ACS Bulletin - September 2017

Results

Figure 1, this page, is an overview of the key data over the course of the project.

We encountered several setbacks in implementing this program, including extreme time demands on clinic and perioperative areas and difficulty in capturing all smoking cessation referrals, with some direct local referrals leaving no signal in the EHR.

Selected workflows continue to be hard to measure, but we are probably doing better than we think. We also are finding that CO measure orders are inconsistently executed, and this is now a quality target for our perioperative areas.

Some facilities are at 90 percent success with this measure.

And lastly, we need to clearly define when a case should be canceled based on CO results.

Solutions to these barriers
include development of simple,
automated workflow and decision
support cards, which are based
on the Mayo Clinic model and
given to patients in the clinic
to focus the conversation on
the importance of preoperative
smoking cessation (see Figure

2, page 53). Other effective means for addressing these setbacks include standardization of referral pathways and measurement and asking patient-specific queries when CO is not completed or documented.

In the near future, a single electronic smoking referral will be generated for all patients and should assist with reliability and data capture, and staff-specific reports will help managers identify and coach when CO measures are missed.

The cancelation of elective cases is evidence-based but highly disruptive and will be the focus for upcoming work. 4 It is important to note that the initial phase of this activity is to get people to willingly stop smoking.

Kaiser has had to make minimal revisions to date in the original QI plan due to limitations encountered during the process.

However, it should be noted that substances smoked other than tobacco, vaping, and chewing tobacco could not be addressed at this time due to lack of resources.

The total cost of implementation during the first two years across the 21-hospital system was $70,000, including cost of disposable measurement device, counseling, and nicotine replacement. It is too soon to determine actual cost savings for this project; however, our goal was a 25 percent quit rate, and we are seeing an approximate 50 percent reduction in active smoking by the day of surgery.

Lessons learned

For those institutions and health care systems seeking to start a preoperative smoking cessation program, the authors offer the following recommendations: