Clinical Nurse Educator, Cardiac Intensive Care Unit St. Paul's Hospital, British Columbia, Canada
Background: Quitting smoking after an acute coronary syndrome (ACS) significantly reduces the risk of recurrent infarction and death. Canadian tobacco cessation guidelines recommend that all hospitalized patients be screened for tobacco use and offered treatment if they smoke. At the St. Paul’s Hospital Cardiac Intensive Care Unit (CICU), nurses are ideally positioned screen their potentially highly receptive patients for nicotine dependence, lead smoking cessation efforts and initiate secondary prevention strategies. However, health record audits revealed majority of CICU admissions did not have the documented screening for nicotine dependence completed. The audits also highlighted an opportunity to strengthen the pathway for linking patients to smoking cessation support.
METHODS AND RESULTS: To address this gap, we implemented a knowledge translation (KT) initiative aimed at improving the identification and support of patients who smoke. Interventions included interprofessional collaboration, streamlined nursing-initiated referrals to smoking cessation experts for inpatients and upon discharge, sustainable training, while incorporating patient partner engagement and feedback on changes made. Regular health record audits and nursing surveys were used to evaluate the initiative. Despite nurses reporting improved levels of knowledge and education on smoking screening and cessation —documentation rates for nicotine dependence did not improve significantly. Overall, screening compliance improved marginally from 28% in February 2024 to a median of 38% in March 2025, representing a 10-percentage point increase. Additional survey findings revealed that addressing educational needs and supporting a streamlined pathway for smoking cessation referral was not enough to overcome persistent barriers such as electronic medical record (EMR) fatigue. These challenges reflect broader system-level issues rather than individual gaps in knowledge or motivation. Interestingly, although documentation rates for nicotine dependence did not increase significantly, 97% (n = 37) of screened patients that required further smoking cessation intervention received referral to specialty services.
Conclusion: CICU nurses represent a highly motivated and relevant group to champion smoking cessation initiatives. Despite targeted quality improvement efforts and active engagement from frontline nursing staff, consistent integration of tobacco screening into routine CICU workflows remains a challenge. Notably, patients with documented tobacco dependence are consistently referred for smoking cessation support, indicating reliable adherence to referral protocols when dependence is identified. These findings highlight the need for system-level changes, including workflow redesign and stronger institutional support, to enable consistent implementation of evidence-based smoking cessation interventions inclusive of documenting a patient's smoking status. Future work will focus on engaging leadership to inform a regional strategy to address screening of patients for smoking cessation.
