Improving smoking cessation assessment and support in geriatric medicine: a quality Improvement project

Introduction
Smoking remains a major modifiable risk factor for chronic disease in older adults yet opportunities for smoking cessation are missed among older patients. The British Thoracic Society states that every inpatient should be asked if they smoke and that electronic records of tobacco dependency should be completed. Hospitalisation offers a chance to identify tobacco dependence and provide support. We conducted a quality improvement project on a Care of the Elderly (COE) ward to improve the documentation of smoking status and delivery of nicotine replacement therapy (NRT).

Methods
We audited inpatients at baseline (n=23) and post-intervention (n=19) on a COE ward over two weeks. We measured the proportion with recorded smoking status, pack-year history, completion of an electronic smoking status proforma, timeliness of documentation, NRT prescription and smoking cessation referrals. Interventions included daily ward-round reviews, staff education, visual prompts, and formal teaching sessions with the Smoking Cessation Team.

Results
At baseline, 22/23 patients (96%) were male with a mean age of 83. 11/23 (48%) of patients had smoking status documented and 5/23 (22%) had a completed proforma. Pack-year history was recorded in 4/7 (57%) of current or ex-smokers. Post intervention, 17/19 patients (89%) were male with a mean age of 84. Post intervention, documentation of smoking status rose to 17/19 (89%), and proforma completion improved to 9/19 (47%). Of current smokers, NRT was offered appropriately in both cycles, though the sample was small (baseline n=2, post-intervention n=1). The proportion of smoking status documentation by the COE team increased, suggesting improved awareness. However, pack-year documentation declined, and the timeliness of documentation did not improve.

Conclusions
This project significantly improved the recording of smoking status and use of the smoking status proforma in older adult inpatients. Increased engagement by COE doctors indicates successful behaviour change, but pack-year documentation and promptness of recording require further work. A second cycle will be undertaken to target these areas and to evaluate the impact of NRT referral and follow-up.