Preoperative Smoking Cessation Counselling in the Hospital District of

Ms Reetta -Maija Luhta , Co -ordinator of Smoking Cessation Services Co-ordinator of the Finnish Smoke-Free Hospital Network, Hospital District of South Ostrobothia,Seinäjoki, [email protected]

www.epshp.fi The Main Goal: Tobacco-Free Finland 2040 -A 10 % decrease in the use of tobacco yearly

3.12.2013 www.epshp.fi 1 Health Services of South Ostrobotnia

Private health care Specialized medical Primary Occupational and services- Central Hospital health care health care occupational health care Unit for the Development of Primary Health Care • 8,500 health care and Health Promotion professionals • 11,000 elective surgeries • Approximately 1,500 smoking patients operated on yearly

3.12.2013 www.epshp.fi 2 Seinäjoki Central Hospital Population of South Ostrobothnia: 198,000

Joint Municipal Authority Kaksineuvoinen Lake Ostrobothnia Cooperative Region – Evijärvi – Lappajärvi Alajärvi – – Soini 23, 048 Evijärvi 15, 543

Lapua Health Centre 14 ,698 Kauhava Lappajärvi Vimpeli Seinäjoki Health Centre Seinäjoki – Isokyrö 65, 326 Isokyrö Alajärvi

Soini Seinäjoki

Ähtäri Jalasjärvi Municipally Owned Company for Joint Municipal Authority for Health Services Primary Health and Social Kuusiokunnat Services Alavus – Kuortane – Ähtäri Kauhajoki – – Isojoki 22 ,249 Karijoki – Teuva 23 ,559 JIK Municipally Owned Company for Primary Health and Social Services Jalasjärvi – Ilmajoki – Kurikka 34,324

www.epshp.fi 1.Initiative for smoke-free surgery

• The Medical Director of South Ostrobothnia Hospital District was the first in Finland to suggest an initiative for smoke-free surgery in Oct 2011 (Consultation with the Senior Medical Officer of the Operative Services) • Aim: Faster recovery, resulting in lower expenditure • The model has been extensively tested in Sweden and Denmark (www.enrokfrioperation.se) • Commitment from senior officers in both primary health care and specialized medical services to start developing the model in Nov 2011.

www.epshp.fi 5 2. Planning the model for Smoke-Free Surgery • The model was planned during the year 2012 in collaboration between representatives from specialized medical services, health centre and occupational health care • Existing material was partly used in planning the model and material kit • Teams were set up in seven health centres to plan the implementation of the smoke-free surgery project.

www.epshp.fi 6 3. Training helps staff approach smokers • In the years 2011-2013, eleven regional smoking cessation courses (1+½ day)were arranged for staff • Total number of participants: 330 • In addition, 31 training sessions (1,5 hour) were arranged in hospitals and health centres • Number of participants: 380 • Smoking cessation material is now included in electronic patient records

www.epshp.fi 7 4. Adverse effects of smoking in South Ostrobothnia: Preventable premature deaths per year, estimate

• Smoking 217 Ennenaikaiset kuolemat • Nutrition 181 250

• Lack of exercise 145 200 • Accidents 101 • Alcohol and drugs 90 150

• Suicides 50 100

50

Anne Pietinalho 0 ti

Filha 2006 semus ähäisyys Tupakoin Itsemurhat Ravit Tapaturmat holi/huumet an v Alko

Liikunn www.epshp.fi 8 What would the yearly consequences be if there were no smokers in South Ostrobothnia?

We could prevent 181–208 premature deaths; −80–107 related to cardiovascular diseases −64 related to lung cancer −37 related to COPD We could save 64 million € per year Anne Pietinalho Filha 2006

www.epshp.fi 9 5. Is it possible to affect people’s lifestyle? • Counselling by a nurse increased smoking cessation by 28%, doctor’s order by 66% (17% of the participants quit smoking) (Cochrane Database Syst Rev 2008 Apr 16; (2))

• Intervention techniques tailored for patients undergoing a “sensitive” period bring better results (Duodecim 2011;127;2265-72)

3.12.2013 www.epshp.fi 10 Health promotion approaches

• ”Health promotion should be embedded in the processes so that it takes place systematically ” • Making use of the authority role of specialized medical services and of the sensitive period in the patient’s care • Can we afford to ignore the contribution specialized medical services could make to health promotion? (Lääkärilehti 45/2011; 3451)

3.12.2013 www.epshp.fi 11 Health counselling

• Patients must have a chance to evaluate the benefits of quitting without judgmental staff attitudes • Permanent self -motivated change can be achieved if doctors support patient autonomy • Even small-scale action can lead to major results among people at risk of getting ill • (Duodecim 2011; 127; 2265-72)

3.12.2013 www.epshp.fi 12 6.Does smoking jeopardize the medical benefits of surgery?

• Sympathicotonia => reduced oxygen supply • Effect on blood coagulation system • Vulnerability to infections • Collagen synthesis can be affected • Pulmonary problems (Suom Lääkäril 2006; 61:3203-8)

3.12.2013 www.epshp.fi 13 Any evidence-based research on the benefits?

• Most critical risks: plastic and foot surgery • Smoking cessation intervention will reduce the risk of complications by half (Br J Surg 2009;96.451 -61) • These interventions are cost-effective (Chest 2009,135:477-83)

3.12.2013 www.epshp.fi 14 Prosthetic surgery

• Preoperative (6-8 weeks) smoking cessation • Complications decreased by 52%=>18% • Wound complications 31%=>5% • Cardiovascular complications 10%=>0% • Second operation 15%=>4% (Lancet 2002;359:114-7) • Average savings resulting from reduced number of hospital days 313€/patient (Chest 2009; 135 no2:477-483)

3.12.2013 www.epshp.fi 15 Lung and wound complications

• Smoking cessation at least 4 weeks before surgery: • Lung complications -50% • Wound complications -30% (Can J Anaesth 2011 Dec 21 )

3.12.2013 www.epshp.fi 16 Long-term results of the intervention • Smoke-free surgery for 36% of the patients • A year later, 90 % of these patients were non- smokers (Anesthesia 2009 Mar; 64(3):259 -65)

”We must, however, remember that it is humane to look for a balance between medical evidence and imperfection of life” Mikael Leppilahti, Senior Medical Officer

3.12.2013 www.epshp.fi 17 7. Smoke-free surgery

• refers the patient for a need for surgery Doctor in primary assessment care/ occupational • recommends smoking cessation counselling health care • informs the nurse of the need for smoking cessation counselling

Nurse in primary health care • invites the patient for individual counselling • the individual counselling lasts 3 months, /occupational health involving 6 times contact care

• The doctor makes the decision to operate • The nurse motivates the smoker to accept Doctor and nurse in individual counselling specialized medical • The nurse gives the patient the contact services information for smoking cessation counselling • The unit that referred the patient is informed by letter of the need for individual counselling

3.12.2013 www.epshp.fi 18 As many smoking cessation counsellors as possible:

• Patients, whose employers have extensive occupational health contracts including medical care, will receive smoking cessation counselling from their own occupational health nurses • Other patients are referred to health centre nurses or adult’s clinic public health nurses for smoking cessation counselling

3.12.2013 www.epshp.fi 19 Future smoking cessation support

Smoke-free surgeries are just the spearhead of the development; later all smoking patients will be offered smoking cessation counselling in primary and occupational health care and in specialized medical services.

3.12.2013 www.epshp.fi 20 Key to Success

• Initiative by management • Planning together • High staff training coverage • The role of the smoking cessation counsellor in consultation • Satisfied patients involved in care decisions

www.epshp.fi 21 -Thank you

3.12.2013 www.epshp.fi 22