Smoking cessation, hospital infections

Summaries from ACP Hospitalist Weekly.

Inpatients more likely to receive nicotine replacement therapy when hospitalists involved

While hospitalists provided much less cessation counseling than the tobacco treatment service at one academic medical center, their involvement was associated with higher inpatient rates of nicotine replacement therapy (NRT) orders and uptake, a recent study found.

Image by Getty Images
Image by Getty Images

Over 12 consecutive months, researchers enrolled adults who were daily tobacco users and discharged from the hospitalist service. Admission nurses performed formal assessments and documented tobacco use in the electronic health record, and daily tobacco users who were identified triggered a tobacco treatment service evaluation. Those who were willing to speak with tobacco treatment service counselors received smoking cessation counseling, and the primary treatment team placed NRT orders based on recommendations from the tobacco treatment service.

The hospitalist service discharged 1,136 daily tobacco users, 567 (49.9%) of whom received tobacco cessation counseling. Counseling was provided by the tobacco treatment service alone in 432 (38%) patients, by hospitalists alone in 72 (6%) patients, and by both groups in 63 (6%) patients, according to results published Oct. 15, 2018, by the Journal of General Internal Medicine.

The highest NRT order and administration rate was in the group counseled by both a hospitalist and the tobacco treatment service (81%), followed by a hospitalist alone (66.7%) and the tobacco treatment service alone (60%). Compared to those who received no counseling, the likelihood of having an NRT order placed was highest for patients advised by both a hospitalist and the tobacco treatment service (adjusted odds ratio [OR], 7.22; 95% CI, 2.94 to 17.72), followed by a hospitalist alone (adjusted OR, 3.28; 95% CI, 1.60 to 6.75), and the tobacco treatment service alone (adjusted OR, 2.60; 95% CI, 1.81 to 3.73). The pattern was similar among patients who both received and accepted an NRT prescription (adjusted ORs, 6.68 [95% CI, 2.90 to 15.08] for both, 2.62 [95% CI, 1.31 to 5.21] for hospitalist only, and 2.09 [95% CI, 1.45 to 3.00] for tobacco treatment service only).

Hospitalists tended to be involved in cessation counseling for patients with minor severity of illness compared to higher-acuity patients and for those discharged home compared to a health facility or other location. “This likely represents a challenge in prioritization of workflow. For the hospitalist, tobacco cessation counseling becomes less urgent among other daily patient management tasks,” the study authors wrote.

They noted limitations, such as the study's single-center design and the fact that the hospital had an existing tobacco treatment service, which may limit generalizability. In addition, counseling was based on claims data, which may have underestimated the effect of hospitalist counseling, they said.

U.S. hospitals saw overall decline in health care-associated infections from 2011 to 2015

Between 2011 and 2015, rates of surgical-site and health care-associated urinary tract infections decreased in U.S. hospitals, driving a decline in health care-associated infections overall, a CDC study found.

The study included data from hospitals participating in the Emerging Infections Program, using a random sample of patients on a single day chosen by each hospital to assess the prevalence of health care-associated infections. A total of 12,299 patients treated in 199 hospitals in 2015 were compared with 11,282 patients treated in 183 hospitals in 2011. Results were published in the Nov. 1, 2018, New England Journal of Medicine.

Fewer patients had health care-associated infections in 2015 than 2011: 394 patients (3.2% [95% CI, 2.9 to 3.5]) versus 452 patients (4.0% [95% CI, 3.7 to 4.4]; P<0.001). This was largely due to reductions in the prevalence of surgical-site and urinary tract infections. The percentages of patients with pneumonia, gastrointestinal infection (including and mostly comprising C. difficile infection), or bloodstream infection did not differ significantly between 2015 and 2011. Pneumonia, gastrointestinal infections, and surgical-site infections were the most common health care-associated infections.

After adjustment for age, presence of devices, days from admission to survey, and being in a large hospital, the risk of having a health care-associated infection was 16% lower in 2015 than in 2011 (risk ratio, 0.84 [95% CI, 0.74 to 0.95]; P=0.005). “These results provide evidence of national success in preventing health care-associated infections, particularly surgical-site and urinary tract infections,” the authors said. However, the lack of decline in pneumonia, C. difficile, and mortality from health care-associated infections “suggests that more work is needed.”

The decline in urinary tract infections might be due to reduced use of urinary catheters, and surgical-site infections might have been prevented by practices such as decolonization of patients with Staphylococcus aureus colonization or implementation of surgical prophylaxis guidelines, the authors speculated. It's possible that increased use of C. difficile nucleic acid amplification testing since 2011 masked reductions in prevalence in the study data, but regardless, there is room for improvement in antibiotic prescribing and infection control, they noted. The authors also pointed out that although most inpatient pneumonia prevention efforts focus on ventilated patients, the majority of pneumonia events found in the study were not ventilator-associated.

The generalizability of the results to hospitals not participating in the program is uncertain and limitations of the study include that fewer patients met the screening criteria in 2015 than in 2011, the authors said.