Emergency department provider preferences related to clinical practice guidelines for tobacco cessation: a multicenter survey

How to persuade more primary care professionals to adopt a valued smoking cessation referral aid: a cross-sectional study of facilitators and barriers

Background

To study the factors associated with the intention of primary care professionals (PCPs) to use or not use a referral aid (RA) for selecting an evidence-based smoking cessation intervention (EBSCI).

Methods

Participants (n = 85) were recruited from June to September 2020 to complete an online questionnaire based on the I-Change Model to assess the factors associated with the adoption of RA. The differences between PCPs with (n = 37) and without (n = 48) the intention to adopt in terms of demographics, motivational factors, and post-motivational factors were subsequently assessed. Correlation and logistic regression analyses were conducted to investigate the factors associated with the intention to adopt.

Results

Both groups indicated that they highly appreciated the RA. However, PCPs without the intention to adopt expressed a more negative attitude towards the RA, experienced less social support, showed low self-efficacy, and encountered barriers such as lack of time and skills. The factors most strongly associated with the intention to adopt were advantages, disadvantages, self-efficacy, less barriers, working in a solo practice and age.

Conclusions

The adoption of RA can be facilitated in two ways. The first one is by increasing the added value of the tool through a second round of co-creation focusing on the adoptability of the RA in practice. The second approach is by communicating the added value of referring to EBSCIS and thereby using the RA by implementing it in smoking cessation training for PCPs, which could also help to improve the attitude, social support, self-efficacy, and perceived skills in terms of RA usage among PCPs.

Impact

This study is the first work in the Netherlands to investigate the willingness of PCPs to actively refer patients to other EBSCIs in addition to providing face-to-face counseling themselves.

Trial registration

The study was registered at the Netherlands Trial Register (NL7020, https://www.trialregister.nl/trial/7020).

Smokeless Tobacco Cessation in an Emergency Room in Rural West Virginia

Background

Emergency room nurses have a strong influence on the population of smokeless tobacco users. If healthcare providers address patient's tobacco use by using a brief intervention strategy (one minute or less), it increases the quit attempt rate threefold. The object of this study is to assess the effectiveness of asynchronous internet based brief tobacco intervention training with rural emergency room nurses.

Methods

A 1-h asynchronous training session on smokeless tobacco use and the 2-A and 1-R (Ask, Advise, and Refer) brief tobacco intervention strategy were given to 13 emergency room nurses at a rural acute care hospital in West Virginia. Paired sample t-tests were used to compare the pre-and post-test results.

Results

The 1-h training session produced significant and positive increases in all items measured: increased motivation to assist patients in quitting; increased knowledge of smokeless tobacco use, its dangers, and cessation processes; increased self-efficacy in implementing brief interventions; increased perception of tobacco cessation as important; increased perception of the effectiveness of tobacco cessation interventions; and increased acknowledgment of barriers and an awareness of how to deal with them.

Conclusions

The results suggest that there is a significant potential benefit from training emergency room nurses. Brief tobacco interventions should be conducted by clinical staff during the medical history check, physical examination, or discharge phases of the emergency room visit.

Barriers to implementation of pediatric emergency department interventions for parental tobacco use and dependence: a qualitative study using the theoretical domains framework

Background

Pediatric emergency department (PED) and urgent care (UC) professionals can play a key role in delivering evidence-based guidelines to address parental tobacco use and child tobacco smoke exposure (TSE). Understanding PED/UC professionals’ perceptions regarding these guidelines is the first step in developing and implementing a TSE screening and counseling intervention in these settings. This study aimed to use the theoretical domains framework (TDF) to identify current screening and counseling behaviors of PED/UC professionals related to parental tobacco use and child TSE, and determine barriers and enablers that influence these behaviors.

Methods

Semi-structured, focused interviews were conducted with 29 actively practicing PED/UC clinical staff who worked at one large, Midwestern children’s hospital. The interview guide was informed by the TDF and included open-ended questions. Content analysis of interview transcripts was guided by the TDF. Nurses, physicians, and healthcare administrators were assessed overall and by group membership to ensure each group was represented based on their varying PED/UC roles.

Results

Fifty-one percent were nurses, 38% were physicians, and 11% were healthcare administrators. Most PED/UC professionals did not currently follow the guidelines, but perceived addressing parental tobacco use as part of their role. All 14 TDF domains were identified by nurses, physicians, and administrators in relation to counseling for parental tobacco use and child TSE. Domains with the most sub-themes were (1) knowledge: lack of knowledge about tobacco counseling, including implementing counseling, cessation resources/referrals, and thirdhand smoke; (2) beliefs about capabilities: not comfortable counseling parents, easier to discuss with parents who are receptive and to ask and advise when patients have a TSE-related complaint, and more likely to discuss if there were resources/referrals; and (3) environmental context and resources: barriers include lack of time, training, and resources and referral information to give to parents, and an enabler is using TSE-related complaints as a context to offer counseling.

Conclusions

Study findings provide a strong foundation for developing and implementing clinical practice guidelines regarding parental tobacco use and child TSE in the PED/UC setting. Future intervention development will address all TDF domains and test the implementation of the intervention in the PED/UC setting.

Physician-directed smoking cessation using patient "opt-out" approach in the emergency department: A pilot program

OBJECTIVE

Using a physician-directed, patient "opt-out" approach to prescriptive smoking cessation in the emergency department (ED) setting, we set out to describe patient actions as they related to smoking cessation behaviors.

METHODS

A convenience sample of smokers at 2 Pennsylvania hospital EDs who met inclusion/exclusion criteria were approached to participate in a brief intervention known as screening, treatment initiation, and referral (STIR) counseling that included phone follow-up. Demographic information, current smoking status, and specific physician prescription and follow-up recommendations were collected. Approximately 3 months later, patients were contacted to determine current smoking status and actions taken since their ED visit.

RESULTS

One hundred six patients were approached and 7 (6.6%) opted out of the intervention. Patients who did not opt out were evaluated for appropriate use of smoking cessation-related medications; 35 (35.4%) opted out of the prescription(s) and 6 (6.1%) were not indicated. Twenty-one (21.2%) patients opted out of ambulatory referral follow-ups with primary care and/or tobacco treatment program; one (1.0%) was not indicated for referral. Nineteen (32.8%) patients who received prescription(s) for smoking cessation-related medications initially also followed the prescription(s). Seventeen (22.1%) patients participated in referral follow-up.

CONCLUSION

In this small ED pilot, using the STIR concepts in an opt-out method, few smokers opted out of the smoking cessation intervention. About one-third of the patients declined prescriptions for smoking cessation-related medications and less than one-quarter declined ambulatory referrals for follow-up. These findings support a willingness of patients to participate in STIR and the benefits of intervention in this setting.

Emergency Nurse Implementation of the Brief Smoking-Cessation Intervention: Ask, Advise, and Refer

PROBLEM

Smoking is the single most avoidable risk factor for many health problems such as cardiovascular disease and pulmonary dysfunction. Emergency departments provide care for many patients who smoke. Patients who smoke and are discharged to home from emergency departments do not customarily receive smoking-cessation information. This project explored the feasibility and acceptability of a brief smoking-cessation intervention as part of emergency nursing practice.

METHODS

This practice improvement project was conducted in a large midwestern emergency department. A review of data from 12 months before the project revealed a 17.6% prevalence of smoking among patients discharged from the emergency department with no patient having received smoking-cessation information, confirming the need for intervention. A survey of emergency nurse attitudes and learning needs indicated that nurses believed offering advice to quit was appropriate but that they had limited smoking-cessation training. A total of 83 nurses received training on an "Ask, Advise, Refer" protocol.

RESULTS

Evaluation after training indicated that emergency nurses gained knowledge about brief smoking-cessation intervention methods, and 75.7% (n=74) felt adequately trained. During the 12-week intervention, data were collected on 7,465 emergency visits. Nurses advised all smokers to quit using the protocol, and 6.3% of patients accepted smoking-cessation referrals.

IMPLICATIONS FOR PRACTICE

Emergency nurses felt comfortable performing the smoking-cessation intervention, suggesting that training was effective. Data indicated that patients were consistently advised to quit smoking. Results suggest that brief smoking-cessation interventions are feasible and acceptable in emergency settings. The training and protocol could be used in other emergency departments, and lessons learned can guide future efforts by emergency nurses to help patients quit smoking.

The Role of Bias by Emergency Department Providers in Care for American Indian Children

BACKGROUND

American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings.

OBJECTIVE

Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care.

RESEARCH DESIGN

We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site.

RESULTS

A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias.

CONCLUSIONS

The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents' characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.