Program Details

Practice Type:	Promising
Program Name:	Second Hand Smoke Exposure Screening and Nursing Intervention During Immunization Clinics
Organization:	Tri-County Health Department
Web site:
Overview:	Goals: 1) Formulate and administer a pre-intervention poll for all Tri-County Health Department (TCHD) nurses who provide immunizations regarding how important they rank second hand smoke (SHS) exposure in patients, how comfortable they feel about initiating a conversation and intervening in a family who self reports SHS exposure, and how much time they feel they can provide for this intervention during and immunization visit. 2) To screen 100% of all patients, parents, guardians or family relatives of patients ages 6 weeks to 21 years old who attend any of TCHD eight immunization clinic locations for second hand smoke (SHS) exposure in the home and in the daycare that the patient may attend. 3) To educate TCHD nursing staff about the dangers and hazards of second hand smoke using the latest research and the 2006 US Surgeon General report titled "Involuntary Exposure to Tobacco Smoke". 4) To add a second hand smoke exposure screening question to the agency-wide documentation form for immunizations in English and Spanish. 5) Encourage all TCHD nurses who provide immunizations to review the new SHS exposure screening question during the immunization visit and document an intervention next to the question. 6) Motivate all TCHD nurses who provide immunizations to address the SHS question with the patient, or guardian of the patient if they self report a positive exposure on the screening question. The nurse will either initiate a discussion about the health risks of SHS (if time allows or provide an informational brochure or DVD produced and distributed at not cost to TCHD by the Colorado State Tobacco Education and Prevention Program (STEPP). 7) To track all patients who are screened for SHS exposure during TCHD's immunization clinics and how many nursing interventions were documented as well as how many opportunities for nursing interventions were missed. 8) Provide continuing educational trainings to the TCHD nursing staff who give immunizations regarding how many interventions were completed, how many missed opportunities for intervention there were each month for each of the eight clinics within TCHD. Provide individual counseling and encouragement for nurses who continually miss opportunities for intervention on a regular monthly basis. 9) Administer a post-intervention survey three to five months after the screening question has been added to the immunization documentation form and after the initial nursing educational training.
Year Submitted:	2008
Responsiveness and Innovation:	Of the ten essential public health services, this practice addresses: 1) Essential service number one: Monitoring health status; Involuntary exposure to tobacco smoke: as titled by the 2006 US surgeon generals report. This report made it very clear that the immunization population that we sere at TCHD is also a population that is high risk for involuntary SHS exposure. 2) Essential service number three: Inform, educate and empower. By educating the patients, parents, guardians and relatives of patients about the latest research and information pertaining to SHS exposure, we are informing patients of the serious health risks associated with tobacco use and offering them ways to reduce or stop using tobacco. 3) Essential service number five: Develop policies and plans This step was vital to the interventions we chose to implement. Without having this support of the nurse managers and leaders of the TCHD immunization clinics, there would be little acceptance of this practice. Policy was changed to incorporate the SHS screening question onto the immunization documentation forms in English and Spanish. 4) Essential service number eight: Assure a competent workforce TCHD had to ensure that their nursing staff was providing the most up-to-date information regarding SHS exposure and the long-term health risks associated with tobacco exposure. The nurses also had to be trained in appropriate ways to approach this subject with patients who may have not be accepting of this new information and offer suggestions for doing so. The TCHD nursing / tobacco liaison completed a NACCHO, CDC, and American Journal of Nursing (AJN) literature review and was unable to find any information that this practice had been implemented at other LHD's. This practice differs from other approaches used to address public health issues in that TCHD had identified a population that they had already had access to for immunizations and collaborated with another division within TCHD to address a different health concern with the population. TCHD had patients, parents guardians and family relatives of patients attending immunization clinics at eight of their clinic locations. Education was already being done with this population in regard to immunizations, vaccines and preventable diseases. After collaborating with TCHD's tobacco division, TCHD was able to use the same population who was identified to be high risk for involuntary tobacco exposure and screen them for this health risk during immunization clinics. The nurse giving them immunizations would educate and help make the mental link between vaccines, preventative health measures, and SHS exposure for this population by initiating a discussion or nursing intervention.
Agency and Community Roles:	This practice was implemented and maintained to be an internal agency practice. The TCHD nursing and tobacco divisions have collaborated together and have a liaison to works and communicate between both divisions to incorporate and share resources. The role of this practice within TCHD was to reallocate resources and combine efforts of the nursing and tobacco divisions to educate and have nurses intervene on a high risk population that TCHD already has access to. The tobacco division at TCHD has access to Colorado STEPP resources that are provided free of charge to healthcare providers, and community partners. These resources are ordered in large quantities monthly and distributed to local TCHD clinics for nurses to provide patients with written, visually stimulating materials to elaborate upon their discussion with the patient about SHS and tobacco cessation.
Costs and Expenditures:	In order to implement this program, it will require a meeting of and permission of nursing managers in the immunization program to discuss and design a SHS exposure question that can be added to the immunization documentation form used at TCHD. Once this screening question was approved and added to the standard TCHD immunization screening form, it was imperative to discard and recycle the old screening form and replace it in all TCHD clinics with the new screening form. A literature search for similar projects in other local health departments within the U.S. was performed by the Nursing and tobacco division liaison. No other projects of this type were found after the literature search and review. There would be no additional cost to TCHD, simply a restructure of how we use resources how we access our current immunization population for tobacco exposure. All educational supplies would be provided by the Colorado STEPP program for patients who requested more information on SHS exposure and tobacco cessation materials. The training that was provided to all TCHD nurses who administer immunizations was done during a monthly meeting using the nursing / tobacco liaison and the tobacco division as the trainers. A short PowerPoint presentation was produced and all of the STEPP brochures, DVD's and other resources were brought to the meeting to show the nurses what was available to patients. Techniques for initiating SHS exposure and tobacco cessation conversations were offered to the nurses during this training. There would be no additional cost to TCHD, simply a restructure of how we use resources, nursing staff and how we access our current immunization population for tobacco exposure. All educational supplies would be provided by the Colorado STEPP program for patients who requested more information on SHS exposure and tobacco cessation materials.
Implementation:	Of the ten essential public health services, this practice addresses: 1) Essential service number one: Monitoring health status; Involuntary exposure to tobacco smoke: as titled by the 2006 US surgeon generals report. This report made it very clear that the immunization population that we sere at TCHD is also a population that is high risk for involuntary SHS exposure. 2) Essential service number three: Inform, educate and empower. By educating the patients, parents, guardians and relatives of patients about the latest research and information pertaining to SHS exposure, we are informing patients of the serious health risks associated with tobacco use and offering them ways to reduce or stop using tobacco. 3) Essential service number five: Develop policies and plans This step was vital to the interventions we chose to implement. Without having this support of the nurse managers and leaders of the TCHD immunization clinics, there would be little acceptance of this practice. Policy was changed to incorporate the SHS screening question onto the immunization documentation forms in English and Spanish. 4) Essential service number eight: Assure a competent workforce TCHD had to ensure that their nursing staff was providing the most up-to-date information regarding SHS exposure and the long-term health risks associated with tobacco exposure. The nurses also had to be trained in appropriate ways to approach this subject with patients who may have not be accepting of this new information and offer suggestions for doing so. The TCHD nursing / tobacco liaison completed a NACCHO, CDC, and American Journal of Nursing (AJN) literature review and was unable to find any information that this practice had been implemented at other LHD's. This practice differs from other approaches used to address public health issues in that TCHD had identified a population that they had already had access to for immunizations and collaborated with another division within TCHD to address a different health concern with the population. TCHD had patients, parents guardians and family relatives of patients attending immunization clinics at eight of their clinic locations. Education was already being done with this population in regard to immunizations, vaccines and preventable diseases. After collaborating with TCHD's tobacco division, TCHD was able to use the same population who was identified to be high risk for involuntary tobacco exposure and screen them for this health risk during immunization clinics. The nurse giving them immunizations would educate and help make the mental link between vaccines, preventative health measures, and SHS exposure for this population by initiating a discussion or nursing intervention.
Sustainability:	The nursing and tobacco divisions at TCHD have contributed significant amounts of time and resources into training, adding a screening questions to TCHD immunization documentation and resources to maintain this practice. Both divisions have agreed to allow members of each division to be allotted the appropriate amount of time each monthly to compile the statistics for each clinics. The nursing / tobacco liaison will be responsible for combining and reporting on the monthly statistics that are collected each month for each clinic. The Colorado STEPP program which supplies all of the brochures and materials given to patients remain free to local healthcare providers at this time and therefore is not a cost for this practice. Long-term plans to sustain this program include the possibility of adding the SHS exposure screening question to the electronic database that TCHD uses for all immunizations given to patients. This would allow faster collection of the monthly statistics for SHS exposure in TCHD's patient population, without requiring team members to go to each clinic and manually review clinic records every month.
Lessons Learned:

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