To Record Your Attendance (Faculty, Fellows, Residents & Students)

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1 To Record Your Attendance (Faculty, Fellows, Residents & Students) Text 5333 to (405) (Please make certain your mobile phone number is listed on your profile at cme.com) Online Evaluation To receive your AMA PRA Category 1 Credits you must complete the online evaluation. The online evaluation will be active at the end of the conference. Log in at cme.com Click on My CME Click on Evaluations and Certificates Once you have completed your evaluation, you will be able to print your CME certificate Relevant Disclosure Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. Morris Gessouroun, MD No relevant financial relationships or affiliations with commercial interests to disclose. 1

2 In Smoke-Filled Wombs, Trouble Looms The effect of tobacco smoking on perinatal and neonatal outcomes and interventions for change Marilyn Escobedo MD Reba McEntire Endowed Chair in Neonatology Chief of Neonatal Perinatal Medicine Professor, Department of Pediatrics Tracie Anderson MS Director of Perinatal and Neonatal Program Development Department of Pediatrics, Department of Obstetrics and Gynecology and OUMC PI TSET Grant for Intervention College of Medicine Pediatrics NEONATAL-PERINATAL MEDICINE Relevant Disclosure Under Accreditation Council for Continuing Medical Education guidelines disclosure must be made regarding relevant financial relationships with commercial interests within the last 12 months. Marilyn Escobedo, MD Tracie Anderson, MS No relevant financial relationships or affiliations with commercial interests to disclose. 2

3 Objectives Recognize the effects of nicotine and carbon monoxide on human physiology Describe the pregnancy risks of tobacco smoking Recognize the effects of maternal tobacco smoking on the fetus, placenta and newborn Value the intervention efforts to diminish cigarette smoking among mothers College of Medicine Pediatrics NEONATAL-PERINATAL MEDICINE 3

4 Jacqueline Kennedy 3 pack a day chain smoker Developed sudden abdominal pain Patrick Bouvier Kennedy was born by emergency caesarean section at 34 wks at the Otis Air Force Base Hospital in Bourne, Massachusetts. His birth weight was 4 pounds ounces (2.11 kg). Shortly after birth, he developed symptoms of hyaline membrane disease, now called infant respiratory distress syndrome (IRDS). He was transferred to Boston Children's Hospital where he died two days later, following treatment in a hyperbaric chamber. Jacqueline Kennedy 3 pack a day chain smoker Developed sudden abdominal pain ABRUPTED PRETERM IUGR Patrick Bouvier Kennedy was born by emergency caesarean section at 34 wks at the Otis Air Force Base Hospital in Bourne, Massachusetts. His birth weight was 4 pounds ounces (2.11 kg). Shortly after birth, he developed symptoms of hyaline membrane disease, now called infant respiratory distress syndrome (IRDS). He was transferred to Boston Children's Hospital where he died two days later, following treatment in a hyperbaric chamber. DEAD 4

5 Jacqueline Kennedy 3 pack a day chain smoker Developed sudden abdominal pain ABRUPTED PRETERM IUGR Patrick Bouvier Kennedy was born by emergency caesarean section at 34 wks at the Otis Air Force Base Hospital in Bourne, Massachusetts. His birth weight was 4 pounds ounces (2.11 kg). Shortly after birth, he developed symptoms of hyaline membrane disease, now called infant respiratory distress syndrome (IRDS). He was transferred to Boston Children's Hospital where he died two days later, following treatment in a hyperbaric chamber. DEAD TRAGIC Is smoking a prevalent health issue among pregnant women in the USA? 5

6 Are there differences in smoking among pregnant women by race? Is smoking a prevalent health issue among pregnant women in Oklahoma? 6

7 What s in tobacco smoke? What are the active products in tobacco smoke? 7

8 What are the active products in tobacco smoke? What happens to the fetus when the mother smokes? Nicotine Vasoconstrictive, neural stimulant Carbon monoxide Lower oxygen delivery College of Medicine Pediatrics NEONATAL-PERINATAL MEDICINE 8

9 Nicotine Epidemiologic studies show increased risk of adverse obstetrical outcomes Lowered fertility Preterm labor Preterm delivery Preeclampsia Hypertension Placental abruption PPROM College of Medicine Pediatrics NEONATAL-PERINATAL MEDICINE 9

10 Relative Infertility Rabbit Ear Vascular Video M q8 10

11 Risk of placental abruption Nicotine 11

12 Nicotine Effects of nicotine infusion on biomarkers of cell damage (ornithine decarboxylase and DNA) in brain areas of rats Slotkin 1987 Nicotine on fetal (rat) lung CONTROL NICOTINE Impaired alveolar development 12

13 Epidemiological studies show adverse effects on fetal growth Significantly more risk for SGA and Preterm birth College of Medicine Pediatrics NEONATAL-PERINATAL MEDICINE All Causes IUGR 13

14 Carbon monoxide CO content 10 times higher than auto exhaust Carbon monoxide X 10 CO content 10 times higher than auto exhaust 14

15 Carbon monoxide 1 pack 15

16 Carbon monoxide Carbon monoxide 1 pack 2pack 16

17 Carbon monoxide 1 pack 2pack Nicotine and Carbon Monoxide Nicotine Vaso constrictive Placenta Previa Abruption Norepinephine effects Preterm labor Brain development Lung development Carbon Monoxide Hypoxia Growth impairment Increased risk for metabolic syndrome in adulthood? 17

18 Does tobacco smoking cause congenital malformations? (Is it teratogenic?) Human Reproduction Update % higher odds of skeletal anomalies including cleft lip/palate 2. 27% increase in GI anomalies 3. 50% higher risk of gastroschisis 4. 20% higher risk of imperforate anus 5. 9% higher risk of heart defect 6. 13% higher risk of undescended testes Does Tobacco smoking have an effect on neonatal adaptation (transition)? Hyperirritability Poorer self-regulation Mild hypertonicity Excitability 18

19 Epidemiological observations on risks for infants whose mothers smoked Cognitive ability Behavioral problems Schizophrenia ADHD, Tourette s other neurological disorders Sleep problems Increased use of tobacco Type II diabetes SIDS Second hand smoke bad? 19

20 SIDS LUNG PROBLEMS OTITIS ASTHMA Smoking immediately after delivery 20

21 Smoking immediately after delivery Do smokers want to quit? 21

22 Most effective ways to reduce smoking in populations? Taxes over time 22

23 Correlation of quantity of smokes and cost of cigarettes 23

24 Lung Cancer Rates Cigarette Taxes Most effective ways to reduce smoking in individuals? 24

25 Hospitals Helping Patients Quit: An system based intervention A Partnership with the Oklahoma Hospital Association and Oklahoma Tobacco Settlement Endowment Trust Oklahoma TSET: Keeping the Promise for Health tells the story of how the Tobacco Settlement Endowment Trust was created, born from the vision of state leaders and voters who were willing to invest in a long term solution to improving Oklahoma's health status, without regard to partisan politics. After the landmark 1998 Master Settlement Agreement between the tobacco industry and 46 states, Oklahoma was the first and only state to establish a constitutionally protected trust fund to ensure that the majority of the settlement payments would be invested to generate earnings that would be used to improve health. In 2000, Oklahoma voters made a momentous decision, a decision that would change the health of generations to come. Fifteen years later, TSET continues to fight Oklahoma's two leading causes of death cancer and cardiovascular disease by encouraging Oklahomans to eat better, move more and be tobacco free. 25

26 Smoking prior, during and after pregnancy 2010 data Overview of Grant The primary goal is reduce tobacco use and improve health by developing a tobacco free culture within our hospital systembeginning with NICU and high risk obstetrical patients by: Implement a permanent embedded system of tobacco treatment Identify and assign administrative and clinical leaders to provide regular oversight and facilitate internal processes of system changes and implementation Develop a work plan for the implementation of a system of inpatient and employee tobacco cessation 26

27 Overview of Grant The Grant is funded one year at a time (July1 June30)and renewable through 2017 Funding for the grant is approx. $100,000 annually Funds offset administration, implementation and IT support Drs. McCaffree, Escobedo and Edwards (MFM Chief) provide inkind support on grant, as does Nurse Navigator and Neonatology administration (billing on grant) Overview of Grant Deliverables Within the first year the program would reach 90 % of all NICU and Maternal transports with Ask, Advise and refer process, training on programic goals and objectives would be shared with NICU and OB/Gyn residents and staff through medical grand rounds and nursing education. Within first year community physicians serving in role of PCP to our patients will be informed about program and included in communication process regarding quit efforts of their patient. Within the second year 90% of all prenatally diagnosed anomalies patients and high risk OB out patients will have contact with the nurse navigator for cessation program. Additionally, we feel confident that we will achieve at least 2 publications on this unique role and progress we see from the interventions. 27

28 Overview of Grant Key Personnel: Tracie Anderson, MS PI for grant Perinatal Neonatal Program Director Cheri Tennery, MSW, LCSW Tobacco Cessation Specialist Drs. McCaffree, Escobedo and Edwards Administrative leadership and medical direction Oklahoma Hospital Association: Joy Leuthard, LCSW, Eric Finley, MPH Contractor with TSET Most Smokers Want to Quit Most smokers are seriously thinking about quitting 50% of adults made a serious attempt to quit in the past year Most do not know how to quit or are not quite ready Many are unaware of new methods of quitting 28

29 Evidence Based Cessation Clinical Practice Guidelines Endorsed by 60+ major national health organizations and provider associations including: CDC AMA AAP CMS ANA AAPA ACS AANP ACOG Work Flow Algorithm Ask every patient about tobacco use Advise every tobacco user to quit Assess their readiness to quit Assist with their quit attempt Arrange for follow-up 29

30 Tobacco-Free Culture Change Nurses and social workers are key in setting the tone for success. We must change the culture to become tobacco-free. Ask every patient about tobacco use Identify and document Status can change 30

31 Advise them to quit Use a clear, strong, personalized message Tie the message to their specific health issues 31

32 Arrange follow-up For patients being referred to OTH: Oklahoma Tobacco Helpline will contact them For patients not ready to make a quit attempt: Ask them about tobacco use on their next visit PATIENTNAME DATE OF BIRTH GENDER FEMAL E ADDRESS CITY MAL ZIP CODE E PRIMARYPHONE NUMBER HM WK CELL SECONDARYPHONE NUMBER HM WK CELL LANGUAGE PREFERENCE(PLEASE CHECK ONE) ENGLISH SPANISH OTHER I am ready to quit tobacco and request the Oklahoma Tobacco Helpline contact me to help me with my quit plan. (Initial) I DO NOT give my permission to the Oklahoma Tobacco Helpline to leave a message when contacting me. (Initial) ** By not initialing, you are giving your permission for the quitline to leave a message. PATIENT SIGNATURE: DATE: /_ /_ The Oklahoma Tobacco Helpline will call you. Please check the BEST 3-hour time frame for them to reach you. NOTE: The Helpline is open 7 days a week; call attempts over a weekend may be made at times other than during this 3-hour time frame. 6AM 9AM 9AM 12PM 12PM 3PM 3PM 6PM 6PM 9PM WITHIN THIS 3-HOUR TIME FRAME, PLEASE CONTACT ME AT (CHECK ONE): Primary # Secondary # 32

33 edemand Packet Tobacco Treatment Workflow in the NICU OUHSC Perinatal Program Patient Registration Registration Clerk (HUC s) Assure completion of Safe Sleep/Tobacco Use questionnaire in the edemand Packet New questions added about tobacco use status Bedside Nursing Initiate completion of tobacco use status questionnaire with patient Return edemand packet back to the appropriate NICU personnel Upon completion Teletracking status changes to Orange Asked Workflow Status in Teletracker Advised Assessed Referred Document in patient record Social Worker Advise parent/guardian to quit, explain tobacco use impact on infant s health, provide tips to quit Assess their readiness to quit with help from Oklahoma Tobacco Helpline Upon completion, Teletracking status changes to Yellow Refer all those ready to quit to the Oklahoma Tobacco Helpline via Fax or e Fax Upon completion, Teletracking status changes to Green including but Doctors, etc. Social work will be supported in this process by multiple professions not limited to DC facilitators, Cessation Specialist, Bedside Nursing, Find Their Motivation You can help your patients find their reason to quit! 33

34 Acknowledgements Information provided by the Oklahoma Hospital Association: Jennifer Watkins Roysdon, MS, Treatment Systems Coordinator Eric Finley, MPH, Treatment Clinic Coordinator Joy L. Leuthard, MS, Manager Health Improvement Initiatives This tobacco treatment partnership is funded in part by the Oklahoma Tobacco Settlement Endowment Trust (TSET). THANK YOU College of Medicine Pediatrics NEONATAL-PERINATAL MEDICINE 34