AB0992 “I Never Had The Verbiage”: Engaging Clinic Staff To Adapt A Tobacco Cessation E-Referral Protocol for Rheumatology Clinics
Authors: C.M. Bartels, A. Gilmore, D. Panyard, C. Maxcy, R. Adsit, A. Skora, E. Ramly
Journal: Annals of the Rheumatic Diseases (2016)

<h3>Background</h3> Smoking increases the severity and cardiopulmonary complications of many rheumatologic conditions. Yet despite tobacco assessment in many rheumatology clinics, we reported that &lt;10% of eligible notes documented cessation counselling. New models show increased efficacy with Ask-Advise-Connect approaches using non-physician staff protocols. Under protocols, front-line clinic staff assessing pre-visit vital signs and tobacco use are cued to recommend and refer patients electronically to telephone tobacco quit line support. Such approaches increased uptake of cessation support 13-fold in primary care studies but have not been adapted for rheumatology clinics. <h3>Objectives</h3> Our objective was to engage clinic staff in participatory work system redesign to develop and plan implementing an Ask-Advise-Connect tobacco protocol in rheumatology clinics. We report the results of this redesign study under the Systems Engineering In Patient Safety (SEIPS) model9s five work system domains: people, organization, technology, environment, and tasks. <h3>Methods</h3> Our multidisciplinary team facilitated participatory work system redesign with medical assistants (MA) and nurses (RN) from three US academic rheumatology clinics. Staff participated in one of two hour-long focus groups. Trained facilitators used semi-structured interview questions informed by the SEIPS domains to appraise pre-visit assessment workflows, educational needs, proposed protocols, brochures, electronic health record (EHR) tools, and implementation plans. <h3>Results</h3> Over 80% (9 MAs, 5 RNs) of clinic nursing staff participated in focus groups. SEIPS domain questions facilitated discussions on intervention design, implementation, and sustainability planning (Table 1). The work system redesign included training (people); a protocol and workflows adapted to specialty care (organization, tasks); customized EHR alerts for assessing tobacco status and an EHR order set for e-referral to quit line services (technology); and physical cues like a desktop patient brochure linking rheumatologic conditions, tobacco use, and cardiovascular risk (environment). Focus group participants reported routinely assessing tobacco use, but most had not asked about readiness to quit. A few had asked such questions, but noted low outcome expectancy and not knowing what to do next. One nurse said, "I9d ask, `Are you ready to quit?9 and they9d say `No9 and then I9d stop." Staff groups identified that education about links between tobacco use and rheumatologic diseases and stepwise support from our Ask-Advise-Connect protocol would help them overcome barriers to tobacco cessation counselling. They requested specific best-practice language in the EHR tools and appreciated rheumatology-specific brochures with printed conversational prompts. <h3>Conclusions</h3> We engaged rheumatology clinic staff in participatory work system redesign to plan implementing a tobacco cessation protocol. The participatory redesign process resulted in a tailored implementation plan for a quasi-experimental trial of a tobacco cessation e-referral protocol in rheumatology clinics. <h3>Disclosure of Interest</h3> C. Bartels Grant/research support from: Independent Grants for Learning and Change (Pfizer), A. Gilmore: None declared, D. Panyard: None declared, C. Maxcy: None declared, R. Adsit: None declared, A. Skora: None declared, E. Ramly: None declared