Cigarette smoking remains one of the most preventable causes of premature death in our society, yet only a third to a half of smokers visiting a physician are counseled to quit. In the primary care setting, chart reminders can increase physician smoking cessation counseling rates. It is unclear, however, whether pulmonary physicians require prompting to discuss smoking cessation with patients. We hypothesized that chart reminders would improve the smoking cessation counseling and referral practices in our pulmonary clinic. Chart reviews were performed for two 1-mo periods and documentation of smoking status, counseling, and referrals to smoking cessation clinic were recorded. After the implementation of chart reminders, charts were reviewed at 1, 3, and 8 mo. Chart reminders increased documentation of smoking status from 33 to 83% (p = 0.0001). The proportion of all patients counseled increased from 6.0 to 13.2% (p = 0.01). The improvement in counseling to quit occurred primarily by increasing the identification of active smokers. Pulmonary physicians counseled 70% of smokers to quit once patients were identified as smokers. Chart reminders, an inexpensive and easily implemented smoking cessation intervention, increased the overall number and proportion of patients counseled to stop smoking by increasing the number of identified smokers. This simple intervention can improve counseling in populations at high risk for smoking related lung disease.

Objective To determine whether a low-intensity versus high-intensity medical intensive care unit (MICU) format in a Veterans Affairs (VA) hospital setting improves patient outcomes, as measured by duration of mechanical ventilation (MV), ventilator-free days (VFDs), and hospital mortality. Design Retrospective cohort study. Setting Medical intensive care unit at the San Francisco Veterans Affairs Medical Center (SFVAMC). Patients On July 1, 2004, the SFVAMC transitioned from a low-intensity MICU to a high-intensity MICU. All patients admitted to the MICU who required MV for 18 months before (n = 96) and 18 months after (n = 131) the transition were included in the analysis. Measurements We prospectively defined the primary outcome measure as the difference in the median duration of MV between groups. Secondary outcomes included VFDs and hospital mortality. Continuous variables were compared using the Wilcoxon rank sum test; dichotomous variables were compared using Fisher exact test. Main results The low-intensity and high-intensity MICU groups were similar in age, gender, weight, and admitting diagnosis (P > .27 in all cases). Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 22.0 in the low-intensity era and 20.0 in the high-intensity era (P = .048). Median duration of MV was significantly lower in the high-intensity MICU format compared to the low-intensity MICU format (102 vs 61 hours, P for log-rank test = .0052). After controlling for covariates, there were 4.2 more VFDs in the high-intensity era (95% CI 1.9 to 6.6 days). The high-intensity era was associated with a reduced hospital mortality rate (27% vs 40%) and an adjusted odds ratio of 0.34 (95% CI 0.15 to 0.74). Conclusions For critically ill veterans admitted to an MICU requiring MV, a high-intensity ICU structure is associated with more favorable mechanical ventilatory outcomes and lower mortality.

At laboratory and clinical levels, therapeutic hypothermia has been shown to improve neurologic outcomes and mortality following cardiac arrest. We reviewed each cardiac arrest in our community-based Veterans Affairs Medical Center over a three-year period. The majority of cases were in-hospital arrests associated with initial pulseless electrical activity or asystole. Of a total of 100 patients suffering 118 cardiac arrests, 29 arrests involved comatose survivors, with eight patients completing therapeutic cooling. Cerebral performance category scores at discharge and six months were significantly better in the cooled cohort versus the noncooled cohort, and, in every case except for one, cooling was offered for appropriate reasons. Mean time to initiation of cooling protocol was 3.7 hours and mean time to goal temperature of 33°C was 8.8 hours, and few complications clearly related to cooling were noted in our case series. While in-patient hospital mortality of cardiac arrest was high at 65% mortality during hospital admission, therapeutic hypothermia was safe and feasible at our center. Our cooling times and incidence of favorable outcomes are comparable to previously published reports. This study demonstrates the feasibility of implementing, a cooling protocol a community setting, and the role of neurologists in ensuring effective hospital-wide implementation.

No abstract