Preoperative smoking cessation:
Every patient, every operation
Smoking adds approximately $200 billion in spending to the U.S. budget annually,
mostly because of health care
spending and lost productivity.
Smoking remains one of the
foremost preventable causes
of mortality and morbidity
and is the cause of close to half
a million deaths per year.
1, 2
Smoking is a well-reported risk
factor for most American College
of Surgeons National Surgical
Quality Improvement Program
(ACS NSQIP®) complications,
and the surgical event is
potentially one of the most
effective times to get patients
to successfully stop smoking.
Nonetheless, efforts to identify,
counsel, treat, and measure
successful smoking cessation
often are sporadic in health care.
Identification of local problem
A 2014 analysis of ACS
NSQIP complications at
Northern California Kaiser
Permanente—a 21-hospital
integrated health care network
that provides comprehensive
care to 4 million patients in
21 medical centers and 12
ambulatory surgery centers
(ASCs)—showed a 1.5- to two-
fold increase in complications in
patients who smoked. Internal
data culled from an in-house
questionnaire of hundreds of
select postoperative patients
suggests that only 50 percent
of smokers remembered being
advised to stop smoking and
only 4 to 8 percent were given
effective smoking cessation
aids. Actual measurement
of smoking cessation and
clear referral pathways
were unclear or nonexistent
(see Table 1, page 51).
How was the QI activity
put in place?
Surgical outcomes measures
using data from ACS NSQIP,
a consistent platform for
electronic health records (EHRs)
and orders, and a proactive
health education group were all
used to carry out this initiative.
A foundational element was
for our surgeons to recognize
the impact they have on
patient behavioral decisions
and to take ownership of
patient smoking cessation.
Other critical planning steps
included the following:
•Identification of best practices
and tested workflows developed
by David O. Warner, MD,
professor of anesthesiology,
Mayo Clinic College of
Medicine, and co-director,
Mayo Clinic Office of Health
Disparities Research, Rochester,
MN. These guidelines needed to
be adapted to the needs of the
network and its patients, but we
determined it was an attainable
goal.
•Development of a defined
screening and referral process for
surgical clinics and preoperative
medical clinics.
•Clear definition of eligible
patients: all smokers, all surgery
types, inpatient and outpatient.
Inpatient surgical patients, direct
transfers from emergency to
operating room, and cataract
operations were exempt.
•Clear agreement on how to
measure a successful quit,
specifically, exhaled carbon
monoxide (CO) reading day of
surgery.
•Provision of equipment to
measure CO preoperatively on all
smokers coming from home.
•Development of clear and
accountable workflows.
•Automated support of screening,
referrals, and prescription of
medications.
by Paul Preston, MD;
Efren Rosas, MD, FACS;
and Tammy Peacock, RN
