Northwick Park Mental Health Centre Smoking Cessation Report October Plan. Act. Study. Introduction

Transcription

1 Northwick Park Mental Health Centre Smoking Cessation Report October 2017 Act Plan Study Do Introduction 1

2 In 2013 the National Institute for Health and Care Excellence recommended that health organisations implemented smoke free polices that would require buildings and hospital grounds to be smoke free and that there should be no staff facilitated smoking. This followed on from the publication in 2011 of the Government Strategy No health without mental health in which it stated that we are clear that we expect parity of esteem between mental and physical health services. The life expectancy of someone experiencing a mental health condition is, on average, - 20 years less than the general population. The largest contributor to this reduced life expectancy is smoking. It has been identified that up to 70% of in-patients are smokers. The culture of smoking that has existed within in-patient settings did not change substantially following the introduction of legislation in 200 that prohibited smoking within the building as it simply moved to outdoor areas and smoking breaks became the norm. This practice took up a significant amount of staff time, in some units 3+ hours of staff time per shift as well as taking time from therapeutic occupations. In 2013 the Health Survey for England (HSE) identified that smoking rates amongst people with a mental health condition had gone largely unchanged since the 1990 s, approximately 40%, whilst that of the general population has reduced and was approximately 19%. This has meant that the physical health consequences between the two groups have gradually increased. In line with NICE guidance PH4 the Mental Health Centre, based at Northwick Park Hospital; (NPH) became smoke free in May Both prior to and subsequent to the implementation, there was significant concern regarding the expected increase in aggression, directed towards staff as a result of the restrictions. The number of studies relating to the impact of the smoke free environment is limited and their conclusions range from no change to increased levels of aggression. The numbers and remits they utilise to draw these conclusions also vary. This, combined with a 2015 study in which rates of violence against staff were identified at 17 assaults per 00 staff within psychiatric settings, compared to 21 per 00 in acute settings, reinforce the reticence that staff have regarding the introduction of a smoke-free environment. The other factor to consider is the drive within the Trust, in line with the national agenda, to decrease the use of restrictive interventions. This includes the use of restraint, rapid tranquilisation and seclusion. During discussion groups with staff, there was a sense that the combination of both these agendas could only lead to failure on both counts. Plan 2

3 Prior to the implementation of the smoke free environment all in-patient nursing staff attended Level 2 Smoking Cessation training and community services attended Level 1 training. In addition, a number of champions were identified within the in-patient services, who undertook Roadshows within the service and group work promoting the health benefits of stopping smoking. NRT is available and the Trust has agreed that people could use first generation e-cigarettes in single rooms. This was following much discussion due to the concerns regarding the perpetuation of the smoking culture within psychiatric settings. It was however, in line with other similar mental health services i.e. South London & Maudsley NHS Trust. It was not possible to obtain reliable data of levels of smoking related incidents pre and post the introduction of smoke-free environment as smoking related information was only added to the Datix matrix in July However, the identification of smoking related incidents had become embedded into practice by 2016, therefore data from April 2017 to March 2017 was reviewed (Appendix 1). One of the prevailing characteristics of the incidents was the refusal to use licensed NRT products that were readily available. Written information was already available regarding the use of e-cigarettes as an alternative product, albeit unlicensed. The difficulty remained that these were not available within the environs of the hospital or immediate locality, the nearest retailer, being approximately half a mile away. Staff did support people to purchase these where family members were not available to do so; however, there was a delay between the time of admission and an e- cigarette being purchased. Public Health England in their 2016 report on the Use of e-cigarettes in public places and workplaces stated that based on the international peer reviewed evidence, e-cigarettes carry a fraction of the risk of cigarettes and have the potential to help drive down smoking rates and improve public health. The report went on further to state that since EC (ecigarettes) were introduced to the market, smoking prevalence among adults and youths has declined. Hence there is no evidence to date that EC s are normalising smoking, it s possible that their presence has contributed to further declines in smoking, or denormalisation of smoking. The decision was therefore taken to trial the use of e-cigarettes being available at the point of admission for in-patients and to measure the impact upon levels of smoking related violence, which for the period April 2016 to March 2017 ran at an average rate of.3 incidents per month. The decision was taken to purchase a supply of the E-burn e-cigarettes. Following a review of the limited options available these were chosen as they were approved for use in prisons and approved for Security and Toxicology by the state Analysts Laboratory in the British Isles. They have a silicon mouthpiece and a flexible transparent tube. As such they can t be used as a stabbing implement although they do still contain a small lithium battery. (For further information see Appendix 2). As there was no facility to vend these devices as there are in other services i.e. West London Mental Health NHS Trust. The decision was taken to provide these free during the period of the study. This was undertaken with a view that the study would identify the 3

4 impact of their effectiveness in acute mental health services and would inform the Trust agenda with regard to their availability on sites and developing the current protocol regarding the use of e-cigarettes. The e-cigarettes were part of a wider strategy that included the use of licensed NRT, stop smoking advice and guidance as well as the promotion of the benefits of stopping smoking in relation to physical health and general well-being. Do 4

5 The E-burn device is a Nicotine Delivery system or e-cigarette and it is estimated that it delivers the equivalent of 35 cigarettes. For the period of the study 500 devices were purchased. NRT was already available. On admission all smokers were provided with an explanation about the smoke free environment and were offered verbal and written information on the use of NHS Licensed medication and the use of e-cigarettes as well as the support available to quit. Where the use of e-cigarettes was the preferred option then people were encouraged to purchase their own e-cigarettes based on the types permitted. Where people were detained or had no recourse to purchase their own e-cigarettes, the clinical team would provide them with a device from the available stock without charge. The provision of all e-cigarettes was based on a risk assessment as to their ability to use the device responsibly and safely with minimal risk of deliberate self-harm. Patients were advised that e-cigarettes could only be used in bedrooms where they are the sole occupant or in shared rooms (2 on each ward) where the other person also uses an e-cigarette or smokes. The e-cigarettes were stored in an office on the ground floor adjacent to the two acute inpatient wards. This ensured that staff could access the devices 24hrs a day in order to ensure that there was no delay between people being admitted and an e-cigarette being available if it was required. Since e-cigarettes are not licensed devices a prescription was not required and the devices could, unlike NRT, be provided by any member of staff. However, their location and the requirement for risk assessments meant that the decision for provision was taken by a qualified member of nursing staff. As stated previously all members of the nursing staff had undertaken level 2 smoking cessation training. A record was kept of the people who had utilised the e-cigarettes in order that they could be invited to participate in a survey regarding their smoking history and their experience of the e-cigarettes. The period of the study was from May 2017 to June 2017; however, the e-cigarettes were made available from the 19 th April During the course of the study the post use questionnaires were undertaken by the Borough lead OT, Di Hurley. This ensured that there was some independence and that they were not influenced by nursing staff that had been dispensing the devices. The study was discussed with the nursing teams and guidance regarding the dispensing of the e-cigarettes was provided (Appendix 3). STUDY 5

6 The smoking status of 24 people admitted to the unit during the two month trial period was ascertained (Table 1). Table 1 Smoking Status Current smokers e-cigarette only users ex-smoker (restarted on admission) Quit during admission Of the 24 people questioned 1 (75%) were smokers and one ex-smoker started again following admission. It is also of note that 3 (12%) people were already using e-cigarettes prior to admission. Two (%) people also quit during the course of admission. Two patients (%) were already non-smokers but regular users of e-cigarettes at the time of admission one provided their own device and the other had no access to their own device and was provided with an e-burn. Table 2 Length of time patient has smoked Years 6- Years -20 Years 20 Year plus Of the 22 people who continued to smoke 20 (90%) of them had smoked for 6 years or more and 9 (40%) had smoked for in excess of 20 years. Table 3 6

7 14 How many cigarettes do you smoke? a day 6- a day a day a day More than 30 a day The majority of people, (54%), smoked up to 20 cigarettes a day with a smaller percentage, (1%), smoking 30 plus cigarettes per day. Table 4 Was support offered to you to quit upon arrival to the ward 33% 67% Yes No Two thirds of the people asked stated that they had been offered support to quit whilst on the ward. The other third could not remember being offered this support. This may be due to staff not providing the relevant information although there were regular roadshows on both the wards as well as a support group. There may also be others who were not in a position to remember the information being offered due to the acuity of their mental state at that time. Table 5 7

8 Types of Support Offered A range of different forms of licensed NRT were offered on the ward, with the exception of Champix, in addition to therapeutic activities and advice. The number of different forms offered demonstrates that more than one form was offered to people as per smoking cessation guidance - combination NRT is considered to be of optimum effectiveness e.g, a patch plus intermittent delivery product such as inhalator or lozenge. Several E-Burn users reported using additional NRT on an ad-hoc basis e.g. a patch or an inhalator. This is an acceptable and recommended combination for heavy nicotine addictions where smoke free restrictions are in place. The only licensed NRT product not offered was Champix. Nursing staff would not routinely offer this as they are not able to make it available without the availability of a medical practitioner willing to prescribe it. There is still an apparent reluctance on the part of medical staff to supply Champix during an acute psychiatric episode, although the former psychiatric caution on this drug has now been removed. Table 6

9 How helpful did you find the e-cigarette that was provided to you on the ward. Slightly or not helpful Moderately Helpful Very Helpful Of the 22 people who used e-cigarettes, 1 people (1%) found e-cigarettes moderately or very helpful. The reasons ranged from positive effects on their physical health, my chest feels clearer, to people feeling less distress and anxiety, the negative comments relate to the short life span of the E-burn. The amount of nicotine in an E-burn amounts to 35 cigarettes per day and whilst on average they lasted people 2.5 days per device for the heaviest users this would be reduced to a day or less. Table 7 Would you like support to try and quit smoking now? No Yes Yes No Of the 1 people who found e-cigarettes helpful (1%) expressed an interest to stop smoking. It is unfortunate however, that the community based service in Harrow is nolonger available as it has been closed down. 9

10 During the period 7 th May 2017 and the 30 th June a total of 291 devices were issued to a total of 62 patients, an average of 4.7 devices per patient of the total sample, patients received more than e-burn devices. 5 of were non-intensive users who used each e-burn for days, before requiring a new device. 5 of were intensive users who used each e-burn for an average of 1.5 days before requiring a new device. The highest user received 22 devices over a period of weeks at an average of 2.5 days. Several E-Burn users also reported using additional NRT on an ad-hoc basis e.g. a patch or an inhalator. This is an acceptable and recommended combination for heavy nicotine addictions where smoke free restrictions are in place. Two patients made an attempt to quit during their admission using a combination of E-burn plus NRT. Most of the sample continued to smoke at intervals when leave was available. However, taking smoking on leave into account and the typical rate of use of the e-burn device it is probable that there was a significant drop in people s normal smoking rates since an e-burn equates to approximately 35 cigarettes As stated earlier in the report the number of incidents related to the implementation of a smoke free environment was, on average,.3 incidents per month. This included people going absent or AWOL as well as aggression, disruptive behaviour and smoking on the premises. In the first quarter of the current financial year (April to June 2017) during which the study took place the number of smoking related incidents went down to two; one patient was found smoking in the garden and one wanted to leave at the ward to have a cigarette at 23:00 hours, this situation was ameliorated by the provision of one of the e- cigarettes. It would appear that the availability of e-cigarettes had a positive impact on the numbers of smoking related incidents on the ward as there was a 92.% reduction in the number of incidents. It also appears to have increased the level of consideration given to quitting. Based on the amount that people were smoking the level of harm was reduced with the introduction of the smoke free environment even with the availability of e-cigarettes. ACT Going forward there are two areas that need to be addressed: 1. Use of licensed NRT products There needs to be a continued education programme of education of both staff and patients regarding the use of licensed NRT products. This is particularly important in relation to the medical staff and the prescribing of Champix. It would appear that this was not offered either during the course of the study or since the introduction of the smoke free environment, despite evidence that it can be helpful in relation to stopping smoking. For patients there needs to be continued roadshows to educate

11 people as to the reasons for the smoke free environment, the use of NRT and the impact on people s health of smoking. Smoking snapshots are being currently being developed in association with the Recovery College in order to address this. 2. Availability of E-cigarettes The Trust should investigate the costs and practicality of siting vending machines in each in-patient unit in order to reduce smoking related harm to patients and to reduce smoking related incidents. The availability of e-cigarettes had a significant impact upon the number of smoking related incidents. Therefore the availability of them in the unit would be helpful. The choice is either to give people the e-cigarettes at a cost of 3.60 each as during the study. The other option is to vend the e-cigarettes however this would increase the cost of each item. In addition to the health benefits this would still represent a cost to the individual that is at least 50% less than the cost of 20 cigarettes, since 1% of the people interviewed smoked in excess of 20 cigarettes per day and the average use of an e-burn was 2.5 days. Christine Elder-Ennis (Matron, Northwick Park Mental Health Centre) Di Hurley (Head OT, Harrow Mental Health Service) 11