P1048 - Improving screening and treatment of tobacco smoke dependence and exposure in the hospitalized pediatric patient

Background: 15.6% of adults in Arizona report smoking and approximately 40% of children show evidence of tobacco smoke exposure (TSE). Pediatric TSE causes a wide variety of disease and is associated with increased emergency room and hospital utilization. The American Academy of Pediatrics (AAP) recommends that pediatricians ask families about smoking, discuss the risks of TSE, and assist with cessation. Interventions aimed at increasing TSE screening and QUITline referral in inpatient and outpatient practices have demonstrated improvements in quit rates and sustained cessation.

Objective: The purpose of this project is to evaluate the process of screening for TSE during inpatient admissions at Phoenix Children’s Hospital, improve identification of these patients, and provide meaningful assistance to their families. Perception of physician and nursing workflow was a secondary outcome.

Methodology: A quality improvement (QI) program was initiated March 1, 2020. The first plan-do-study-act (PDSA) cycle consisted of
1) Expanding the nursing intake form to include more open-ended questions about tobacco use and sources of secondhand smoke.
2) Providing an educational session for physicians and nursing staff that stressed using non-judgmental questions to screen for TSE and aiding in cessation.
3) Creating TSE handouts that included QUITline referral information.
4) Designing a discharge smart phrase to document cessation assistance in the discharge summary.
Patient charts were reviewed from December 2019 through April 2020 on one medical floor. TSE screen was positive if noted in the nursing intake form or in the physician admission note. Meaningful tobacco cessation assistance included counseling regarding current tobacco habits, discussion of strategies to quit smoking, or referral to the state quitline as documented in the discharge summary.

Discussion: A total of 1,004 charts were reviewed with 68 positive screens (6.7%) from December 1, 2019 through April 27, 2020. 6% of patients (43/717) in the preintervention weeks were positive for TSE and 8.7% (25/287) of patients screened were positive in the postintervention period. No meaningful assistance was documented in the pre or post intervention period. 92.6% of attendings, 75% of residents, and 89.5% of nurses reported that changes to TSE screening did not affect their workflow.

Conclusion: All patients are screened for TSE in the nursing intake form upon admission to PCH. Given the prevalence of smoking in Arizona, the baseline data suggests TSE is underreported during admission. By broadening the questions asked on intake and reviewing education with nursing and physician staff, we saw an increase in positive screens. We did not see a change in documented meaningful assistance. Our intervention coincided with the novel coronavirus outbreak, which resulted in lowered patient volumes during our first PDSA cycle. Data collection is ongoing and the next PDSA cycle will focus on EMR-based interventions to improve assistance given to families.