In-hospital cardiac arrests (IHCAs) are catastrophic and often terminal events. Despite improvements in resuscitation efforts, fewer than 25% of patients who experience an IHCA  survive to discharge. Survival varies significantly across hospitals and by race. Racial disparities in IHCA survival have been linked, in part, to the quality of care during hospitalization.

Due to direct and frequent contact with patients, nurses constitute around‐the‐clock surveillance systems and can detect changes in patient status and prompt appropriate interventions when conditions deteriorate. In our new study in Medical Care, we examined whether nurse staffing levels affect between-hospital racial differences in IHCA outcomes. We found that survival differences between Black and white patients are associated with medical-surgical nurse staffing levels in the hospital where they receive care.

The study included more than 14,000 adult patients who had an IHCA between 2004 and 2010 in 75 U.S. hospitals. Overall, we found that Black patients were up to 30% less likely to survive an IHCA than white patients, even after accounting for other patient and hospital characteristics. Notably, Black patients were more likely than their white counterparts to be treated in hospitals where nurses cared for more patients.

Figure 1. Odds on survival to discharge for Black and white patients in hospitals with different staffing levels. Source: Brooks Carthon et al., Medical Care, 2021.

While the likelihood of survival to discharge after an IHCA was lower for Black patients than white patients in both poorly staffed (e.g., 10 patients per nurse) and well-staffed (e.g., 4 patients per nurse) hospitals, the survival difference associated with better nurse staffing was more pronounced for Black patients (Figure 1). Each additional patient per nurse was associated with greater odds of mortality after IHCA for Black patients (8%) than for white patients (3%), suggesting that Black patients are more vulnerable to adverse outcomes when staffing conditions are poor. For example, we found that IHCA survival decreased by 37% when Black patients were cared for in a well-staffed hospitals, compared to poorly staffed hospitals.

Many Black patients enter hospitals with a range of vulnerabilities (e.g., more severe and chronic conditions) and greater care needs. Hence, their risk for adverse outcomes is heightened when cared for by providers with fewer staffing resources. A growing number of studies have found that low staffing levels are associated with other racial health disparities, including excess mortality and post-surgical readmissions. To our knowledge, this is the first study to examine the relationship among race, nurse staffing, and IHCA survival.

Our findings suggest that reducing disparities in IHCA outcomes must include efforts to maximize the clinical resources of nurses at the bedside. Future research should examine how nurse staffing influences the delivery of appropriate care for IHCA, including timely compressions, defibrillation, and medication administration.

Margo Brooks Carthon, PhD, RN, FAAN is an LDI Senior Fellow, an Associate Professor of Nursing, and core faculty in the Center for Health Outcomes Policy and Research (CHOPR) at the University of Pennsylvania. Heather Brom, PhD, RN, NP-C is a former LDI Associate Fellow, a CHOPR alum, and an Assistant Professor of Nursing at Villanova University.

The study, Better Nurse Staffing Is Associated With Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests, was published in the February 2021 issue of Medical Care. Authors include Margo Brooks Carthon, Heather Brom, Matthew McHugh, Douglas M. Sloane, Robert Berg, Raina Merchant, Saket Girotra, and Linda Aiken.