Safety Issues for Hospital Patients

Hospitals across Canada have strict no-smoking policies, but how are patients addicted to nicotine faring in these circumstances? Researchers tried to find some answers by questioning patients, health-care professionals and other staff at two large acute-care hospitals -- the University of Alberta Hospital and Winnipeg's Health Science Centre. Smoke-free policies often prohibit smoking near entrances, in parking lots or anywhere on hospital grounds. The researchers found non-compliance, as well as inadequate treatment for tobacco dependence. "Just because you put this kind of policy into place doesn't mean people are just going to quit smoking," said co-author Annette Schultz, an assistant professor at the University of Manitoba's faculty of nursing. She's also an ex-smoker who has worked in primary-care settings. The paper appeared Monday in the Canadian Medical Association Journal. The study period was December 2008 to May 2009, which means some of the information was collected over a cold Canadian winter. Patients often can be seen congregating outside the doors of a hospital even when it's -30 or -40 C, Schultz observed. "This is somebody who's sick enough to be in the hospital. That's concerning because that means they're off the unit, and they're also exposed to this kind of weather condition," she said, adding that intravenous lines can freeze at low temperatures and need to be restarted. Some hospitals are in parts of town that are not always particularly safe, she said, and patients build little networks so they can go outside in a group, especially in the evening so they won't be outside alone. "I think one of the more striking stories that we hinted at in the paper was somebody in a wheelchair who went out the door, but because they're in a wheelchair, their height of vision was not such that they saw the signage that said the door closed and was locked after (a certain time)," she said. "So they went out to go have their cigarette, and of course couldn't get back in that door ... that meant they had to go around on the outside part of the hospital to get to a door that was open." The researchers also collected data on patients in isolation due to infection who would put on a mask and gown, then go outside for a cigarette. "That is also concerning because then that cigarette that gets thrown on the ground is something that somebody else could come and pick up, to either take and roll into their own, or perhaps if there's enough of a cigarette left there, they themselves would actually smoke that cigarette. So that becomes a bit of an infection-control issue." Schultz said she's watched nurses negotiate and accommodate smoking by patients. In a previous study, a nurse told her she'd rather do a dressing change on somebody who's calm after a cigarette, rather than someone who's going through withdrawal symptoms, which can include irritability, not being able to focus and being fairly persistent about wanting to go outside for a smoke. If a patient can't go outside, he or she might light up in the room. "Sometimes it also leads to confiscating cigarettes from the patient, which means then when they do want to go out, they have to go to the desk, they ask for one, to then be able to go out," noted Schultz, who is also with the Psychosocial Oncology and Cancer Nursing Research Group at the St. Boniface Hospital Research Centre. "Do you see how it's another layer of something that the nurses are doing to accommodate the situation?" There's a saying that hospitalization is an opportune time for a smoker to quit. In Schultz's view, non-compliance with no-smoking policies isn't an enforcement issue, but rather a treatment issue that should involve supporting abstinence while patients are in hospital. She doesn't expect hospitals to step away from clean-air policies in order for patients to have a safe place to smoke, so at a minimum, the staff need to become a lot more proactive in working with patients and offering a variety of nicotine-replacement therapy products, including the patch, gum, lozenges and perhaps inhalers. "It's not necessarily about asking somebody to quit -- but it is about during the three or four or five or six days, whatever it is in the hospital, that we really work with them around supporting them to alleviate the withdrawal symptoms," she said. In many cases, if the patch is offered and the patient says "no," that is the end of the conversation. "To me, the next question could be something like, 'Well, have you tried the patch before? How much did you try? What was your experience?' and to really start to work with them." In a commentary in the journal, Sharon Lawn of the department of psychiatry at Flinders University in Bedford Park, Australia, writes that Schultz's study shows how the notion of responsibility can become distorted when smoking is viewed as a morally interpreted behaviour -- a lifestyle choice -- rather than an addiction that requires clinical support. "Very few staff felt that enforcing the smoke-free policy was their responsibility," she wrote. "Hospital staff need to see themselves as a necessary component of a larger set of supports for smoking cessation across the continuum of care."