A Nurse-Associated Epidemic of Cardiac Arrests in an Intensive Care Unit
- Jeffrey J. Sacks, MD, MPH;
- Donna F. Stroup, PhD;
- Marcia L. Will, MD;
- Emily L. Harris, PhD, MPH;
- Ebenezer Israel, MD;
- Centers for Disease Control—Maryland Department of Health and Mental Hygiene Study Team;
- Donna Anderson, RN;
- Khin Hla Aung, MD, MPH;
- Barbara Nelson, RN-C, BSN;
- John Quinley, MD;
- A. Leroy Hathcock, Jr, PhD;
- Kathleen L. Irwin, MD;
- Joseph Sniezek, MD, MPH;
- Carl W. Tyler, Jr, MD
- Office of Disease Control and Epidemiology, MDHMH; Epidemiology Program Office; Center for Health Promotion and Education; National Institute of Occupational Safety and Health; Epidemiology Program Office, all from the CDC.
- From the Divisions of Field Services (Dr Sacks) and Surveillance and Epidemiologic Studies (Dr Stroup), Epidemiology Program Office, Centers for Disease Control, Atlanta; EIS Officers, Epidemiology Program Office, detailed to the Divisions of Cancer Prevention and Control (Dr Will) and Cancer Etiology (Dr Harris), National Cancer Institute, Bethesda, Md; and the Office of Disease Control and Epidemiology Maryland Department of Health and Mental Hygiene, Baltimore (Dr Israel).
Abstract
Review of 2219 admissions to an intensive care unit at a large urban hospital from 1983 to 1985 revealed an epidemic of cardiac arrests during the evening shift from January 1984 to March 1985. Of the 88 evening-shift cardiac arrests during this time, one specific nurse (Nurse 14) was the care giver for 57 (65%). Eight of ten epidemic-period patients who experienced shift-specific circadian recurrences of cardiac arrests were patients of Nurse 14. No therapeutic intervention and no other health care provider was as strongly associated with evening-shift cardiac arrests as was Nurse 14. Multiple logistic regression analysis demonstrated that when risk of cardiac arrest was adjusted for age, sex, severity of illness, and postoperative status, patients of Nurse 14 were 47.5 times more likely to experience arrest than were other nurses' patients. An expert determined that, compared with other nurses, the cardiac arrests among Nurse 14's patients were more likely to be consistent with unexplained hyperkalemia, to be unexpected in timing, and to be inconsistent with the clinical course. The epidemic ceased when Nurse 14 left employment at the intensive care unit in March 1985. Epidemiologic surveillance of adverse outcomes in health care settings is recommended.
(JAMA 1988;259:689-695)
Footnotes
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Reprint requests to the Division of Injury Epidemiology and Control (F36), Center for Environmental Health and Injury Control, Centers for Disease Control, 1600 Clifton Rd NE, Atlanta, GA 30333 (Dr Sacks).
