Promoting Physician Referrals to A Perinatal Smoking Cessation Resource Nurse

As part of a government initiative to reduce smoking rates in Quebec (Canada), the McGill University Health Center-Royal Victoria Hospital (MUHC-RVH) received external funding in 2007 to launch a perinatal smoking cessation program. The role of an in-hospital smoking cessation resource nurse was created to provide smoking cessation and smoking relapse prevention counseling to prenatal and postpartum clients. Based on current evidence, targeted clients for this new smoking cessation program included pregnant women who smoked, those who had quit for pregnancy, as well as live-in partners/family members who smoked. However prenatal access to these potential clients was limited, as routine prenatal care is predominantly performed in private physician offices.  Initial review of physician practices further revealed poor and inconsistent prenatal screening for parental tobacco use, and the lack of a system for referral of pregnant smokers and/or their family members to available resources.  Therefore the purpose of this project was to develop and pilot the implementation of an effective system for identifying and referring eligible clients to the in-hospital smoking cessation resource nurse. We partnered with two MUHC-RVH obstetricians to explore optimal ways of improving screening for tobacco use and to help secure physician buy-in for the new smoking cessation program.  To address limited clinician time for in-depth assessment of tobacco use during busy prenatal care clinics, we created a patient self-administered tool to obtain key information on maternal and family member smoking patterns, as well as maternal consent for referral to the smoking cessation resource nurse. To evaluate the tool’s acceptability/feasibility and engage clinicians in the practice change process, we will invite all MUHC-RVH physicians and nurse clinicians who provide routine prenatal care to participate in an interview about their 1) current practices related to parental tobacco use, 2) perceived barriers and facilitators to improved screening and referral for parental tobacco use, and 3) opinions about using a patient self-report questionnaire to manage referrals for prenatal tobacco cessation/relapse prevention support. The interview data will be used to refine the referral tool and to identify optimal strategies for implementing the new referral system.  A select group of physician and nurse-clinician volunteers will then be recruited to pilot test the referral system for a 4-month period, prior to institution-wide implementation.  Evaluation criteria for the referral system’s success will include evidence of improved clinician assessment and documentation of parental smoking patterns; number and nature of prenatal referrals to the smoking cessation resource nurse; and clinician satisfaction with the practice change. As rpenatal smoking remains the most signficant risk factor for adverse perinatal health outcomes, systematic detection and referral of families to smoking cessation support will contribute to improved infant, maternal and family health.  Project results will also help inform optimal strategies for improving interdisciplinary collaboration and coordination of care when physicians are the “gate-keepers” for patients who would benefit from available nursing care resources.