1. 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

2. 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

3. Enablers London Clinical Senate (LCS) – Helping Smokers Quit Program
3yr Making Every Contact Count (MECC) CQUIN
CO monitors paid for from CQUIN funds

4. 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

5. Recording the CO test via Electronic Patient Record (EPR)

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

7. 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

8. CO test completion by ward and month
RD Lawrence
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

9. 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

10. 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

11. 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

12. 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

13. Staff feedback on the pilot study

14. 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?

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

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

17. 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 ?”

18. 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”.

19. 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

20. 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!

21. Thank you