Disparities in the Outcomes and Processes of Care for In-Hospital Cardiac Arrest: The Role of Differences in the Organization and Delivery of Nursing

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Project Summary In-hospital cardiac arrests (IHCA) represent catastrophic, often terminal events and affect up to 700,000 patients annually. Despite the resources and opportunity to intervene early when cardiac arrests occur, fewer than a quarter of patients survive to discharge, and survival varies significantly across institutions and by race. Black patients, in particular, experience up to 12% lower odds of survival and more pronounced neurologic and functional impairment following a cardiac arrest. Disparities in cardiac arrest outcomes are largely attributed to quality gaps at the institutions where minorities receive care. Variations in the process of care delivery in these settings suggests that hospitals where Blacks receive care may be fundamentally different in their ability to detect and prevent death and significant debilitation. Our study will examine institutional mechanisms underlying IHCA disparities through a focused examination of front line care providers. In the hospital, nurses are the primary clinical surveillance system and play an integral role in the initiation and delivery of emergency responses. Nurses are at the bedside 24 hours a day; they are responsible for early warning system monitoring; they have direct knowledge of patient conditions and changes in conditions and are often the first on the scene of a cardiac arrest. The ability for nurses to respond appropriately to acute changes in patient status has been linked to nursing organizational factors, including nurse staffing, nurse education, nursing skill mix, and the nurse work environment. The relationship between the organization of nursing and minority IHCA outcomes, however, is unknown. We posit that nurses play a significant, yet underexplored, role in IHCA patient outcomes, and that variation in nursing across hospitals may help explain IHCA outcome disparities. To examine this relationship, we take advantage of multiple large and unique databases: The American Heart Association's Get with the Guidelines–Resuscitation (GWTG-R) clinical registry and the NINR-funded RN4CAST-US studies (R01-NR004513 and R01-NR014855). The clinical registry incorporates uniformly reported and precisely defined clinical variables developed by international experts. Using unique hospital identifiers to link patient outcomes with measures of nursing care from RN4CAST-US, we will identify specific, actionable elements of nursing that influence minority IHCA patient outcomes. The data set that we will assemble includes nurse survey data collected in 2006 and 2015. Using independent cross-sections of tens of thousands of patients in the same large sample of hospitals, enables us to examine trends and relationships between nursing and minority IHCA outcomes and determine if they vary over time. Knowing whether these associations are stable and enduring, in spite of changes in both patient case-mix and acuity and in the nursing characteristics that may be greater in some hospitals than others, will provide stronger evidence that the associations are persistent and that our results are generalizable.