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Nursing roles for in-hospital cardiac arrest response: higher versus lower performing hospitals
  1. Timothy C Guetterman1,2,
  2. Joan E Kellenberg3,
  3. Sarah L Krein3,4,
  4. Molly Harrod5,
  5. Jessica L Lehrich6,
  6. Theodore J Iwashyna3,5,
  7. Steven L Kronick7,
  8. Saket Girotra8,
  9. Paul S Chan9,
  10. Brahmajee K Nallamothu3
  1. 1 Interdisciplinary Studies, Creighton University, Omaha, Nebraska, USA
  2. 2 Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
  3. 3 Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
  4. 4 Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
  5. 5 Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan, USA
  6. 6 Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
  7. 7 Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
  8. 8 Internal Medicine, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
  9. 9 Internal Medicine, Saint Luke's Health System, Kansas City, Missouri, USA
  1. Correspondence to Dr Timothy C Guetterman, Creighton University, Omaha, NE 68178, USA; timguetterman{at}


Background Good outcomes for in-hospital cardiac arrest (IHCA) depend on a skilled resuscitation team, prompt initiation of high-quality cardiopulmonary resuscitation and defibrillation, and organisational structures to support IHCA response. We examined the role of nurses in resuscitation, contrasting higher versus lower performing hospitals in IHCA survival.

Methods We conducted a descriptive qualitative study at nine hospitals in the American Heart Association’s Get With The Guidelines-Resuscitation registry, purposefully sampling hospitals that varied in geography, academic status, and risk-standardised IHCA survival. We conducted 158 semistructured interviews with nurses, physicians, respiratory therapists, pharmacists, quality improvement staff, and administrators. Qualitative thematic text analysis followed by type-building text analysis identified distinct nursing roles in IHCA care and support for roles.

Results Nurses played three major roles in IHCA response: bedside first responder, resuscitation team member, and clinical or administrative leader. We found distinctions between higher and lower performing hospitals in support for nurses. Higher performing hospitals emphasised training and competency of nurses at all levels; provided organisational flexibility and responsiveness with nursing roles; and empowered nurses to operate at a higher scope of clinical practice (eg, bedside defibrillation). Higher performing hospitals promoted nurses as leaders—administrators supporting nurses in resuscitation care at the institution, resuscitation team leaders during resuscitation and clinical champions for resuscitation care. Lower performing hospitals had more restrictive nurse roles with less emphasis on systematically identifying improvement needs.

Conclusion Hospitals that excelled in IHCA survival emphasised mentoring and empowering front-line nurses and ensured clinical competency and adequate nursing training for IHCA care. Though not proof of causation, nurses appear to be critical to effective IHCA response, and how to support their role to optimise outcomes warrants further investigation.

  • nurses
  • health services research
  • standards of care
  • quality improvement

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  • Contributors All authors participated in preparation and review of this manuscript.

  • Funding The study was supported by the National Institutes of Health (5R01HL123980-03) (K01 LM012739-01).

  • Competing interests PC receives funding from the National Institutes of Health and has received consultant funding from the American Heart Association and Optum Rx. BK is a principal investigator or co-investigator on research grants from the NIH, VA HSR&D, the American Heart Association, Apple, Inc, and Toyota. He also receives compensation as Editor-in-Chief of Circulation: Cardiovascular Quality & Outcomes, a journal of the American Heart Association. Finally, he is a co-inventor on U.S. Utility Patent Number US15/356,012 (US20170148158A1) entitled “Automated Analysis of Vasculature in Coronary Angiograms” that uses software technology with signal processing and machine learning to automate the reading of coronary angiograms, held by the University of Michigan. The patent is licensed to AngioInsight, Inc., in which BK holds ownership shares (although it has yet to be funded). None of these are related to the current work.

  • Patient consent for publication Not required.

  • Ethics approval The University of Michigan Institutional Review Board approved this study (HUM00095267).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.