NR 505 The COPD Patient in the ED Education for Smoking Cessation

NR 505 The COPD Patient in the ED Education for Smoking Cessation The COPD Patient in the ED: Education for Smoking Cessation Working in any Emergency Department across the country, one can count on seeing COPD patients that smoke tobacco in some form or another. A number of these patients have quit smoking, but many more continue to do so. While not all COPD patients are smokers, smoking is the biggest risk factor for developing COPD (Lo Tam Loi, Hoonhorst, Franciosi, Bischoff, Hoffman, Heijink, van Oosterhout, Boezen, Timens, Postma, Lammers, Koenderman, & ten Hacken, 2013). Many of these COPD patients that smoke continue to do so, even with having symptoms of respiratory illness, and many times require intensive assistance to stop smoking; one such study found that smokers who were given an intensive smoking cessation program did much better over the long term (Gratziou, Florou, Ischaki, Eleftheriou, Sachlas, Bersimis, & Zakynthinos, 2014). The goal of this paper is to discuss the COPD smoker that comes into the Emergency Department and whether or not smoking cessation education while in the Emergency Department assists the patient with smoking cessation. Discussions will include how this issue impacts the Master of Science in Nursing Family Nurse Practitioner specialty track; what the issue actually is, why it is an issue, and discussing how the literature has been researched for this paper; and a conclusion, providing a summary of the key elements, discussing expected outcomes for this project proposal, and self-reflection regarding this assignment. Application to Selected MSN Program Specialty Track There are several ways to apply the issue of the smoking COPD patient coming into the Emergency Department over and over because of their illness, and being able to assist them with education while they are in the Emergency Department regarding smoking cessation. This writer is currently working in the Emergency Department as a Registered Nurse, but will possibly not be continuing employment in the Emergency Department as a Family Nurse Practitioner. This has not been completely decided yet, so for the purpose of this paper both aspects will be discussed. Description of Impact to Family Nurse Practitioner Specialty Track The majority of the time in the Emergency Department, when patients get discharged, they get printed instructions in their discharge packet. The information in this packet ideally should have already been discussed with them by the provider that saw them while they were in the Emergency Department and should ideally be discussed again by the discharging nurse. In real life, sometimes at least one of these discussions does not take place, most often the one that should be done by the Emergency Department provider. This leaves a large responsibility on the shoulders of the discharging nurse. Emergency Department Family Nurse Practitioner As a Family Nurse Practitioner in the Emergency Department, the opportunity to change this is offered up. However, one more change needs to be made for the smoking COPD patient in the Emergency Department: smoking cessation education and resources should be provided. As mentioned in the introductory paragraph, many of the COPD smokers are still smoking. From personal Emergency Department nursing experience, many encountered have the mindset that they have already damaged their lungs, so there is no sense in trying to quit now. However, it has been shown that smoking cessation is the single best intervention in slowing down the disease process of COPD and decreasing the signs and symptoms; smokers also tend to need intense education and follow-up in order to be successful in smoking cessation (Gratziou et al, 2014). Obviously, this cannot all be done in the Emergency Department; but if it can be started there, then possibly the initial prompting will inspire more smoking COPD patients to stop. A trial that was done in 2015 studied whether or not a predischarge bundle instituted in one particular hospital had any effect on decreasing return visits to the Emergency Department and readmissions to the hospital. This bundle had a screening tool and an educational tool that were given to patients who were in acute exacerbations of COPD while in the Emergency Department. The study was conducted over a period of three years and included 172 patients, which were assigned either to a control group which received the standard care and discharge planning, or to a group that received specialized care and discharge teaching. This bundle not only discussed smoking cessation education, but also included screening for gastroesophogeal reflux disease, screening for depression and anxiety, education on inhaler administration, and a 48-hour post-discharge follow-up phone call to check on them and see how they were doing and if they had any questions regarding their Emergency Room visit or their discharge instructions. After the three-year period, the results were gathered and analyzed a couple of different ways, but ultimately the differences between the control group and the bundle group were not found to be incredibly significant. This led to the conclusion that more research is needed on this subject and that the discharge bundle possibly needs to be more detailed toward the COPD patient’s concerns and issues (Jennings, Thavarajah, Mendez, Eichenhorn, Kyale, & Yessayan, 2015). Another study looked at 122 COPD patients in retrospect over a 6-month period to see if there were any other factors that pre-disposed them to Emergency Department visits and to hospitalizations related to acute exacerbations of COPD; it also looked at the management of their COPD exacerbations in the Emergency Department to see if it was adequate and in conjunction with the current management standards. When the investigators were done with the study, they found that 98% of the patients that presented in acute exacerbation wound up hospitalized and the following were consistent throughout: elderly in age, former smokers, increased WBC and CRP counts, SpO2 less than ninety percent, home oxygen use, and weekday presentation. Upon deeper investigation, the biggest contributing factor was found to be older age. At the conclusion of the study, it was determined that more research needs to be done regarding how the COPD patient is being managed in the Emergency Department. This information could be very valuable to forming a better discharge process for the COPD smoker when they present to the Emergency Department in acute exacerbation (Khialani, Sivakumaran, Keijzers, & Sriram, 2014). Family Nurse Practitioner in Family Practice One article reviewed multiple different studies to see how family members feel about caring for those that have diagnosis of COPD and what their expectations are. The authors decided to do this review because they were discovering that there was a very specific knowledge gap where family members of COPD patients were concerned, specifically in the area of counseling needs. This can be extremely important for a Family Nurse Practitioner in the family practice setting, because that is where the long-term management of COPD patients will be. If there are specific needs for the family members of the COPD patient, then these could be addressed in the family practice setting and potentially lead to a decrease in smoking and in better management for COPD patients (Siltanen, Jylha, & Paavilainen, 2016). One other article that had some very important information was one that discussed how important it is to know the home conditions of the patients with COPD who are receiving long- term oxygen therapy. The authors used a cross-sectional descriptive analysis study to gain their information, which helped them form a specific questionnaire. This was given to ninety-seven patients during initial home visits. The data was analyzed after all the questionnaires were received back and the conclusions were that seventy-five percent of the patients that were receiving long-term oxygen therapy were formally diagnosed with COPD and eleven percent were actively smoking; the majority of the patients did not use their oxygen like they were instructed to or as often as instructed; and twenty-six percent of these patients had been to the Emergency Department in acute COPD exacerbation during the year prior to the study. The final conclusions were that smoking cessation was absolutely vital to a COPD patient’s management; education was extremely necessary regarding how to use the oxygen properly, along with all equipment prescribed along with the oxygen; and that home visits were extremely important so that patients knew what was expected of them and so that any questions they had could be answered efficiently. As a Family Nurse Practitioner in a family practice setting, this information regarding a patient’s home conditions and their ability or willingness to comply to treatment is vital to being able to help them manage this chronic illness (Godoy, Il., Tanni, Hernandez, & Godoy, Ir., 2012). The Issue and Supporting Evidence The issue of COPD patients, especially those that have smoked or continue to smoke, is a large-scale problem and an extremely familiar one in the healthcare industry. As an Emergency Room nurse, the prevalence of COPD patients coming in to the ER is seen every single day and many of them wind up being hospitalized for at least one to two days at a time. This leads one to start thinking, “What can we do in the Emergency Department to help these smoking COPD patients to stop smoking so that they can have better outcomes and better management of their COPD?” According to the Centers for Disease Control, the death rate related to COPD in males in the United States has decreased between the years 1999 and 2010; there has been no significant change in the death rate in females with COPD, and only a slight decrease in the total death rate. The prevalence of COPD in the United States ranges from 4% to 9% of the population (Centers for Disease Control, 2014). Smoking is the main cause of COPD, with as many as eight out of ten COPD-related deaths being directly related to smoking. However, it has been found that as many as one out of every four patients with COPD have never smoked in their lives. The absolute best way to prevent COPD is to never start smoking, and the best way to decrease the acute exacerbations of COPD is to stop smoking (Centers for Disease Control, 2017). So to be able to effectively assist COPD patients to stop smoking could make an incredibly large impact on the COPD population. Stakeholders There are many different stakeholders that are involved in the issue of smoking cessation for COPD patients that actively smoke. The patients themselves are obviously affected, along with their families and support systems due to the physical, mental, emotional, and financial strains that COPD causes and that the COPD patient’s death could cause. If smoking cessation could increase in COPD patients, then the strain on the patients and their families would decrease; the patients would also likely be in less acute exacerbations, so their Emergency Department visits would likely decrease, which would decrease the volume in our already severely overcrowded ED’s across the U.S., as well as decrease their chances of having to be hospitalized for acute exacerbations. Overall, the effects of being able to assist COPD patients with smoking cessation would be long-reaching, both volume-wise and financially, for both Emergency Departments and hospitals; and the patients and their families would feel the positive effects of not having multiple ED visits and hospitalizations. PICOT Question The PICOT question for this particular issue is: “In the COPD patient who smokes, does smoking cessation education in the Emergency Department assist the patient in quitting, versus not ever mentioning it during their visit or visits?” The PICOT elements for this issue are as follows: P: The COPD patient who smokes I: Educating patient on smoking cessation while in Emergency Department C: Not ever introducing education regarding smoking cessation O: Patient feels more capable of quitting smoking. T: Over the period of a year. Literature Research Strategy The literature research strategy for this project thus far has been to search databases such as PubMed/MEDLINE, EBSCO, and the Joanna Briggs Institute, using search terms such as “COPD,” “COPD smoker,” “COPD smoking,” “smoking cessation,” “COPD prevalence,” “COPD statistics,” “COPD Emergency Department,” “COPD hospitalizations,” “smoking education,” and “COPD management.” This has rendered a great many results, of which have been found the articles used in this paper and more articles that will be used in the future. The search will continue in a similar fashion since there were quite a few results gleaned from this type of search already. Conclusion In conclusion, there is a great need to address the smoking COPD patient so that they have better outcomes and better management by smoking cessation. This can be addressed when they present to the Emergency Department in acute exacerbation. As a Family Nurse Practitioner in the Emergency Department, this can be addressed with some specific smoking cessation education and possibly by formulating a discharge packet specifically addressing smoking cessation with a plan and resources for the patient. As a Family Nurse Practitioner in the family practice setting, this can be addressed to even greater detail and greater follow-up, since constant contact with the patient is more likely. Some expected outcomes of this project proposal would be that the smoking COPD patient would be able to quit smoking sooner and with greater success. This would essentially decrease the number of visits to the Emergency Department with the patient in the acute exacerbation and decrease hospitalizations as well, which would make the financial burden on the patient, and potentially the community, lighter; the mental, physical, and emotional strain on the patient and family would decrease; and the mortality rate for the patients would likely decrease. There are quite a few things that I have learned from this assignment, including how prevalent COPD really is and how highly likely it is that the COPD patient is a smoker. One area that would be area that will need to be researched further would be how to track whether a patient is able to quit smoking based on the discharge instructions that are given while they are in the Emergency Department. Ideally, there would have to be something set in place such as an agreement between the project leader and the patients stating that follow-up phone calls can be made to them to track whether or not they are able to quit smoking.