New recommendations for tobacco control in the ED
A joint task force of emergency medicine organizations, including the Emergency Nurses Association, has issued new recommendations for tobacco control interventions in the ED, with nurses playing a key role.1
EDs have not been a major focus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care, says the statement.
Here are the task force's three recommendations:
- Routinely assess patients' smoking status.
- Offer brief advice to quit.
- Refer patients to the National Smokers' Quitline [(800) QUIT-NOW] or a locally available program.
The task force found that most ED nurses and physicians are asking about patients smoking status but are not assessing their willingness to quit. "We would like for ED nurses to ask all patients about tobacco use and to "advise, assess, assist, arrange," if smokers want to quit smoking," says Rita K. Cydulka, MD, MS, committee member and vice-chair of the Department of Emergency Medicine at MetroHealth Medical Center in Cleveland. This intervention can be accomplished in just a few minutes in the ED, she says.
"We recently participated in a demonstration project looking at this concept, and ran through 1,000 Quit Cards in a very short time period," says Cydulka. "When we ran out, the doctors and nurses were asking for more because it was so simple to engage patients." The cards came from the San Francisco-based Smoking Cessation Leadership Center, a national program office of the Robert Wood Johnson Foundation that aims to increase the number of health professionals who help smokers quit. (To order a minimum of 500 quit cards for your ED, go to smokingcessationleadership.ucsf.edu. On the left side of the page, click on "1-800-QUIT-NOW," "Fill out the order form," and "Quit NOW card order form." The cost is 18 cents per card including shipping and handling, which is $90 for 500 cards.)
ED nurses can incorporate brief screening and referral into the routine care they deliver to patients, says Steven L. Bernstein, MD, committee member and associate professor of clinical emergency medicine at Albert Einstein College of Medicine in Bronx, NY. Ask the patient if he or she smokes, and if so, advise the patient to quit by saying it's the best thing they can do to improve his or her health, he says. Next, refer the patient to the National Smokers Quitline, which is answered by counselors at the patient's own state quitline.
"Quitlines provide free one-on-one counseling, referrals to local treatment programs, self-help materials, and, in some states, nicotine replacement therapy," says Bernstein. "They are evidence-based and effective." A good time to intervene is when the patient is being discharged, when you are reviewing the plan of aftercare, he suggests.
At MetroHealth's ED, many patients do not have a primary care physician, says Heather Federle, RN, ED nurse and clinical research coordinator for the Department of Emergency Medicine. "There is certainly a need to intervene on behalf of patients," she says. "All of our patients identified as smokers are given our hospital's smoking cessation phone number on their discharge instructions."
Patients may be more willing to pursue quitting when you are able to spend time discussing their smoking history and health implications, Federle says. "Assessing logistics and financial resources also seems to play a large role in their willingness to participate in programs, but this also can be time-consuming," she says.
Federle acknowledges that nurses lack adequate time to discuss smoking cessation, and simply providing the resources isn't always enough. "In an ED filled with patients who are critically ill and injured, we rarely have the time to sit down for 10 or 15 minutes with each patient to assess comprehension, assist them in finding resources that are convenient and financially feasible, and ensuring they will follow up," she says.
However, regardless of the amount of time you can spend with a patient, any education or resources you provide are beneficial, adds Federle. "We may be the only health care providers they have contact with."
- Bernstein SL, Boudreaux ED, Cydulka, RK, et al. Tobacco control interventions in the emergency department: A joint statement of emergency medicine organizations. J Emerg Nurs 2006; 32:370-381.