Achieving High Quality Outcomes for Patients with Acute Respiratory Distress Syndrome: Lessons Learned from Nurses in High Performing Hospitals - Acute respiratory distress syndrome (ARDS) is a severe, rapidly progressing lung condition characterized by hypoxic respiratory failure that requires intensive supportive care during hospitalization, with nearly 40% of patients requiring invasive mechanical ventilation. This life-threatening syndrome can be precipitated by infectious processes or trauma with the largest risk among patients with sepsis, pneumonia, and shock. ARDS affects over 200,000 adults in the U.S. annually, and accounts for 10% of intensive care unit (ICU) admissions. The average hospital mortality rate among patients with ARDS has been estimated between 41-58%, with rates ranging from 17-73% across hospitals. Despite advances in our understanding of its pathophysiology, mortality has remained steady in recent years with few studies seeking to understand the variation in hospital outcomes. Our study focuses on differences in nursing resources, an important hospital characteristic that has not been adequately addressed in the ARDS literature. With no known cure, the treatment of ARDS is largely supportive, with respiratory management being a key focus as well as maintaining adequate fluid balance. These responsibilities, in addition to the extensive care coordination that ARDS patients require, largely belong to registered nurses. Our primary objective is to examine how variations in nursing resources are associated with differences in ARDS outcomes, including mortality and readmissions. We employ tapered multivariate matching, a novel approach which allows us to carefully control for differences in clinical risk of patients to clearly identify the basis of ARDS outcome differences. A second objective is to identify the nursing and hospital characteristics of “high performing” hospitals where variations in ARDS outcomes between patients were minimized. After identifying high and low performing hospitals, we will explore the open-ended responses of thousands of nurses who shared their perspectives of supports and barriers to care delivery in hospital settings. By examining patient, community, nurse and system-level factors, we seek to uncover whether there are combinations of nursing resources, organizational supports and care processes that are most effective in reducing ARDS outcome differences. If our study hypotheses are supported and we can identify characteristics of high performers, it will strengthen the evidence regarding the link between nursing resources and high-quality outcomes for seriously ill patients. Our proposal is well-aligned with multiple goals of NINR, including creating structures that ensure high quality outcomes, using lessons learned about nursing factors that influence unwanted variation. Collectively, the results of this study will provide the foundation for the next phase of our research, which includes the development of innovative models of care delivery that integrate evidence-based nursing resources that are associated with high quality outcomes for hospitalized patients with serious illness.
