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World J Crit Care Med. Sep 9, 2026; 15(3): 119122
Published online Sep 9, 2026. doi: 10.5492/wjccm.119122
Impact of nurse empowerment for early adrenaline administration for in-hospital cardiac arrest resuscitation: A pre-post intervention study
Binila Chacko, Anju Susan Jacob, Lovely Thomas, Anitha L, Staney Arul Selvan John, Anisha Elizabeth Sanghi, Nixon Raja P, Shoma Vinay Rao, Debasis Das Adhikari, Sophia Vijayananthan, Esther Agnes Anita, Amala V, Bijesh Yadav, John V Peter
Binila Chacko, Anju Susan Jacob, Lovely Thomas, Staney Arul Selvan John, Anisha Elizabeth Sanghi, Nixon Raja P, John V Peter, Department of Medical Intensive Care, Christian Medical College Vellore, Vellore 632004, Tamil Nadu, India
Anitha L, Quality Management Cell, Christian Medical College Vellore, Vellore 632004, Tamil Nadu, India
Shoma Vinay Rao, Department of Surgical Intensive Care, Christian Medical College Vellore, Vellore 632004, Tamil Nadu, India
Debasis Das Adhikari, Department of Paediatric Emergency, Christian Medical College Vellore, Vellore 632004, Tamil Nadu, India
Sophia Vijayananthan, Esther Agnes Anita, Amala V, College of Nursing, Christian Medical College Vellore, Vellore 632004, Tamil Nadu, India
Bijesh Yadav, Department of Biostatistics, Christian Medical College Vellore, Vellore 632004, Tamil Nadu, India
Bijesh Yadav, Division of Biostatistics, Department of Population Health, King Abdullah International Medical Research Center (KAIMRC), King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
Co-first authors: Binila Chacko and Anju Susan Jacob.
Author contributions: Chacko B and Jacob AS contributed equally to this manuscript and are co-first authors. Jacob AS, Peter JV, Chacko B discussed and designed the study; Jacob AS wrote the first draft of the manuscript; Chacko B, Peter JV and Thomas L revised the first draft; Jacob AS, John SAS, L A, Sanghi AE, P NR, Vijayananthan S, Anita EA, V A had an equal role in the data collection; Jacob AS and BC did the literature review, initial analysis and interpretation; Peter JV, Chacko B and Yadav B were involved in the statistical analysis; Chacko B and Peter JV helped in further revisions of the manuscript; and supported the writing of the manuscript equally; Chacko B, Peter JV, Jacob AS, Thomas L, Rao SV, Adhikari DD, John SAS, Sanghi AE, P NR, L A, Vijayananthan S, Anita EA, V A and Yadav B did the final review.
Institutional review board statement: This study was approved by the Medical Ethics Committee of Christian Medical College Vellore, approval No. 14322.
Clinical trial registration statement: This was a prospective study that did not require clinical trial registration, and hence it was not undertaken.
Informed consent statement: As the corresponding author of the above study, I hereby submit that the consent for this study was waived as per institutional policy for a retrospective study with de-identified patient data.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Data sharing statement: Corresponding author(s) agreed with the data sharing policy.
Corresponding author: John V Peter, MD, FRACP, FRCPE, Professor, Department of Medical Intensive Care, Christian Medical College Vellore, Ida Scudder Road, Vellore 632004, Tamil Nadu, India.
peterjohnvictor@yahoo.com.au
Received: January 21, 2026
Revised: February 11, 2026
Accepted: May 9, 2026
Published online: September 9, 2026
Processing time: 213 Days and 3 Hours
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.
Core Tip: We evaluated whether empowering nurses to administer the first dose of adrenaline for in-hospital cardiac arrest for non-shockable rhythms could reduce delays and improve outcomes. In this pre-post intervention study spanning over 3 years, we observed that nurse empowerment resulted in a reduction in the time to administer adrenaline, leading to faster return of spontaneous circulation. However, this did not translate to improved mortality.
