Physician intervention and patient risk perception among smokers with acute respiratory illness in the emergency department

A single-centre observational study of delayed defaecation in brain-injured patients in an adult intensive care unit

BACKGROUND

The incidence of delayed defaecation is high in enterally fed ventilated patients in intensive care units (ICUs). Those with brain injury may be harmed by increased intracranial pressure if delayed defaecation leads to abdominal distension. There are no studies evaluating a bowel guideline in the treatment of delayed defaecation in ventilated brain-injured ICU patients.

OBJECTIVE

The objective of this study was to assess the incidence and clinical associations of delayed defaecation and level of compliance to an ICU bowel guideline.

METHODS

Data were collected on ventilated adult patients with brain injury admitted for more than 3 days to one New Zealand ICU over a 2-year period.

RESULTS

Data were analysed for 117 patients; 56 (48%) who defaecated within 3 days of ICU admission (Group one) and 61 (52%) with delayed defaecation after 3 days (Group two). Compliance with the bowel guideline was low. Only 1 of 61 patients who should have had a rectal examination did so, and only 7 of 61 patients who should have had an aperient on day 3 did so. All seven received Movicol®, which was not part of the guideline. Use of aperients and enemas was found to be associated with stool passage (odds ratio: 93; 95% confidence interval: 5.2-1668; p = 0.002). Patients with delayed defaecation had longer ICU stays (mean 7.1 ± 4 SD vs 5.9 ± 3 days, p = 0.07) and more often had high gastric residual volumes after day 4 (27/61 vs 14/56; p = 0.003). No differences were seen between the groups in the incidence of ventilator-associated pneumonia, bacterial infections, diarrhoea, vomiting, duration of mechanical ventilation, or mortality.

CONCLUSION

Delayed defaecation was common, and compliance with the guideline was low. Movicol® and phosphate enemas were effective in stool production.

An Automated Tobacco Cessation Intervention for Emergency Department Discharged Patients

Introduction

Nearly 14% of US adults currently smoke cigarettes. Cigarette smoking causes more than 480,000 deaths each year in the United States. Emergency department (ED) patients are frequently asked for their use of tobacco. Manual selection of pre-formed discharge instructions is the norm for most ED. Providing tobacco cessation discharge instructions to ED patients presents another avenue to combat the tobacco use epidemic we face. The objective of the study is to evaluate the effectiveness of an automated discharge instruction system in increasing the frequency of discharging current tobacco users with instructions for tobacco cessation.

Methods

The study was done at an urban academic tertiary care center. A before and after study was used to test the hypothesis that use of an automated discharged instruction system would increase the frequency that patients who use tobacco were discharged with tobacco cessation instructions. Patients that were admitted, left against medical advice, eloped or left without being seen were excluded. The before phase was from 09/21/14–10/21/14 and the after phase was from the same dates one year later, 09/21/15–10/21/15. This was done to account for confounding by time of year, ED volume and other factors. A Fisher’s Exact Test was calculated to compare these two groups.

Results

Tobacco cessation DC instructions were received 2/486 (0.4%) of tobacco users in the pre-implementation period compared to 357/371 (96%) in the post-implementation period (p < 0.05).

Conclusions

The automated discharge instructions system increases the proportion of tobacco users who receive cessation instructions. Given the public health ramifications of tobacco use, this could prove to be a significant piece in decreasing tobacco use in patients who go to the emergency department.

Heart failure education in the emergency department markedly reduces readmissions in un- and under-insured patients

BACKGROUND

Heart failure (HF) readmissions are a longstanding national healthcare issue for both hospitals and patients. Our purpose was to evaluate the efficacy of a structured, educational intervention targeted towards un- and under-insured emergency department (ED) HF patients.

METHODS

HF patients presenting to the ED for care were enrolled between July and December 2015 as part of an open label, interventional study, using a parallel observational control group. Eligible patients provided informed consent, had an established HF diagnosis, and were hemodynamically stable. Intervention patients received a standardized educational intervention in the ED waiting room before seeing the emergency physician, and a 30-day telephone follow-up. Primary and secondary endpoints were 30- and 90-day ED and hospital readmission rates, as well as days alive and out of hospital (DAOH) respectively.

RESULTS

Of the 94 patients enrolled, median age was 58.4 years; 40.4% were female, and 54.3% were African American. Intervention patients (n = 45) experienced a 47.8% and 45.3% decrease in ED revisits (P = 0.02 &P < 0.001), and 60.0% and 47.4% decrease in hospital readmissions (P = 0.049 &P = 0.007) in the 30 and 90 days pre- versus post-intervention respectively. Control patients (n = 49) had no change in hospital readmissions or 30-day ED revisits, but experienced a 36.6% increase in 90-day ED revisits (P = 0.03). Intervention patients also saw a 59.2% improvement in DAOH versus control patients (P = 0.03).

CONCLUSION

An ED educational intervention markedly decreases ED and hospital readmissions in un- and under-insured HF patients.

Factors Associated with Smoking Cessation Counseling at Clinical Encounters: The Behavioral Risk Factor Surveillance System (BRFSS) 2000

Purpose

Characterize factors associated with smoking-cessation counseling in clinical encounters.

Design

Cross-sectional analysis of Behavioral Risk Factor Surveillance System (BRFSS) 2000 data.

Setting

U.S. households.

Subjects

10,582 smokers (aged ≥ 18 years) reporting one or more clinical encounters during the prior year.

Measures

Multivariate-adjusted odds ratios (OR) and 95 % confidence intervals (CI) for quit advice associated with respondent and encounter variables.

Results

Almost 55 % of respondents were advised to quit smoking. Young men were advised to quit least often. Increasing age (18–24, 25–39, 40–64, ≥65 years) was associated with increasing odds of receiving quit advice (OR = 1.33, CI 1.10–1.61) for men. Other positive associations with quit advice included patient education, BMI, diagnosis of asthma, and private health insurance. Patients seeing physicians had greater odds of being advised to quit smoking (OR = 3.29, CI 2.13–5.06) than those seeing dentists. There was a 4% to 23% chance of receiving quit advice at any given nondental clinical encounter; the odds of such counseling did not rise significantly with the number of visits.

Conclusion

Smoking cessation counseling may be provided preferentially on the basis of patient demographics, and often is not provided at all. In a given year, just over half of smoking patients are advised to quit, and such counseling is provided at less than a quarter of clinical encounters.

Randomized controlled trial of emergency department initiated smoking cessation counselling and referral to a community counselling service

OBJECTIVE

Worldwide, tobacco smoke is still the leading cause of preventable morbidity and mortality. Many smokers develop chronic smoking-related conditions that require emergency department (ED) visits. However, best practices for ED smoking cessation counselling are still unclear.

METHODS

A randomized controlled trial was conducted to determine whether an "ask, advise, and refer" approach increases 12-month, 30-day quit rates in the stable adult ED smoking population compared to usual care. Patients in the intervention group were referred to a community counselling service that offers a quitline, a text-based program, and a Web-based program. Longitudinal intention-to-treat analyses were performed.

RESULTS

From November 2011 to March 2013, 1,295 patients were enrolled from one academic tertiary care ED. Six hundred thirty-five were allocated to usual care, and 660 were allocated to intervention. Follow-up data were available for 70% of all patients at 12 months. There was no statistically significant difference in 12-month, 30-day quit rates between the two groups. However, there was a trend towards higher 7-day quit attempts, 7-day quit rates, and 30-day quit rates at 3, 6, and 12 months in the intervention group.

CONCLUSION

In this study, there was a trend towards increased smoking cessation following referral to a community counselling service. There was no statistically significant difference. However, if ED smoking cessation efforts were to provide even a small positive effect, such an intervention may have a significant public health impact given the extensive reach of emergency physicians.

Cognitive-Behavioral Treatment of Nicotine Dependence for a Female With a History of Alcohol and Respiratory Problems

This case study describes the effectiveness of cognitive-behavioral therapy for nicotine dependence among smokers with comorbid alcohol dependence and severe respiratory difficulties. Although clinical practice guidelines exist for the treatment of nicotine dependence, smokers with complicated psychological and medical histories remain resilient to recommended treatments. Successfulsmoking cessation programs for these patients require a comprehensive biopsychosocial assessment as well as a tailored treatment approach. A theoretical and empirically based rationale for cognitive-behavioral treatment is provided followed by the development of a case conceptualization, course of treatment, use of assessment data, and recommendations.

Helping patients to reduce tobacco consumption in oncology: a narrative review

The present overview focuses on evidence of smoking cessation approaches in oncology settings with the aim to provide health personnel a critical perspective on how to help their patients. This narrative review is structured in two main sections: the first one describes the psycho-cognitive variables involved in the decision to continue smoking after a cancer diagnosis and during the treatment; the second section relates methods and tools may be recommended, being evidence-based, to support smoking cessation in oncology settings. Active smoking increases not only susceptibility to common cancers in the general population, but also increases disease severity and comorbidities in cancer patients. Nowadays, scientific evidence has identified many strategies to give up smoking, but a lack of knowledge exists for treatment of nicotine dependence in the cancer population. Health personnel is often ambiguous when approaching the problem, while their contribution is essential in guiding patients towards healthier choices. We argue that smoking treatments for cancer patients deserve more attention and that clinical features, individual characteristics and needs of the patient should be assessed in order to increase the attempts success rate. Health personnel that daily work and interact with cancer patients and their caregivers have a fundamental role in the promotion of the health changing. For this reason, it is important that they have adequate knowledge and resources in order to support cancer patients to stop tobacco cigarette smoking and promoting and healthier lifestyle.

What are the factors that influence the delivery of smoking cessation advice in critical care?

BACKGROUND

The world's leading cause of preventable deaths, diseases and disabilities is smoking. Hospitalization can provide an opportunity for smokers to quit. Previous research found that smokers make up a high percentage of patients admitted to intensive care. Health care professionals working in critical care environments can make a valuable contribution to this public health issue by providing smoking cessation advice.

AIM

To identify factors that inhibit and facilitate the delivery of smoking cessation advice by nurses and doctors in critical care settings.

DESIGN

Quantitative design using an online survey.

METHODS

This research was a single centre study carried out in a large tertiary hospital. Study sites were two adult critical care departments including a 14-bed general intensive care and a 16-bed cardiovascular intensive care unit. The target population for this research was the nursing and medical staff working in adult critical care environments.

RESULTS

The data suggests that doctors and nurses have a good understanding of the complications related to tobacco use and also have education on smoking cessation. Additionally the data suggest that doctors and nurses at the study sites generally have positive attitudes towards smoking cessation. Patient acuity and competence were concerns raised in relation to the delivery and effectiveness of smoking cessation advice in critical care environments.

CONCLUSIONS

The recovery phase following critical illness might be an opportunity to provide cessation advice. This could include focusing cessation advice efforts on awake, orientated and extubated patients. Further research might be required to confirm this.

RELEVANCE TO CLINICAL PRACTICE

The provision of smoking cessation advice is an on-going World Health Organization and New Zealand Government priority and all parts of the health sector need to provide responses. However, responses need to be adapted to the specific context such as the unique challenges of critical care.

Motivation to quit smoking in parental smokers in the pediatric emergency department

OBJECTIVE

To examine if motivation to quit is associated with parental smoker's perceived presence of a personal or child health illness or risk due to tobacco use.

DESIGN/METHODS

This was a cross-sectional study of a convenience sample of 218 parental smokers who presented to the pediatric emergency department with their child. We assessed factors related to motivation to quit, including personal and child smoking-related illness, perceived personal and child health risk, smoking behaviors, and demographic characteristics. Motivation to quit was measured using the Contemplation Ladder score.

RESULTS

The mean score on the Contemplation Ladder was 6.2 (SD, 2.5), representing the response: thinking about cutting down or quitting . Eighty-four participants (39%) had high motivation to quit (Contemplation Ladder score 8). Bivariate analysis showed significant associations between high motivation to quit and perceived child health risk with continued smoking and perceived personal and child health benefit following smoking cessation. Parents with high motivation to quit were more likely to have high perceived self-efficacy and confidence in their ability to quit, prior quit attempts, and lower nicotine dependence. With the exception of race/ethnicity, demographic variables were not associated with motivation to quit.

CONCLUSIONS

A significant proportion of parental smokers who present to the pediatric emergency department endorse strong motivation to quit. Parents who endorse health risk or quitting-related health benefits in their child are more likely to have high motivation to quit smoking. Future studies are needed to determine if high motivation translates into smoking cessation.

Emergency department provider preferences related to clinical practice guidelines for tobacco cessation: a multicenter survey

OBJECTIVES

The objective was to assess current emergency department (ED) provider practices and preferences for tobacco cessation interventions. The ED is an opportune place to initiate smoking cessation interventions. However, little is known about ED provider current practices and preferences for cessation counseling in the ED.

METHODS

This was a survey of ED providers conducted in 2008-2009 (including physicians, nurse practitioners, physician assistants, and nurses), working at least half-time at 10 U.S. academic EDs, regarding adherence to clinical practice guidelines ("5 As") and preferences for cessation interventions/styles. Data analysis occurred in 2012-2013.

RESULTS

The response rate was 64% (800 out of 1,246 completed surveys). Providers reported strongest adherence to asking about patient smoking status, followed by advising, with significant variance by clinical role. Assessing, assisting, and arranging support for patients was low overall. Most frequently used interventions were to provide patients with a list of telephone numbers for stop-smoking counseling (87%), pamphlets on smoking health risks and the benefits of stopping (85%), and referrals to the National Toll-Free Smoker's Quitline (84%). Most providers (80%) were supportive of personally conducting brief (less than 3 minutes) smoking cessation counseling sessions during the ED visit, emphasizing education and encouragement. The least appealing intervention was writing a prescription for nicotine replacement therapies or medications to stop smoking (35%).

CONCLUSIONS

Interventions most likely to be used were brief and delivered with a positive tone and included referral to external resources. The logical next step is to design and test interventions that ED providers find acceptable.

Smokers' knowledge about smoking-related health problems in Lebanon

The relationship between smokers' knowledge about smoking related health problems and the motivation to quit smoking in a sample of Lebanese smokers was evaluated. The first group of smokers was composed of hospitalized subjects for a cardiologic or a respiratory health problem (n = 42). The second group was composed of smokers who have not suffered from any smoking-related health problem (n = 69). A positive correlation was found between the Richmond test score and the knowledge level about smoking related health problems (r = .302; p = .0013).

Implementation of smoking cessation guidelines in the emergency department: a qualitative study of staff perceptions

Background

The US Public Health Service smoking cessation practice guideline specifically recommends that physicians and nurses strongly advise their patients who use tobacco to quit, but the best approach for attaining this goal in the emergency department (ED) remains unknown. The aim of this study was to characterize emergency physicians’ (EPs) and nurses’ (ENs) perceptions of cessation counseling and to identify barriers and facilitators to implementation of the 5 A’s framework (Ask-Advise-Assess-Assist-Arrange) in the ED.

Methods

We conducted semi-structured, face-to-face interviews of 11 EPs and 19 ENs following a pre-post implementation trial of smoking cessation guidelines in two study EDs. We used purposeful sampling to target EPs and ENs with different attitudes toward cessation counseling, based on their responses to a written survey (Decisional Balance Questionnaire). Conventional content analysis was used to inductively characterize the issues raised by study participants and to construct a coding structure, which was then applied to study transcripts.

Results

The main findings of this study converged upon three overarching domains: 1) reactions to the intervention; 2) perceptions of patients’ receptivity to cessation counseling; and 3) perspectives on ED cessation counseling and preventive care. ED staff expressed ambivalence toward the implementation of smoking cessation guidelines. Both ENs and EPs agreed that the delivery of smoking cessation counseling is important, but that it is not always practical in the ED on account of time constraints, the competing demands of acute care, and resistance from patients. Participants also called attention to the need for improved role clarity and teamwork when implementing the 5 A’s in the ED.

Conclusions

There are numerous challenges to the implementation of smoking cessation guidelines in the ED. ENs are generally willing to take the lead in offering brief cessation counseling, but their efforts need to be reinforced by EPs. ED systems need to address workflow, teamwork, and practice policies that facilitate prescription of smoking cessation medication, referral for cessation counseling, and follow-up in primary care. The results of this qualitative evaluation can be used to guide the design of future ED intervention studies.

Trial registration

ClinicalTrials.gov registration number NCT00756704

The Computer-Assisted Brief Intervention for Tobacco (CABIT) program: a pilot study

Background

Health care providers do not routinely carry out brief counseling for tobacco cessation despite the evidence for its effectiveness. For this intervention to be routinely used, it must be brief, be convenient, require little investment of resources, require little specialized training, and be perceived as efficacious by providers. Technological advances hold much potential for addressing the barriers preventing the integration of brief interventions for tobacco cessation into the health care setting.

Objective

This paper describes the development and initial evaluation of the Computer-Assisted Brief Intervention for Tobacco (CABIT) program, a web-based, multimedia tobacco intervention for use in opportunistic settings.

Methods

The CABIT uses a self-administered, computerized assessment to produce personalized health care provider and patient reports, and cue a stage-matched video intervention. Respondents interested in changing their tobacco use are offered a faxed referral to a “best matched” tobacco treatment provider (ie, dynamic referral). During 2008, the CABIT program was evaluated in an emergency department, an employee assistance program, and a tobacco dependence program in New Jersey. Participants and health care providers completed semistructured interviews and satisfaction ratings of the assessment, reports, video intervention, and referrals using a 5-point scale.

Results

Mean patient satisfaction scores (n = 67) for all domains ranged from 4.00 (Good) to 5.00 (Excellent; Mean = 4.48). Health care providers completed satisfaction forms for 39 patients. Of these 39 patients, 34 (87%) received tobacco resources and referrals they would not have received under standard care. Of the 45 participants offered a dynamic referral, 28 (62%) accepted.

Conclusions

The CABIT program provided a user-friendly, desirable service for tobacco users and their health care providers. Further development and clinical trial testing is warranted to establish its effectiveness in promoting treatment engagement and tobacco cessation.

The Emergency Department Action in Smoking Cessation (EDASC) trial: impact on delivery of smoking cessation counseling

OBJECTIVES

The focus on acute care, time pressure, and lack of resources hamper the delivery of smoking cessation interventions in the emergency department (ED). The aim of this study was to 1) determine the effect of an emergency nurse-initiated intervention on delivery of smoking cessation counseling based on the 5As framework (ask-advise-assess-assist-arrange) and 2) assess ED nurses' and physicians' perceptions of smoking cessation counseling.

METHODS

The authors conducted a pre-post trial in 789 adult smokers (five or more cigarettes/day) who presented to two EDs. The intervention focused on improving delivery of the 5As by ED nurses and physicians and included face-to-face training and an online tutorial, use of a charting/reminder tool, fax referral of motivated smokers to the state tobacco quitline for proactive telephone counseling, and group feedback to ED staff. To assess ED performance of cessation counseling, a telephone interview of subjects was conducted shortly after the ED visit. Nurses' and physicians' self-efficacy, role satisfaction, and attitudes toward smoking cessation counseling were assessed by survey. Multivariable logistic regression was used to assess the effect of the intervention on performance of the 5As, while adjusting for key covariates.

RESULTS

Of 650 smokers who completed the post-ED interview, a greater proportion had been asked about smoking by an ED nurse (68% vs. 53%, adjusted odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.3 to 2.9), assessed for willingness to quit (31% vs. 9%, adjusted OR= 4.9, 95% CI = 2.9 to 7.9), and assisted in quitting (23% vs. 6%, adjusted OR = 5.1, 95% CI = 2.7 to 9.5) and had arrangements for follow-up cessation counseling (7% vs. 1%, adjusted OR = 7.1, 95% CI = 2.3 to 21) during the intervention compared to the baseline period. A similar increase was observed for emergency physicians (EPs). ED nurses' self-efficacy and role satisfaction in cessation counseling significantly improved following the intervention; however, there was no change in "pros" and "cons" attitudes toward smoking cessation in either ED nurses or physicians.

CONCLUSIONS

Emergency department nurses and physicians can effectively deliver smoking cessation counseling to smokers in a time-efficient manner. This trial also provides empirical support for expert recommendations that call for nursing staff to play a larger role in delivering public health interventions in the ED.

Intentions to quit smoking: causal attribution, perceived illness severity, and event-related fear during an acute health event

BACKGROUND

Experiencing a serious consequence related to one's health behavior may motivate behavior change.

PURPOSE

This study sought to examine how causal attribution, perceived illness severity, and fear secondary to an acute health event relate to intentions to quit smoking.

METHODS

Using a cross-sectional survey design, adult emergency department patients who smoked provided demographic data and ratings of nicotine dependence, causal attribution, perceived illness severity, event-related fear, and intentions to quit smoking.

RESULTS

A linear regression analysis was used to examine the relations between the independent variables and quit intentions. We enrolled 186 participants. After adjusting for nicotine dependence, smoking-related causal attribution and event-related fear were associated with intentions to quit (β = 0.26, p < 0.01 and β = 0.21, p < 0.01, respectively). Perceived illness severity was correlated with event-related fear (r = 0.46, p < 0.001) but was not associated with intentions to quit (β = -0.08, p = 0.32).

CONCLUSION

While causal attribution and event-related fear were modestly associated with quit intentions, perceived illness severity was not. Longitudinal studies are needed to better explicate the relation between these variables and behavior change milestones.

Risk perception and smoking behavior in medically ill smokers: a prospective study

AIMS

To examine the influence of risk perception on intentions to quit smoking and post-treatment abstinence.

DESIGN

Prospective and longitudinal.

SETTING

United States.

PARTICIPANTS

A total of 237 adult smokers (mean age 56 years) receiving medical care from home health-care nurses. Participants did not have to want to quit smoking to participate, but received cessation counseling within the context of their medical care.

MEASUREMENTS

Three measures of risk perception were given pre- and post-treatment: perceived vulnerability, optimistic bias and precaution effectiveness. Smoking status was verified biochemically at end of treatment and at 2, 6 and 12 months later.

FINDINGS

Principal components analysis supported the theoretical discriminability of the risk perception measures, and intercorrelations provided evidence for concurrent and predictive validity. Elevated risk perception was associated with a variety of socio-demographic and psychosocial characteristics. Optimistic bias was associated significantly with older age and ethnic minority status. Smokers in pre-contemplation had lower perceived vulnerability and precaution effectiveness and greater optimistic bias than those in contemplation and preparation. Smokers in preparation had higher perceived vulnerability and lower optimistic bias than those in earlier stages. Change in perceived vulnerability predicted smoking cessation at follow-up. Optimistic bias predicted a lower likelihood of cessation and precaution effectiveness predicted a greater likelihood of smoking cessation, but only among those with a smoking-related illness.

CONCLUSIONS

In patients receiving medical care from home health-care nurses, change in perceived vulnerability to smoking-related disease is predictive of smoking cessation. In those with smoking-related illnesses, optimistic bias predicts continued smoking while precaution effectiveness predicts cessation.

The adoption of tobacco dependence treatment by rehabilitation clinicians

PURPOSE

Individuals with disabilities tend to smoke at rates that surpass those of the general population. The Pubic Health Service Guideline on the treatment of tobacco dependence suggests that all smokers be screened at every health care visit and counselled regarding how best to quit smoking. We review the literature on the adoption of tobacco dependence treatment by rehabilitation clinicians working with disabled individuals. Despite the deleterious health effects of smoking on individuals with disabilities, the limited data suggests that rehabilitation clinicians rarely encourage their clients who smoke to quit.

METHOD

Studies were collected using various computerized databases from 1980 to the present. Because of the paucity of literature on tobacco dependence treatment utilization among rehabilitation clinicians, we also examine research on the use of tobacco dependence treatment by health care providers in the general population and in substance abuse treatment settings.

RESULTS

Despite the efficacy of tobacco dependence treatment in smokers with disabilities, tobacco dependence treatment appears to be underutilized by rehabilitation clinicians.

CONCLUSIONS

Interventions that have successfully increased adoption by the two other clinician groups should be utilized to increase tobacco dependence treatment provision by rehabilitation clinicians. Additional research is warranted to determine how to overcome obstacles to adoption.

Efficacy of a brief intervention to improve emergency physicians' smoking cessation counseling skills, knowledge, and attitudes

The objective of this study was to test whether a brief educational/administrative intervention could increase tobacco counseling by emergency physicians (EPs). Pre-/post-study at eight emergency departments (EDs) with residency programs were carried out. EPs received a 1-hour lecture on the health effects of smoking and strategies to counsel patients. After the lecture, cards promoting a national smokers' quitline were placed in EDs, to be distributed by providers. Providers completed pre-/ post-intervention questionnaires. Patients were interviewed pre-/post-intervention to assess provider behavior. Two hundred eighty-seven EPs were enrolled. Post-intervention, providers were more likely to consider tobacco counseling part of their role, and felt more confident in counseling. Data from 1168 patient interviews and chart reviews showed that, post-intervention, providers were more likely to ask patients about smoking, make a referral, and document smoking counseling. Post-intervention, 30% of smokers were given a Quitline referral card. An educational intervention improved ED-based tobacco interventions. Controlled trials are needed to establish these results' durability.

Health beliefs toward cardiovascular risk reduction in patients admitted to chest pain observation units

OBJECTIVES

Even after acute coronary syndrome (ACS) is ruled out, observational studies have suggested that many patients with nonspecific chest pain have a high burden of cardiovascular risk factors (CRFs) and are at increased long-term risk of ischemic heart disease (IHD)-related mortality. The aim of this study was to evaluate the premise that evaluation in an observation unit for symptoms of possible ACS is a "teachable moment" with regard to modification of CRFs.

METHODS

The authors conducted a baseline face-to-face interview and a 3-month telephone interview of 83 adult patients with at least one modifiable CRF who presented with symptoms of possible ACS to an academic medical center. Existing questionnaires were adapted to measure Health Belief Model (HBM) constructs for IHD. Stage of change and self-reported CRF-related behaviors (diet, exercise, and smoking) were assessed using previously validated measures. The paired t-test or signed rank test was used to compare baseline and 3-month measures of health behavior within the analysis sample.

RESULTS

Of the 83 study patients, 45 and 40% reported having received clinician advice regarding diet and physical activity during the observation unit encounter, respectively; 69% of current smokers received advice to quit smoking. Patients reported lower susceptibility to IHD (13.3 vs. 14.0, p = 0.06) and greater perceived benefit of healthy lifestyles (27.5 vs. 26.4, p = 0.0003) at 3-month follow-up compared to baseline. Patients also reported greater readiness to change and improved self-reported behaviors at follow-up (vs. baseline): decreased intake of saturated fat (10.1% vs. 10.5% of total calories, p = 0.005), increased fruit and vegetable intake (4.0 servings/day vs. 3.6 servings/day, p = 0.01), and fewer cigarettes (13 vs. 18, p = 0.002).

CONCLUSIONS

Observed changes in IHD health beliefs and CRF-related behaviors during follow-up support the idea that observation unit admission is a teachable moment. Patients with modifiable risk factors may benefit from systematic interventions to deliver CRF-related counseling during observation unit evaluation.

A smoking cessation intervention plus proactive quitline referral in the pediatric emergency department: a pilot study

The prevalence of adult tobacco users who utilize the emergency department as patients or parents is disproportionately higher than the national average rates of tobacco use. Thus, it is advised that the emergency department be utilized as a venue for providing tobacco cessation counseling to adult tobacco users. Using a randomized control trial design, this pilot study evaluated the effect of a brief tobacco cessation intervention for tobacco using parents of children brought to a pediatric emergency department. Participants received either usual care or a brief tobacco cessation intervention based on the first 2 of the 5A's of the Clinical Practice Guidelines and fax referral to the Quitline. The primary outcome was self-reported repeated point prevalence of tobacco use at 6 weeks and 3 months following the intervention. Secondary aims included number of quit attempts, increases in readiness to quit, comparisons of participants who were successfully retained, and contact rates by Quitline counselors. At 3-month follow-up, compared to the Usual Care Control group, intervention participants were more likely to have made at least one quit attempt (59% vs. 34%; p<.01), be seriously thinking about quitting (68% vs. 37%; p<.001), and have higher Ladder scores (6.2 vs. 5.3; p<.05). Study personnel were able to contact 68% and 52%, respectively, of participants at 6-week and 3-month follow-up. Quitline counselors were unable to reach 54% of participants. Our results reveal increased intentions to quit and trends toward quitting, however we experienced difficulties with participant retention. Suggestions for improvements in point prevalence and retention are given.

Acceptability of tobacco cessation interventions in the pediatric emergency department

OBJECTIVES

To assess the acceptability to parents and staff of providing a brief tobacco cessation intervention incorporating the first 2 A's of the Clinical Practice Guideline on Treating Tobacco Use and Dependence (Ask and Advise) + fax referral to a state tobacco quitline from the emergency department (ED) of a large children's hospital.

METHODS

Data were collected from a written survey of (1) parental smokers accompanying their children to a pediatric ED who consented and were randomized to participate in a tobacco cessation intervention and (2) medical doctors (MDs) or nurse practitioners (NPs) caring for their child. Acceptability of the intervention was measured on a 5-point Likert scale ranging from "strongly agree" to "strongly disagree."

RESULTS

Of the 1643 parental subjects that were screened to participate in this study, 557 (33.9%) were smokers, 240 of whom were enrolled in the intervention group and a total of 215 (90%) completed the survey. A total of 230 (100%) of the MDs/NPs approached completed the survey. Of the 215 parental subjects in the intervention group, 212 (98.6%) and 208 (96.7%) agreed that the intervention provided them with "useful information" and "easy to understand" advice, respectively. Most parental subjects agreed that the advice given was sufficient and met their needs (n = 208, 96.7%) and that the study length was "just right" (n = 206, 95.8%). On a rating scale of 1 to 10, the mean (SD) rating of the study was 9.1 (1.3). Of the MDs/NPs participating in this survey, 224 (97.4%) and 206 (89.6%) agreed that the "ED is a good place to screen parents for tobacco use" and that the "ED is a good place to give advice about tobacco cessation," respectively. In addition, 202 (87.8%) and 196 (85.2%) reported that they felt comfortable giving tobacco cessation advice to parents or referring parents to the national quitline, respectively. Only 7 (3%) felt that the study interfered with patient care.

CONCLUSIONS

An ED tobacco cessation intervention using the 2 A's + Quitline referral had excellent acceptability in this study of parents and staff of pediatric patients. The use of the pediatric ED as a venue to providing tobacco cessation counseling to a population with a high prevalence of parental smokers warrants further consideration.

Provision of smoking care in NSW hospitals: opportunities for further enhancement

The provision of smoking care, including the management of nicotine withdrawal and assistance with a quitting attempt, is identified as an important part of the overall care of hospitalised patients. Levels of smoking care delivery in hospitals have been less than optimal. Increasing this care across multiple facilities and units within NSW Health represents a significant challenge. This article examines levels of smoking care delivery in NSW hospitals, and research evidence and best practice recommendations to inform potential strategies to increase such care. It also reviews statewide initiatives implemented by NSW Health to enhance the delivery of smoking care and suggests further strategies that could facilitate this.

Changes in smoking associated with an acute health event: Theoretical and practical implications

BACKGROUND

Experiencing a serious adverse behavior-related consequence may motivate behavior change.

PURPOSE

To examine how a sentinel health event is associated with changes in smoking.

METHODS

We used a prospective cohort design. Adult emergency department (ED) patients provided demographic data, a smoking history, ratings of quit intentions, and endorsement of self-identified smoking-related health problems. A chart review collected data on acuity, ED disposition, and medical diagnoses. Smoking was reassessed 1 month postvisit. Hierarchical regression analyses were conducted to predict (a) intention to quit, (b) any quit attempt of 24 hr or more, and (3) 7-day abstinence.

RESULTS

Of 717 smokers enrolled, 189 (26%) intended to quit within the next month. Of the 253 participants reached 1 month postvisit, 126 (50%) reported they had attempted to quit, with 44 (19%) reporting 7-day abstinence. After controlling for other predictors, several event-related variables, such as having a smoking-related ED visit and being admitted to the hospital, were strong predictors of outcomes.

CONCLUSION

Compared to community-based estimates, many more smokers in our sample attempted to quit and achieved 7-day abstinence. This was especially true among smokers who attributed their ED visit to a smoking-related health problem and who were admitted to the hospital. We discuss the implications for tobacco intervention design in medical settings.

Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations

Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.

Nicotine dependence, motivation to quit, and diagnosis in emergency department patients who smoke

OBJECTIVES

To assess the effect of diagnosis on motivation to quit in adult smokers in an emergency department (ED).

METHODS

A survey of patients visiting two EDs from September to November, 2003. Patients screening positive for smoking completed a Fagerstrom Test for Nicotine Dependence and Ladder of Contemplation. ICD9 codes and disposition status were recorded. Smoking-related diagnoses were drawn from standard sources. Data were analyzed with parametric and non-parametric statistics.

RESULTS

Five hundred and eighty-five were interviewed, median age 40 (interquartile range 29-50); 323 (55%) were female. Ninety percent of all patients were non-White; 69% were uninsured or had Medicaid. Of 152 patients with smoking-related diagnoses, the median Fagerstrom score was 4.7 vs. 4.1 for patients with a non-smoking-related diagnosis (p=0.02, 95% CI for the difference 0.2, 0.9). Patients with smoking-related and non-smoking-related diagnoses had similar levels of motivation to quit (Ladder score, respectively, 5.5 vs. 5.1, p=0.03, 95% CI for difference 0.03, 0.8).

CONCLUSIONS

Adult ED smokers exhibit mild-moderate levels of nicotine addiction and interest in quitting. ED-based tobacco control should target all smokers.

Predicting smoking stage of change among emergency department patients and visitors

OBJECTIVES

Little is known about whether emergency department (ED) patients or those who accompany them (visitors) are interested in smoking cessation. The authors hypothesized that several variables would be associated with stage of change, including nicotine dependence, self-efficacy, presence of a smoking-related illness, and anticipated cessation-related health improvement.

METHODS

For two 24-hour periods, consecutive patients and visitors aged 18 years and older presenting to four Boston EDs were interviewed. The authors assessed a range of smoking-related constructs. Exclusion criteria included severe illness, cognitive insufficiency, and acute distress.

RESULTS

One thousand ten subjects were screened (56% patients, 44% visitors). Two hundred thirty-seven (23%) subjects were current smokers, with 57% being in precontemplation, 31% in contemplation, and 12% in preparation stages. When ordinal regression was used, the variables most strongly associated with stage of change were as follows: self-efficacy (odds ratio [OR] = 5.1; p < 0.001), anticipated cessation-related health improvement (OR = 2.7; p = 0.02), and having a smoking-related health problem (OR = 1.9; p = 0.08).

CONCLUSIONS

Because many disenfranchised Americans use the ED as a regular source of health care, increased attention to smoking in the ED setting holds tremendous public health potential. This study's results reinforce the validity of the stage-of-change model within the ED setting. Developers of ED-initiated interventions will have to consider the heterogeneity in stage of change when designing their treatments.

Increasing smoking cessation care in a preoperative clinic: a randomized controlled trial

BACKGROUND

Evidence suggests that preoperative clinics, like other hospital outpatient clinics and inpatient wards, fail to systematically provide smoking cessation care to patients having planned surgery.

METHODS

The aim of the study was to assess the efficacy, acceptability, and cost of a multifaceted intervention to facilitate the provision of comprehensive smoking cessation care to patients attending a preoperative clinic. Two hundred ten smoking patients attending a preoperative clinic at a major teaching hospital in Australia took part in the study. One hundred twenty-four patients were randomly assigned to an experimental group and 86 patients to a usual cessation care group. A multifaceted intervention was developed that included the use of opinion leaders, consensus processes, computer-delivered cessation care, computer-generated prompts for care provision by clinic staff, staff training, and performance feedback.

RESULTS

Ninety-six percent of experimental group patients received behavioral counseling and tailored self-help material. Experimental group patients were significantly more likely than usual care patients to report receiving brief advice by nursing (79% vs. 47%; P < 0.01) and anaesthetic (60% vs. 39%; P < 0.01) staff. Experimental group patients who were nicotine dependent were also more likely to be offered preoperative nicotine replacement therapy (NRT) (82% vs. 8%; P < 0.01) and be prescribed postoperative NRT (86% vs. 0%; P < 0.01). The multifaceted intervention was found to be acceptable by staff.

CONCLUSION

A multifaceted clinical practice change intervention may be effective in improving the delivery of smoking cessation care to preoperative surgical patients.

Smoking stage of change and interest in an emergency department-based intervention

OBJECTIVES

To examine factors associated with motivation to quit smoking and interest in an emergency department (ED)-based intervention.

METHODS

Consecutive ED patients 18 years of age and older were interviewed. Severely ill and cognitively disabled patients were excluded. Smoking history, stage of change, self-efficacy, presence of a smoking-related illness, interest in an ED-based smoking intervention, and screening/counseling by the patient's ED provider were assessed.

RESULTS

A total of 1,461 of 2,314 patients (64%) were interviewed. A total of 581 (40%) currently smoked, with 21% in precontemplation (no intention to quit), 43% in contemplation (intention to quit but not within the next 30 days), and 36% in preparation (intention to quit within the next 30 days). Approximately 50% indicated a willingness to remain 15 extra minutes in the ED to receive counseling. Only 8% received counseling by their ED provider. A regression analysis showed that greater readiness to change was associated with multiple lifetime quit attempts, presence of a quit attempt in the past 30 days, and higher self-efficacy. Interest in an ED-based intervention was more likely among patients who reported higher self-efficacy.

CONCLUSIONS

Approximately 50% of smokers reported at least moderate interest in an ED-based intervention and a willingness to stay 15 extra minutes, but only 8% reported receiving counseling during their ED visit. Considering time and resource constraints, counseling/referral may be best suited for patients characterized by a strong desire to quit, multiple previous quit attempts, high self-efficacy, a smoking-related ED visit, and strong interest in ED-based counseling.

Interest in Smoking Cessation Among Emergency Department Patients

The authors interviewed adult patients presenting to 4 Boston emergency departments (EDs) about their smoking, quit attempts, and interest in an outpatient referral. Of the 539 patients enrolled, 26% were current smokers. Of the current smokers, 72% had tried to quit in the past year, and 34% wanted an outpatient referral. Current smokers were younger than nonsmokers and were less likely to have a high school education, primary care provider, and private insurance. The findings of this study reinforce the potential benefit of routine screening for smoking and interest in quitting in the ED. Because many underinsured Americans use the ED as a source of regular health care, the public health implications of increasing screening, counseling, and referral for smokers are substantial.