠitum, Head City of Zagreb Health, Prof.DavorMiličić, Dean Medical School University of Zagreb, Prof.JadrankaBožikov, Director AndrijaŠtampar School of Public Health, Medical School University of Zagreb, Selma Šogorić, The SEEHN Network, All teachers and presenters, All the participants

2. Day 1 Welcome addresses Break Evidence-Based Clinical HP (H Tønnesen) The International HPH Network (T B Jensen) WHO Country Office Croatia (A Kaić-Rak) Example: HPH National Network of Ireland (N Eldin) Lunch Importance of HPH Development in Croatia (SŠogorić) Workshop: HP in your department? (H Tønnesen) Break Workshop: HP in your department? (cont.) (H Tønnesen) Final reflections and wrap-up of day 1 (All participants)

3. Day 2 Welcome The WHO HPH Standards (H Tønnesen) Workshop: Using WHO HPH Standards (All participants) Break The HPH DATA Model (H Tønnesen) Lunch The HPH Doc Act Model (H Tønnesen) Workshop: Using the HPH Models (All participants) Break Other HPH Resources and Training (T B Jensen) Example: HPH Task Forces (H Tønnesen) Final reflections and wrap-up of day 2 (All participants)

4. Day 3 Welcome WHO HPH Recognition Process: Fast track implementation (H Tønnesen) Ex: WHO HPH Recognition Project Slovenia (J Farkas-Lainscak) Break Possibility of development of WHO HPH Recognition Project in Croatia (H Tønnesen) Panel discussion: Networking and collaboration to sustain and expand HPH developments in Croatia (Key persons) Lunch Final Reflections (H Tønnesen) Evaluation, Certificates and Photos (All participants) Farewell

5. Take active part in the Seminar Become familiar with HPH topics at hand Ask questions and discuss Make your own network within the Seminar Give us inspiration for subjects, content and form for the upcoming HPH Seminars and Schools Use your new knowledge at home We hope that you will

6. Evidence-Based Clinical Health Promotion Prof. Hanne Tønnesen MD PhD CEO at the International HPH secretariat, WHO-CC Copenhagen

8. WHO: Terms of references • WHO-CC support countries to: • Implement WHO principles for HP • Use HP strategies and standards • Create further evidence • Teach and train staff in EB HP • Implement best EB practice for HP

9. Distribution of members by April 2014 >950 member Hospitals and Health Services worldwide

10. Best Evidence Staff expertise Patient preference Best HP PracticeIncludes all three parts (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

11. What is CHP? Health Promotion = “enabling people to increase control over, and to improve their health”* Clinical = involving patients (klinikos) EB: Evidence at highest possible levels *WHO 1998

12. What is CHP? HPH CHP bridges clinical treatment and public health - thus helping patients, families, community and society

13. Why is HP important in health care? • High prevalence of patients with unhealthy lifestyle and NCDs • Adding HP to treatment improves the outcome on short and long term • Hazardous working conditions in hospitals • Reduce risks & improve working conditions • Hospitals as knowledge-organizations • Intersectoral development of HP activities for community orientation • Production of waste & hazardous substances • Ecological approach towards waste, energy management

14. Facts about Clin HP Poor lifestyle + Treatment ----------------------------------------- = Poor outcomes

15. Facts about Clin HP Poor lifestyle + Clinical Health Promotion +Treatment ----------------------------------------- = Bettertreatmentresults

16. Smoking abuse Aggravation of other diseases & conditions, outcome & prognoses Improved outcome & prognoses of others Description Smoking-related physical and psychosocial damage Reduced smoking-related damage Intervention No abuse

17. Disease / diagnosis Intervention Organisation Individual patient-related factors Health Diet and nutrition Smoking Alcohol Physical activity Co-morbidity (chronic diseases) Factors of importance for the outcome in patient path-ways

18. Surgical patients 30% daily smokers 7-49% hazardous alcohol consumption (Tønnesen et al 2008, Neumann et al 2008) Prevalence • Hazardous intake: >14 units/week for women and >21 for men • 1 unit =12 g ethanol

19. Smokers and drinkers are over-represented in hospitals compared to the general population Cont.

20. Focus on a clear risk reduction Changing to a better risk group Fixed day for surgery Short preoperative period Long postoperative stay for complicated patients Patient expectation Complication-free surgery Support of motivation to doing their “home-work” Window of opportunity The surgical agenda

21. > 40 studies have shown that hazardous alcohol intake is related to increased postoperative morbidity > 300 studies have shown that smoking is associated to increased postoperative morbidity Postoperative morbidity Br J Anaesth 2009

22. Daily smoking Alcohol shows a dose respons relationship How much is too much?

23. OR 8 6 4 2 Units per week 0 0 1 - 7 8 - 14 15 - 21 22 - 35 >35 How much is too much? Dose response curve for anastomosis leakage after colorectal resection Sørensen LT: Ann Surg 2002

24. 3-4 units per day in average 50% increased complications 5 units per day or more: 400% increased complications Alcohol intake(compared to 0-2 units per day)

25. 200% increase in posoperative morbidity Daily smoking

26. Alcohol Wound rupture & infections Cardiac compl Pulmonary compl Bleeding episodes Smoking Wound rupture & infections Pulmonary compl The most frequent compl.

27. All types of surgical interventions All types of surgical settings Increased risk for postoperative compl. Br J Anaesth 2009

28. Smoking

29. What is the documentation? Effect of intervention on postop morbidity

30. + Quality Meta-analysesSyst reviews RCT (intervention) CCT (intervention) Cohorts, Case-Control studies (Obs) Cases (Obs) Editorial papers and Consensus (’GOBSAT’) Animal Studies In Vitro studies Evidence degree: Pyramid (Eccles M BMJ 1998)

31. Quit smoking before surgery (OBS) Conclusion It is very dangerous to stop smoking less than 8 weeks before surgery ! (i.e. it is better to recommend cont smoking instead of risking more complications) (DO Warner Anaest 1984)

32. DO Warner Evidence degree: Pyramid Meta-analysesSyst reviews RCT (intervention) CCT (intervention) Cohorts, Case-Control studies (Obs) Cases (Obs) Editorial papers and Consensus (’GOBSAT’) Animal Studies In Vitro studies

33. Smoking cessation intervention at surgery 13 RCT on preoperative smoking cessation intervention 6 RCT have evaluated the effect on postoperative complications 3 RCT showed significant reduction in complication rate (T Thomsen, Cochrane 2014)

34. Periop. SCI 6 included complications (T Thomsen, Cochrane 2014)

35. All complications Brief intervention incl. Q RR = 0.96 (0.74 – 1.25) Intensive programmer = Gold Standard Programs (GSP) RR = 0.42 (0.27 – 0.65) Postop complications

36. Wound compl Brief intervention incl. Q RR = 0.99 (0.70 – 1.40) Intensive programs = Gold Standard Programs (GSP) RR = 0.31 (0.16 – 0.62) Postop complications

37. Effect on postop complication6-8 week intensive prior to knee and hip replacement surgery AM Møller et al: Lancet 2002

38. Is smoking cessation >50% possible ?RSB Standard: > 80 000 ptt %

39. Møller SørensenLindström Thomsen Thomsen DO Warner Evidence degree: Pyramid Meta-analysesSyst reviews RCT (intervention) CCT (intervention) Cohorts, Case-Control studies (Obs) Cases (Obs) Editorial papers and Consensus (’GOBSAT’) Animal Studies In Vitro studies

40. Alcohol

41. Postoperative complications (BMJ 1999) (Pilot project) (Alc Alc 1999) (K Oppedal, Cochrane 2012)

42. Tønnesen Oppedal Shourie Evidence degree: Pyramid Meta-analysesSyst reviews RCT (intervention) CCT (intervention) Cohorts, Case-Control studies (Obs) Cases (Obs) Editorial papers and Consensus (’GOBSAT’) Animal Studies In Vitro studies

43. R n =20 7 (5-40) n = 22 6 (5-40) n = 1 withdrawn: polyneurop 0-4w n =20 0 (0-0) n =21 6 (5-40) n = 2 withdrawn: 1 no OP 1 laparosc n = 4 withdrawn: 2 no OP 1 laparosc 1 delayed OP 4-8w n =16 0 (0-7) n =19 1 (0-11) Alcohol intake in units/day RCT: 4 weeks abstinence program before colorectal resection 42alc patients 7 (5-40)

44. Prophylaxis: B-vitamins + thiamine Clordiazepoxide 10x10 mg tablets Controlled Disulfiram 2 x 200 mg/ wk Psychosocial: Weekly visits at surgical dept Open hotline Measurements of organ functions 4 weeks preop program - aimed at abstinence from alcohol (BMJ 1999)

45. Intervention • Effective alcohol intervention program • 5% effect on alcohol abuse: NNT = 40, • 90% effect: NNT = 2-3 • The long-term effect is a positive ‘side-effect’ • Brief intervention has no significant effect in hospital settings Cochrane Review 2008

46. Alcohol cessation int. Colorectal Resection Smoking cessation int. Hip/Knee Replacement Physical exercise int. Spine Surgery Postop recovery (BMC Health Serv Res 2008) Postop complications (BMJ 1999) Postop complications (Lancet 2002) Even physical exercise …

47. Best Evidence Staff expertise Patient preference Staff expertise (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)

48. 100 + 100 Emergency patients (smokers and alcohol abusers) 47 of 100 accepted when offered brief intervention by the staff nurses 97 of 100 accepted when offered BI by an trained nurse from HP Clinic Clinical expertise The influence of especially trained nurses Nelbom et al 2004, Backer et al 2007

49. Smokers and alcohol abusers from the emergency wards accepted BI 97 / 100 from dept internal medicine 121 / 200 from orthopaedic department 68 / 100 from dept neurology Quit rates 30 to 50% stopped smoking and alcohol abuse for a short period 5 to 10% stopped for at least a year Trained nurses Nelbom et al 2004, Backer et al 2007, Tonnesen et al 2009 submitted

50. Patient experiences Best Evidence Staff expertise Patient preference (Sackett, DL, Strauss SE, Richardson WS et al. Evidence-based medicine. Churcill Livingstone 2000)