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 Get With the Guidelines Resuscitation Database Prospective resuscitation data from participating hospitals nationwide 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) 6

Study Population 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) 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 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 56% Medical-surgical unit 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 Other RN4CAST GWTG-R Hospitals Hospital Characteristics Hospitals p-value (n = 45) (n = 508) Percent BSN, mean (SD) (range) 60.3 (12.7) (33.3, 85.7) 50.9 (18.2) (0, 100) <0.001 Bed size, n (%) <0.001 < 250 13 (29%) 263 (52%) 251-500 8 (18%) 188 (37%) > 501 24 (53%) 57 (11%) Hospital teaching status <0.001 None (no residents or fellows) 15 (33%) 281 (52%) Minor (1:4 resident to bed ratio) 15 (33%) 219 (41%) Major (>1:4 resident to bed ratio) 15 (33%) 44 (7%) Hospital technology status – high <0.001 34 (76%) 223 (44%) 10

Discharge neurologic status among patients who survived IHCA 5% 31% 64% CPC 1: Good cerebral performance CPC 2/3: Moderate to severe cerebral disability CPC 4/5: Coma, vegetative state, or brain death 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). 28% lower likelihood +10% BSN of 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 0.83 (0.35, 1.96) 0.95 (0.30, 3.02) Patient and event characteristics 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) 13 Metastatic/hematologic malignancy 1.65* (1.00, 2.70) 1.36 (0.83, 2.23)

1 Predicted Probability of Favorable Neurologic Outcome at Varying Levels of BSN Staffing Predicted probability of outcome 0.8 0.6 0.4 0.2 0 30% 40% 50% 60% 70% 80% 90% Percent of BSN-prepared nurses per hospital 14

Conclusions • In hospitals with higher proportions of BSN-prepared nurses, patients who survive IHCA have lower likelihood of 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 of BSN-prepared nurses – State of New York BSN in 10 Law 16

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