Improving Screening for Tobacco Use in Adolescent Inpatients at a Children's Hospital

Abstract

Introduction: Tobacco use is the leading preventable cause of death and disease in the United States. The majority of tobacco users begin before 19 years of age and approximately 25% of high school students report using tobacco products with 16% of those using electronic cigarettes. Despite high rates of tobacco use in adolescents and known associations with poor health outcomes, screening and treatment in the inpatient setting often is lacking. The specific aims of this quality improvement project were 1) to increase screening for tobacco use to 95% of hospitalized patients 13 years and older; 2) to increase reporting of tobacco use by 20%; and 3) to increase reporting of electronic cigarette use by 20% in 13 months. Methods Our study used the Institute for Healthcare Improvement Plan-Do-Study-Act (PDSA) cycles and included all medical-surgical units of a tertiary care, freestanding, urban children's hospital with the exception of the inpatient psychiatric unit. Four iterative PDSA cycles included workgroups with nursing leadership, focus groups with nursing staff, adding electronic cigarette use to the mandatory nursing admission intake questionnaire, and dissemination of an educational video to nursing staff on tobacco screening. Run charts were created of monthly data on the percentage of patients admitted to the institution ≥ 13 years of age screened for tobacco use, percentage of those screened who reported tobacco use, and types of tobacco products used. Results were analyzed using statistical process control analysis using QI Macros Excel® software. Results During the study period (January 2017-January 2018), 3940 patients ≥ 13 years were admitted to a medical-surgical unit. Overall screening for tobacco use in children ≥13 years for the one year prior and throughout the study period was 92.5% and remained unchanged throughout the project. Prior to interventions, reported tobacco use in patients who were screened was 2%. After the 4 PDSA cycles there was an increase to 3% reported tobacco use. Reported electronic cigarette use increased from 0 to 3 patients per month. Further review of data noted that two hospital units accounted for 50% of the deficits in tobacco screening. Conclusions Screening for tobacco use in admitted patients ≥13 years at a children's hospital was high and did not increase after interventions. Reported tobacco use was much lower than expected based on national data. Implementation of interventions resulted in a 50% increase in the reporting of tobacco use and electronic cigarette use was the major reason for the increased reporting of tobacco use. Next steps include targeting of specific hospital units with real-time feedback to improve tobacco use screening. Future goals include tobacco use cessation interventions to inpatient adolescents who report tobacco use.