Clark BJ, Moss M. Secondary prevention in the intensive care unit: Does intensive care unit admission represent a “teachable moment?”

University of Colorado Denver, Division of Pulmonary Sciences and Critical Care Medicine, Aurora, CO, USA.
Critical care medicine (Impact Factor: 6.31). 06/2011; 39(6):1500-6. DOI: 10.1097/CCM.0b013e31821858bb
Source: PubMed


Cigarette smoking and unhealthy alcohol use are common causes of preventable morbidity and mortality that frequently result in admission to an intensive care unit. Understanding how to identify and intervene in these conditions is important because critical illness may provide a "teachable moment." Furthermore, the Joint Commission recently proposed screening and receipt of an intervention for tobacco use and unhealthy alcohol use as candidate performance measures for all hospitalized patients. Understanding the efficacy of these interventions may help drive evidence-based institution of programs, if deemed appropriate.
A summary of the published medical literature on interventions for unhealthy alcohol use and smoking obtained through a PubMed search.
Interventions focusing on behavioral counseling for cigarette smoking in hospitalized patients have been extensively studied. Several studies include or focus on critically ill patients. The evidence demonstrates that behavioral counseling leads to increased rates of smoking cessation but the effect depends on the intensity of the intervention. The identification of unhealthy alcohol use can lead to brief interventions. These interventions are particularly effective in trauma patients with unhealthy alcohol use. However, the current literature would not support routine delivery of brief interventions for unhealthy alcohol use in the medical intensive care unit population.
Intensive care unit admission represents a "teachable moment" for smokers and some patients with unhealthy alcohol use. Future studies should assess the efficacy of brief interventions for unhealthy alcohol use in medical intensive care unit patients. In addition, identification of the timing and optimal individual to conduct the intervention will be necessary.

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    ABSTRACT: Objective: The objective of this review was to systematically review and evaluate available literature describing the effect of nicotine replacement therapy (NRT) on mortality and other outcomes in nicotine-dependent critically ill patients admitted to the intensive care unit (ICU). Data Sources: A systematic search of the following databases was performed: MEDLINE (1948-August 2011), EMBASE (1980-August 2011), Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts (1970-August 2011), Google, and Google Scholar. Study Selection: Studies that reported outcomes associated with any form of NRT in any intensive care setting were included. Studies were included regardless of design or number of participants reported. Studies published in languages other than English were excluded. Data Extraction: Data from each study were extracted using a standardized data extraction tool. Information included the study design, number of patients, classification of ICU, baseline characteristics, outcomes assessed, and overall results. Data Synthesis: Our search identified 8 studies, of which 7 met the inclusion criteria. These 7 studies were qualitatively reviewed and critically appraised for methodological quality, robustness of results, and internal and external validity. The results of similar studies and populations were compared in order to draw conclusions pertaining to specific intensive care settings. Conclusions: We conclude that NRT should not be routinely prescribed to patients admitted to intensive care settings. With only equivocal evidence of efficacy and signals suggesting increased toxicity, we believe that its use should be limited to selected patients where the potential benefit clearly outweighs the risk. There is a need for adequately powered randomized controlled trials to confirm the benefits and risks of NRT in the ICU overall but also in its unique subpopulations.
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    ABSTRACT: Emergency departments (ED) are a point of care for many young adults and may provide a teachable moment leading to behavioral change. We determined the descriptive epidemiology of health-compromising behaviors in the young adult ED population by computing demographic-adjusted estimates of prevalence and frequency of hazardous drinking, risky driving, cigarette smoking, fast-food consumption, lack of exercise, and sleep deficit. We screened 8,815 young adults during an ED visit. Younger males had higher levels of fast-food and cigarette consumption. Non-Whites and females reported more days of little to no exercise. Whites and older individuals reported more nights of less sleep. Younger Whites reported consuming the most alcohol, with males consuming more than females. Risky driving was more frequent among younger males. Prevalence of health-compromising behaviors varied by demographics, but was higher than in the general population. Prevention strategies such as implementing a teachable moment in the ED may hold promise to reduce health-compromising behaviors.
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    ABSTRACT: BACKGROUND: There have been no studies describing post-intensive care unit (ICU) alcohol use among medical-surgical ICU survivors. OBJECTIVE: To examine alcohol use and identify potentially modifiable risk factors, such as in-hospital probable acute stress disorder, for increased alcohol use following medical-surgical ICU admission. METHOD: This longitudinal investigation included 150 medical-surgical ICU survivors. In-hospital interviews obtained baseline characteristics including pre-ICU alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) and in-hospital probable acute stress disorder with the Post-traumatic Stress Disorder Checklist-civilian version. Clinical factors were obtained from medical records. Post-ICU alcohol use was ascertained via telephone interviews at 3 and 12 months post-discharge using the AUDIT. Mixed-model linear regression was used to examine potential risk factors for increased post-ICU alcohol use. RESULTS: There was a significant decline in the mean AUDIT score from baseline (3.9, 95% confidence interval [95% CI]: 2.9, 5.0) to 3 months post-ICU (1.5, 95% CI: 1.0, 2.1) (P < 0.001 by one-way analysis of variance [ANOVA]), with a significant increase between 3 and 12 months post-ICU (2.7, 95% CI: 1.8, 3.5) (P < 0.001 by one-way ANOVA). After adjusting for patient and clinical factors, in-hospital probable acute stress disorder (beta: 3.0, 95% CI: 0.9, 5.0) and pre-ICU unhealthy alcohol use (beta: 5.4, 95% CI: 3.4, 7.4) were independently associated with increased post-ICU alcohol use. CONCLUSIONS: Alcohol use decreases in the early aftermath of medical-surgical ICU admission and then increases significantly by one year post-ICU. Interventions for unhealthy alcohol use among medical-surgical ICU survivors that take into account comorbid psychiatric symptoms are needed.
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