Implementing routine carbon monoxide testing on two acute medical wards – a pilot study Arran Woodhouse Tobacco Liaison Specialist Dr Irem Patel Consultant Respiratory Physician/ Smokefree Lead

Background King’s has approximately 6,500 smoking related admissions per year Smokefree Policy and grounds since January 2015 2 Acute Medical Wards chosen for CO pilot Nurse led Develop the conversation with patients that smoke Record test via Electronic Patient Record Oliver/ RD Lawrence ward commenced October 2015 Annie Zunz ward commenced February 2016

Enablers London Clinical Senate (LCS) – Helping Smokers Quit Program www.londonsenate.nhs.uk/helping-smokers-quit/ 3yr Making Every Contact Count (MECC) CQUIN CO monitors paid for from CQUIN funds

CO monitor use training 15 minute sessions on the ward 2-4 staff members per session Trained by Tobacco Liaison Specialist Supporting materials issued - LCS materials and CO monitor guide Posters displayed in staff areas Attendance at board round/ handover meetings

Recording the CO test via Electronic Patient Record (EPR)

Challenges Staff availability Ward changes Monitors False positive readings Recording data Patients not completing the test

Ward Champions Recruited during the pilot study Train and advise staff Ensure tests are completed Raising problems/issues Disseminate performance to colleagues Link with Tobacco Liaison Specialist

CO test completion by ward and month RD Lawrence 2015-16   Total screened Total CO tests % Oct 217 26 12 Nov 260 130 50 Dec 194 156 80 Jan 95 61 Feb 131 76 58 Mar 137 92 67 Apr 179 115 64 May 104 Total 1404 794  56% Annie Zunz 2016   Total screened Total CO tests % Feb 136 73 54 Mar 175 120 69 Apr 272 237 87 May 176 141 80 Total 759 577  76% Over 1,300 patients have had their CO level tested on admission

Incomplete screening/CO tests by month   Patients that declined screening Unable to conduct screening Total Feb 3 8 11 Mar 4 7 April 13 14 27 May 18 30 48

Smoke more than 10 cigs per day % of patients that smoke CO pilot data Smoking status and number of cigarettes smoked by patients prior to admission by month for both wards Smoke more than 10 cigs per day 3-9 cigs per day Less than 3 cigs per day Non-smoker Total % of patients that smoke Non-smoker CO>6ppm February 39 12 5 237 293 19 33 March 23 17 7 279 163 14 59 April 50 31 11 354 446 21 60 May 30 10 335 408 18 67 An average of 18% of self-reported non-smokers had an elevated CO level

Elevated CO levels CO level >6ppm for smokers and self-reported non-smokers by month CO level 6-10 ppm 11-15 ppm 16-20 ppm 20+ ppm Smoker Non-smoker Feb 20 16 4 7 1 3 Mar 14 39 9 6 2 5 Apr 30 46 11 8 May 26 56

Provision of NRT/Champix Provision of stop smoking medications by month for both wards Total no. of patients issued NRT No. of smokers Self-reported non-smokers Patients declined screening Not screened Feb 31 19 6 1 5 Mar 17 8 4 April 23 14 May 27 12 3

Staff feedback on the pilot study

How confident are you to explain to a patient their CO level? Staff feedback How confident are you to explain to a patient their CO level?

Staff feedback How does the CO test help you understand a patient's level of smoking?

Staff feedback In your opinion do you think the CO test is a useful tool to motivate patients to be smokefree?

Staff comments on the pilot study “CO monitoring is useful. But personally still struggle in having confidence to discuss stop smoking and CO reading with patients. Currently inform patient that the CO test shows a reading of X number and if stopped smoking the number would drop significantly even within 24 hours. I believe this is helpful for them but its difficult to understand the CO reading properly as it is not quantifiable or is it ?”

Staff comments on the pilot study “There have been difficulties in getting the whole team to understand the importance of the initiative and completing the CO test”. “Due to nature of the ward being busy not always the priority”. “Finding that if it is not done during the shift the patient was admitted it is not always picked up”. “When people get a high CO score they often become unduly concerned with it. It is hard sometimes to explain the importance of the score whilst enabling the patient to maintain perspective and not panic”. “Feel that we should continue to test CO levels. Proud to be part of this initiative”.

Summary of initial findings CO monitoring in AMU setting; Is feasible and acceptable Improves clinician understanding of patient’s tobacco dependence Improves clinician confidence to have the ‘right’ conversation Provides a clinical assessment of smoking status Highlights patients at risk of acute nicotine withdrawal Can identify patients who do not self report Reinforces a smokefree culture within the organisation

Next steps Medical teams trained in VBA Develop expertise of ward staff Study extended to observe affect on referral levels and NRT prescribing Paediatric and Emergency departments The next routine observation!

Thank you arranwoodhouse@nhs.net 0203 299 2600