Impact of nurse empowerment for early adrenaline administration for in-hospital cardiac arrest resuscitation: A pre-post intervention study.

Abstract

Background: Timely administration of adrenaline during in-hospital cardiac arrest (IHCA) with non-shockable rhythms is recommended, yet delays are common when drug administration depends on physician authorisation.

Aim: To evaluate whether empowering nurses to administer the first dose of adrenaline could reduce delays and improve outcomes.

Methods: In this study of prospectively collected registry data, the primary outcome of time to first dose of adrenaline in IHCA events with non-shockable rhythms (asystole/pulseless electrical activity) was compared between the pre-intervention phase (September 1, 2018 to November 26, 2019), when adrenaline administration was physician-led, and the post-intervention phase (November 27, 2019 to December 31, 2021), when nurse-led administration of adrenaline without physician order was implemented. Secondary outcomes included return of spontaneous circulation (ROSC), time to ROSC, 24-hour survival, and survival to discharge. Logistic regression analysis was performed to assess for factors associated with ROSC and whether timely adrenaline administration (defined as within 2-minutes) was independently associated with ROSC.

Results: Among 450 IHCA events, 162 occurred in the pre-intervention and 288 in the post- intervention period. The mean (standard deviation) age was 52.5 (16.1) years; 63.1% were male. Timely adrenaline administration improved from 46% in the pre-intervention period to 74.3% (P < 0.001) in the post-intervention period, reducing the median (interquartile range) time to first dose from 4 (1-6) minutes to 2 (0-3) minutes (P < 0.001). Although this did not improve ROSC rates, pre-post intervention (56.8% vs 58.3%, P = 0.74), ROSC was achieved faster (P < 0.001) in the post-intervention period when compared with the pre-intervention period. Combining pre- and post-intervention data, timely adrenaline administration when compared with delayed administration was associated with shorter time to ROSC (P = 0.006) but did not improve survival. On multivariate logistic regression analysis, shorter time to Cardiac Arrest and Resuscitation Team arrival and identification of a reversible cause were independently associated with ROSC, whereas the time to first dose of adrenaline was not.

Conclusion: Nurse-led early adrenaline administration during IHCA significantly reduced treatment delays and enhanced resuscitation efficiency, though it did not translate to reduced hospital mortality. This model is feasible in low- and middle-income settings and underscores the value of system-level empowerment to improve IHCA care.