Nursing and Neurologic Outcomes Following In-Hospital Cardiac Arrest - - PowerPoint PPT Presentation

Nursing and Neurologic Outcomes Following In-Hospital Cardiac Arrest

Jordan M. Harrison, PhD, RN

Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing National Clinician Scholars Program University of Pennsylvania Perelman School of Medicine

Acknowledgements

Linda H. Aiken, PhD, RN Margo Brooks Carthon, PhD, RN Raina Merchant, MD, MSHP Robert A. Berg, MD Matthew McHugh, PhD, JD, MPH, RN, CRNP The American Heart Association's Get With the Guidelines- Resuscitation Investigators This research received support from the National Clinician Scholars Program and the National Institute of Nursing Research (R01NR016002, R01NR014855, and NINR T32 NR007104). Powered by Outcome, an IQVIA Company, Parsippany, New Jersey

2

Neurologic Outcomes Following IHCA

• Each year nearly 200,000 patients experience IHCA
• Neurologic impairment affects an estimated 28% of

IHCA survivors

– Reduced quality of life – High hospital costs and readmissions – Increased mortality risk

• Variation in quality of guideline-based care for IHCA

à wide variation across hospitals in likelihood of surviving IHCA with favorable neurologic outcome

3

Nursing and IHCA Outcomes

• Evidence shows better outcomes (lower mortality and

failure-to-rescue) for hospital patients cared for by BSN- prepared nurses

• Nursing surveillance is critical in response to IHCA
• Nurse staffing linked to incidence of cardiac arrest and

survival after IHCA

4

Study Design

• Cross sectional study to evaluate the relationship

between nurse education level and neurologic outcomes in patients who survive IHCA

• Hypothesis: In hospitals with higher proportions of BSN-

prepared nurses, patients who survive IHCA have lower likelihood of neurologic impairment

5

Data Sources

6

RN4CAST-US Nationally representative survey of hospital nurses in 4 states: California, Florida, New Jersey, Pennsylvania American Hospital Association Annual Survey Hospital organizational characteristics (bed size, teaching status, technology) Get With the Guidelines Resuscitation Database Prospective resuscitation data from participating hospitals nationwide

Study Population

Inclusion Criteria Aged 18 and older Survived to discharge Event occurred on cardiac, intensive care, medical surgical, or telemetry units Initial documented rhythm of pulseless electrical activity, asystole, ventricular tachycardia, or ventricular fibrillation Exclusion Criteria Hospitals with <10 cardiac arrests Patients with implantable cardioverter defibrillators Discharge neurologic status not documented

N=1,222 adult patients who survived IHCA between 2013 and 2015 in 45 general acute care hospitals in 4 states (California, Florida, New Jersey, and Pennsylvania)

7

Methods

Validated risk adjustment approach developed by Chan et al.

• Age
• Initial shockable rhythm
• Pre-arrest conditions (malignancy, sepsis, hepatic insufficiency,

hypotension)

• Pre-arrest critical care interventions (vasopressors, assisted/mechanical

ventilation, cardiac monitoring)

• Additional control variables: arrest in ICU, witnessed
• Ordered logistic regression to determine association between nurse

education (percent BSN) and neurologic outcomes after IHCA

• Outcome: Cerebral Performance Category at hospital discharge

1 = good cerebral performance (CPC 1) 2 = moderate to severe cerebral disability (CPC 2 or 3) 3 = vegetative state, coma, or brain death (CPC 4 or 5) 8

Table 1. Characteristics of IHCA Patients Who Survived to Discharge

Patient and Event Characteristics Age, mean (SD) 63.8 (15.7) Male Sex 57% Arrest location Intensive care unit Medical-surgical unit 56% 44% Witnessed 89% Initial shockable rhythm 25% Pre-arrest interventions Cardiac monitoring 86% Mechanical ventilation 31% Intravenous vasopressors 25% Pre-arrest conditions Hypotension 17% Septicemia 14% Metastatic/hematology malignancy 7% Hepatic insufficiency 5%

9

Table 2. Comparison of Hospital Characteristics in GWTG-R Hospitals

• vs. Other Adult General Acute Care Hospitals in the RN4CAST-US Sample

Hospital Characteristics GWTG-R Hospitals (n = 45) Other RN4CAST Hospitals (n = 508) p-value Percent BSN, mean (SD) (range) 60.3 (12.7) (33.3, 85.7) 50.9 (18.2) (0, 100) <0.001 Bed size, n (%) < 250 251-500 > 501 13 (29%) 8 (18%) 24 (53%) 263 (52%) 188 (37%) 57 (11%) <0.001 Hospital teaching status None (no residents or fellows) Minor (1:4 resident to bed ratio) Major (>1:4 resident to bed ratio) 15 (33%) 15 (33%) 15 (33%) 281 (52%) 219 (41%) 44 (7%) <0.001 Hospital technology status – high 34 (76%) 223 (44%) <0.001 10

64% 31% 5% CPC 1: Good cerebral performance CPC 2/3: Moderate to severe cerebral disability CPC 4/5: Coma, vegetative state, or brain death

Discharge neurologic status among patients who survived IHCA

11

Results

• Among patients who survived, each 10% increase in the percent of

BSN-prepared nurses was associated with 28% lower likelihood of neurologic impairment following IHCA (odds ratio 0.72, 95% CI: 0.55, 0.94).

+10% BSN

28% lower likelihood

• f neurologic impairment

following IHCA

12

Table 3. Odds Ratios Indicating the Effects of Nurse Education and Other Hospital and Patient Characteristics on Neurologic Outcomes Following In-Hospital Cardiac Arrest

Odds Ratios (95% CI) Unadjusted (Bivariable) Adjusted (Multivariable) Nurse education (% BSN) 0.78* (0.61, 0.99) 0.72* (0.55, 0.94) Other hospital characteristics Beds 251-500 0.78 (0.32, 1.92) 1.04 (0.46, 2.34) >501 0.82 (0.36, 1.88) 0.92 (0.38, 2.26) Teaching status Minor 0.90 (0.47, 1.72) 1.09 (0.51, 2.32) Major 0.96 (0.46, 2.00) 1.52 (0.53, 4.32) High technology status Patient and event characteristics 0.83 (0.35, 1.96) 0.95 (0.30, 3.02) Age 1.02** (1.01, 1.03) 1.02*** (1.01, 1.03) Arrest location in ICU 1.04 (0.76, 1.42) 1.08 (0.76, 1.52) Initial shockable rhythm 0.48*** (0.35, 0.67) 0.44*** (0.31, 0.63) Witnessed 0.95 (0.64, 1.41) 0.89 (0.62, 1.27) Monitored 1.00 (0.72, 1.39) 0.85 (0.63, 1.16) Mechanical ventilation 1.48 (0.96, 2.27) 1.67* (1.04, 2.68) Intravenous vasopressor 1.10 (0.79, 1.54) 1.11 (0.74, 1.67) Septicemia 1.56* (1.06, 2.29) 1.45 (1.00, 2.11) Hepatic insufficiency 1.14 (0.66, 1.98) 1.17 (0.68, 2.00) Hypotension 0.97 (0.70, 1.34) 0.92 (0.64, 1.32) Metastatic/hematologic malignancy 1.65* (1.00, 2.70) 1.36 (0.83, 2.23)

13

1 0.2 0.6 0.8 0.4

Predicted probability of outcome

30% 40% 50% 60% 70% 80% 90%

Percent of BSN-prepared nurses per hospital

Predicted Probability of Favorable Neurologic Outcome at Varying Levels of BSN Staffing

14

Conclusions

• In hospitals with higher proportions of BSN-prepared

nurses, patients who survive IHCA have lower likelihood

• f neurologic impairment
• BSN-prepared nurses may be better equipped to

recognize deterioration prior to IHCA and respond appropriately

• Limitation: Observational study

– Additional hospital resources may impact response to IHCA

15

Policy Implications

• Institute of Medicine: 80% of nursing workforce should

have a BSN by 2020

• State level and national level workforce planning

policies should emphasize recruitment and retainment

• f BSN-prepared nurses

– State of New York BSN in 10 Law

16

References

• 1. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United
• States. Crit Care Med. 2011;39(11):2401-2406. doi:10.1097/CCM.0b013e3182257459.
• 2. Girotra S, Nallamothu BK, Spertus JA, Li Y, Krumholz HM, Chan PS. Trends in Survival after In-Hospital Cardiac
• Arrest. N Engl J Med. 2012;367(20):1912-1920. doi:10.1056/NEJMoa1109148.
• 3. Chan PS, Nallamothu BK, Krumholz HM, et al. Readmission rates and long-term hospital costs among survivors of

an in-hospital cardiac arrest. Circ Cardiovasc Qual Outcomes. 2014;7(6):889-895. doi:10.1161/CIRCOUTCOMES.114.000925.

• 4. Herlitz J, Ekström L, Wennerblom B, Axelsson Å, Bång A, Holmberg S. Prognosis Among Survivors of Prehospital

Cardiac Arrest. Ann Emerg Med. 1995;25(1):58-63. doi:10.1016/S0196-0644(95)70356-X.

• 5. Anderson ML, Nichol G, Dai D, et al. Association between hospital process composite performance and patient
• utcomes after in-hospital cardiac arrest care. JAMA Cardiol. 2016;1(1):37-45. doi:10.1001/jamacardio.2015.0275.
• 6. Chan PS, Krumholz HM, Nichol G, Nallamothu BK. Delayed Time to Defibrillation after In-Hospital Cardiac Arrest.

N Engl J Med. 2008;358(1):9-17. doi:10.1056/NEJMoa0706467.

• 7. Herlitz J, Aune S, Bång A, et al. Very high survival among patients defibrillated at an early stage after in-hospital

ventricular fibrillation on wards with and without monitoring facilities. Resuscitation. 2005;66(2):159-166. doi:10.1016/j.resuscitation.2005.03.018.

• 8. Girotra S, Cram P, Spertus JA, et al. Hospital variation in survival trends for in-hospital cardiac arrest. J Am Heart
• Assoc. 2014;3(3). doi:10.1161/JAHA.114.000871.
• 9. Girotra S, Nallamothu BK, Chan PS. Using risk prediction tools in survivors of in-hospital cardiac arrest. Curr

Cardiol Rep. 2014;16(3):457. doi:10.1007/s11886-013-0457-0. 10.Aiken LH. Educational Levels of Hospital Nurses and Surgical Patient Mortality. JAMA J Am Med Assoc. 2003;290(12):1617-1623. doi:10.1001/jama.290.12.1617. 11.Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. JONA J Nurs Adm. 2008;38(5):223-229. doi:10.1097/01.NNA.0000312773.42352.d7.

17

References

12.Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: A retrospective observational study. Lancet. 2014;383(9931):1824-1830. doi:10.1016/S0140- 6736(13)62631-8. 13.Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43(4):1145-1163. doi:10.1111/j.1475-6773.2007.00825.x. 14.Kelly DM, Kutney-Lee A, McHugh MD, Sloane DM, Aiken LH. Impact of Critical Care Nursing on 30-Day Mortality

• f Mechanically Ventilated Older Adults. Crit Care Med. 2014;42(5):1089-1095.

doi:10.1097/CCM.0000000000000127. 15.McHugh MD, Kelly LA, Smith HL, Wu ES, Vanak JM, Aiken LH. Lower mortality in magnet hospitals. Med Care. 2013;51(5):382-388. doi:10.1097/MLR.0b013e3182726cc5. 16.Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011;49(12):1047-1053. doi:10.1097/MLR.0b013e3182330b6e. 17.White EM, Smith JG, Trotta RL, McHugh MD. Lower Postsurgical Mortality for Individuals with Dementia with Better-Educated Hospital Workforce. J Am Geriatr Soc. 2018. doi:10.1111/jgs.15355. 18.Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K. Nurse-Staffing Levels and the Quality of Care in

• Hospitals. N Engl J Med. 2002;346(22):1715-1722. doi:10.1056/NEJMsa012247.

19.Chen LM, Nallamothu BK, Spertus JA, Li Y, Chan PS. Association between a hospital’s rate of cardiac arrest incidence and cardiac arrest survival. JAMA Intern Med. 2013;173(13):1186-1194. doi:10.1001/jamainternmed.2013.1026. 20.McHugh MD, Rochman MF, Sloane DM, et al. Better Nurse Staffing and Nurse Work Environments Associated with Increased Survival of In-Hospital Cardiac Arrest Patients. Med Care. 2016;54(1):74-80. doi:10.1097/MLR.0000000000000456. 21.Chan PS, Berg RA, Spertus JA, et al. Risk-standardizing survival for in-hospital cardiac arrest to facilitate hospital

• comparisons. J Am Coll Cardiol. 2013;62(7):601-609.

18