Evaluation of tobacco screening and counseling in a large, midwestern pediatric emergency department

Abstract

INTRODUCTION The study objective was to assess tobacco screening and cessation counseling practices of pediatric emergency department (PED) and urgent care (UC) nurses and physicians, and factors associated with these practices. Secondarily, we assessed factors associated with performing tobacco smoke exposure reduction and tobacco cessation counseling. METHODS We conducted a cross-sectional survey of 30 PED/UC nurses and physicians working at one large, urban, Midwestern children's hospital. Measures included current practices of performing the 5 As of tobacco counseling (Ask, Advise, Assess, Assist, Arrange), and attitude and practice factors that may influence practices. RESULTS Overall, 90.0% of participants had not received recent tobacco counseling training, 73.3% were unaware of the 5 As, and 63.3% did not have a standardized, routine screening system to identify patients exposed to secondhand smoke. The majority of participants reported that they: asked about patients' secondhand smoke exposure status (70.0%) and parents' tobacco use status (53.3%), and advised parental smokers to not smoke around their child (70.0%) and to quit smoking (50%). One in five participants reported they assessed smokers' interest in quitting smoking, and 16.7% talked with smokers about cessation techniques and tactics; of these, 10% referred/enrolled smokers to the Tobacco Quitline or cessation program, and 6.7% made a quit plan or recommended nicotine replacement therapy medication. CONCLUSIONS Key findings identified are the need for professional tobacco counseling training, standardizing efforts during visits, and emphasizing pediatric patients' potential health benefits. This information will be used for developing a PED/ UC-based parental tobacco cessation and child tobacco smoke exposure reduction intervention.

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

“…Overall, PED/UC professionals’ adherence to the Clinical Practice Guideline of Treating Tobacco Use and Dependence [ 17 ] were mixed, and those who performed tobacco counseling usually only performed the “ask” and “advise” steps. This aligns with prior research that indicates ED professionals often “ask” and “advise,” but infrequently proceed to the next three steps [ 22 , 37 – 39 ]. Further, PED/UC professionals noted that they are not skilled beyond asking and advising due to the barriers of lack of training and resources.…”

“…In addition, parents are satisfied with receipt of the “5 A’s” from PED/UC professionals during their children’s visits [ 15 ]. However, research indicates that PED/UC professionals do not regularly screen for or systematically follow evidence-based guidelines to address parental tobacco use and child TSE [ 3 , 22 – 27 ]. There is a need to understand why there is suboptimal delivery of evidence-based guidelines by PED professionals in order to develop strategies for implementing and sustaining consistent adherence to these guidelines.…”

Tobacco Screening Practices and Perceived Barriers to Offering Tobacco Cessation Services among Texas Health Care Centers Providing Behavioral Health Treatment

“…The lack of consistent tobacco screening provision in health care settings has been attributed to limited knowledge and training of treatment providers [ 36 , 37 , 38 , 39 , 40 , 41 ]. For example, a recent study reported that 90% of surveyed health care providers did not have recent tobacco counseling training within the last 12 months, and 73.3% of them were unaware of evidence-based brief interventions for tobacco dependence that included asking patients about their use [ 36 ].…”

“…The lack of consistent tobacco screening provision in health care settings has been attributed to limited knowledge and training of treatment providers [ 36 , 37 , 38 , 39 , 40 , 41 ]. For example, a recent study reported that 90% of surveyed health care providers did not have recent tobacco counseling training within the last 12 months, and 73.3% of them were unaware of evidence-based brief interventions for tobacco dependence that included asking patients about their use [ 36 ]. Limited training and a lack of standardized screening procedures for tobacco use disorder have significant impacts on intervention provision, as can the perception of limited time to provide preventive screening services if not related to the patient’s chief complaint [ 31 , 40 , 41 , 42 , 43 ].…”

“…Limited training and a lack of standardized screening procedures for tobacco use disorder have significant impacts on intervention provision, as can the perception of limited time to provide preventive screening services if not related to the patient’s chief complaint [ 31 , 40 , 41 , 42 , 43 ]. Research suggests that integrating tobacco screenings into standardized clinical procedures encourages routine screening and intervention; an example of such practice is the implementation of hard-stop alerts in patients’ electronic health records (EHR), which prevents clinicians from further modifying the EHR without an entry about tobacco use status or a manual override [ 24 , 36 , 37 , 44 , 45 ]. However, hard stops are not ubiquitous within EHR systems, and some settings where tobacco-using patients are routinely seen are still utilizing paper charts for clinical encounters [ 46 , 47 ].…”