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).

Table 1. 2014 ACS NSQIP complication rates for 21 Northern California Kaiser Permanente Hospitals

	Smokers	Nonsmokers
Postoperative complication	NCAL = 6.5%	NCAL = 5.3%
	National = 9.1%	National = 7.6%
Pneumonia	NCAL = 1.6%	NCAL = 0.7%
SSI	NCAL = 1.8%	NCAL = 1.4%
Unplanned intubation	NCAL = 0.8%	NCAL = 0.4%
Sepsis	NCAL = 3.3%	NCAL = 2.3%

NCAL: Northern California

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.
• Provision of reports to facilities and departments showing percent compliance with these processes.
• Automated CO orders in the EHR. EHRs prepopulate only for current and recent smokers. These triggers are created by medical assistant screening and documentation in the clinic.
• Obtain support from smoking cessation experts in health education, who can provide over-the-phone smoking cessation counseling and can prescribe smoking cessation aids.
• Consult the literature and regional practitioners to plan changes.^3-6

Description of the QI activity

Based on our data, Kaiser leadership chartered a small group of smoking cessation champions, including surgeons, anesthesiologists, preoperative medicine clinicians, smoking cessation counselors, data analysts, and project managers. Conversations with all parties (referring physicians, surgeons, preoperative medicine clinics, clinic medical assistants, preoperative nurses, and anesthesiology personnel) revealed support, in principle, with this initiative, as well as the need for clear and simple workflows developed with maximum automation and support. Patients expressed a clear preference for hearing about the importance of smoking cessation from their surgeon. We agreed to use a hard measure, CO, to evaluate the effectiveness of smoking cessation and also decided to make all elective surgeries eligible.⁷

Several pilot facilities volunteered for this project, which greatly helped in refining the actual workflows that could be applied within our system. A linear workflow was tested. Using this system, clinic medical assistants screened for smoking, surgeons counseled and referred patients, and smoking cessation experts supported patient efforts to quit and prescribed appropriate cessation aids. The value of these smoking cessation educators is notable due to the fact that they both counsel and prescribe smoking cessation aids, which can triple the chance of success.^8,9 Preoperative registered nurses were tasked with measuring CO upon admission, with referring providers and perioperative medicine clinics serving as a safety backup.

This clear definition of workflows allowed documentation, orders, and discrete measurement fields to be added to the EHR. Pilot work showed that automating this process and requiring minimal extra work was critical to its success.

Necessary resources and skills

A regional task force of eight members led this effort. No additional staff was required at the local facility. Programmer resources and health education resources used were already in place.

The addition of CO measurement equipment cost each perioperative location approximately $2,000. Because these devices are not subject to Clinical Laboratory Improvement Amendment (CLIA) regulations, no extra training was required. Cost of complications far outweighs the cost of smoking cessation.

Results

Figure 1 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.

Figure 1. Overview of the key data over course of project

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). 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.

Figure 2. Perioperative patient smoking cessation cards

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:

• Identify a surgical champion and multidisciplinary team
• Have reliable data
• Secure the needed funding
• Assess what other resources are needed
• Identify a pilot site
• Get buy-in from the institutional leadership

To sustain the activity, the authors recommend the following:

• Have regular team meetings
• Continue to gather patient feedback
• Engage the frontline staff
• Adhere to a continuous measurement process
• Regularly monitor the activity, and communicate findings based on data
• Celebrate achievements
• Institute best practices

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References

1. Chakravarthy U, Wong TY, Fletcher A, et al. Clinical risk factors for age-related macular degeneration: A systematic review and meta-analysis. BMC Ophthalmol. 2010;10:31.
2. Warner DO. Helping surgical patients quit smoking: Time to bring it home. Anesth Analg. 2015;120(3):510-512.
3. Lee SM, Landry J, Jones PM, Buhrmann O, Morley-Forster P. Long-term quit rates after a perioperative smoking cessation randomized controlled trial. Anesth Analg.2015;120(3):582-587.
4. Musallam KM, Rosendaal FR, Zaatari G, et al. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. JAMA Surg. 2013;148(8):755-762.
5. Nasell H, Adami J, Samnegard E, Tonnesen H, Ponzer S. Effect of smoking cessation intervention on results of acute fracture surgery: A randomized controlled trial. J Bone Joint Surg Am. 2010;92(6):1335-1342.
6. Scolaro JA, Schenker ML, Yannascoli S, Baldwin K, Mehta S, Ahn J. Cigarette smoking increases complications following fracture: A systematic review. J Bone Joint Surg Am. 2014;96(8):674-681.
7. Shi Y, Ehlers S, Hinds R, Baumgartner A, Warner DO. Monitoring of exhaled carbon monoxide to promote preoperative smoking abstinence. Health Psychol. 2013;32(6):714-717.
8. Nolan MB, Warner DO. Safety and efficacy of nicotine replacement therapy in the perioperative period: A narrative review. Mayo Clin Proc. 2015;90(11):1553-1561.
9. Warner DO, Patten CA, Ames SC, Offord K, Schroeder D. Smoking behavior and perceived stress in cigarette smokers undergoing elective surgery. Anesthesiology. 2014;100(5):1125-1137.