July 1, 2010

A program using pre-health professional students as Research Associates (RAs) in hospital emergency rooms can be effective in screening large numbers of patients and visitors in the emergency department for compliance with a wide variety of primary health care recommendations, including smoking cessation.

Hospital emergency departments see over 120 million patients, plus their accompanying family and friends each year. Patients are in the emergency department (ED) for an average of 3.3 hours.  Much of this time is spent waiting, time which has the potential to be used for health promotion.  One study, covering, used RAs to identify smokers (both current and ever for at least one month) and refer them to the state quitline.

The RA program emerged from the observation that some of the busiest emergency departments could be the sites for research studies but have not been, in large part because the staff is overburdened with its basic responsibilities.  Dr. Keith Bradley, of St. Vincent’s Medical Center in Bridgeport, CT, thought that this problem could be overcome by using pre-med college students looking for clinical experience.  These students could be given a short orientation in the basics of clinical research, ethical issues, safety, volunteer duties, and the specifics on data collection for each study. In as little as one four hour shift per week, these RAs could identify subjects, obtain demographic and historical information, read informed consent, and generally facilitate the research.

Since 1995 a number of studies based on work by the RAs have been published.  The cessation study used RAs to assess tobacco use among adult non-critical ED patients and visitors and to determine rate of referrals to a telephone-based tobacco cessation service. Over twenty-one weeks during the spring and summer semesters in 2008, RAs approached as many non-critical patients and visitors 18 years of age or older as possible.  After obtaining informed consent, they used a scripted format to get demographic information and a detailed tobacco history. If subjects had used tobacco products for more than 30 days at any time in their lives, they were offered a referral to the Connecticut Quitline, a service provided by the Connecticut Department of Public Health.  Those who indicated an interest in stopping tobacco use or to have help maintaining their tobacco cessation had a referral request and contact information sent to Free and Clear, Inc., the agency responsible for implementing Connecticut Quitline’s treatment program.

During the course of the study, 63 RAs spoke to approximately 4600 people.  RAs successfully enrolled 67% to study completion, of which 53% were patients and 47% visitors were visitors.  Among the subjects, 54% used tobacco for more than one month at some time in their lives, almost all cigarettes, and 22% had used tobacco within the last 30 days.    Of those subjects who had used tobacco, 18% accepted a Quitline referral.  For those who used tobacco within the last 30 days, 38% were referred.  This represents about 40% of all the Quitline referral in the entire state of Connecticut during that time period.

This study demonstrates the potential for a substantial public health intervention in the emergency department setting with minimal financial impact. It is also an important complement to Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations, published in 2006.  That statement recommended, among other things, conducting research on novel approaches to ED-based smoking cessation.