Nurses allowed to close units of hospital

[smg]

Twin Cities nurses using ward-closing power

Maura Lerner

Star Tribune

Published May 27, 2002

From the moment Joan Johnson arrived for her 7 a.m. nursing shift, she knew it was crunch time at Mercy Hospital in Coon Rapids.

The "house" was filling up fast, though there were still some empty beds on Station 2 East, the 45-bed unit that Johnson oversees.

But on that first Saturday in May, she wasn't eager to take any more patients: The day shift was short three nurses and a nurse's aide.

So, for the next five hours, her entire unit was officially closed to new admissions. Any incoming patients would have to wait until she got more nursing help -- which didn't arrive until noon.

In the past year, she and other registered nurses have closed inpatient units hundreds of times in the metropolitan area, bolstered by a unprecedented clause in their union contracts. Hammered out a year ago in the face of threatened or actual strikes, the clause gives nurses at six metro-area hospitals the power to freeze admissions temporarily to their units if staffing reaches unsafe levels.

The clause is a first for a nurses union contract.

According to the American Nurses Association, no other contracts in the United States give nurses such a right.

So Twin Cities nurses have become, in effect, a test case; one that other hospitals throughout the Twin Cities area and the nation are watching.

Hospital officials insist that it's more of a nuisance than a danger to the patients who are left in limbo. It generally means that they're stuck in emergency rooms, recovery rooms or other temporary quarters longer than usual, or if necessary, shuttled off to other hospitals.

There's no sign that patients have suffered harm because of admission delays, according to Arnie Rosenthal, director of the state Office of Health Facility Complaints. "For patients, as long as they get good care, it probably doesn't matter where they are," he said.

It can, however, unnerve doctors and occasionally fluster hospital administrators. Yet, by most accounts, just the power to say "no" has brought a measure of relief to the pressure-cooker atmosphere that helped fuel last year's nurses strike in the Twin Cities.

For Johnson, who's been a nurse at Mercy for 23 years, turning away patients is a new experience.

"Since the new contract language, it really has empowered the . . . nurses on the unit," she said. "This way, I don't allow more patients in than we can safely care for."

It's not an everyday occurrence, but the language is getting a workout.

At Abbott Northwestern in Minneapolis, hospital records show that nurses closed units at least 170 times between August and March -- sometimes for 90 minutes, sometimes for entire 8-hour shifts.

At Fairview Southdale Hospital in Edina, officials counted 62 closings from September through April.

At Mercy, no one has kept a running total. But on May 4, half of its eight wards -- including behavioral health and critical care -- were closed by nurses for part of the day shift, according to Vince Rivard, the hospital's spokesman. It was, officials say, highly unusual, and by 3 p.m. all were reopened. But it showed, as nurse Johnson put it, "we're all sort of in this predicament."

Easing the strain

Nurses have been clamoring for some way to ease the strain caused by chronic shortages of nurses and other hospital workers around the country. They argue that staffing is often dangerously low, leaving too few nurses to care for too many patients.

But it was only last year that their frustration boiled over into a full-blown labor dispute in Minnesota. Last spring, the Minnesota Nurses Association made staffing a central issue in contract negotiations for almost 9,000 nurses at 13 hospitals. In response, some of the hospitals set up committees to study the problem.

Some, though, went further. Last May, four hospitals owned by Allina Hospitals & Clinics agreed to give nurses a say in closing patient wards -- the first nursing contracts in the country to do so, according to the American Nurses Association. The contract applied to Abbott, Mercy, United Hospital in St. Paul and Phillips Eye Institute in Minneapolis.

Then, in June, Fairview Health Services offered virtually the same language to striking nurses at its Southdale and Riverside hospitals, as part of a deal to end a 23-day walkout.

No one claimed it was an ideal solution. But in a crunch, supporters say, closing units can buy nurses time to regroup, call in reinforcements or finish up with the patients they have.

"Sometimes you just need a little breather to catch up," said Sandy Thimmesch, a nurse in charge of a 54-bed unit at Fairview Southdale. "That's where it's been very successful. To give us room to get caught up before the next wave of patients come."

Patient impact

In practice, hospitals say this isn't entirely new.

"It truly was happening before on an informal basis," said Jeanne Jacobson, a Fairview vice president. This just formalized the process, she said, setting guidelines on when and how it should be done. "So this isn't a huge change."

Kathy Wilde, vice president of patient care at Mercy, agrees. "We've always done it," she said. "I think that the charge nurses [who oversee each unit] really felt that they had that ability before."

But many nurses say the new rule has made it much easier. In the past, they say, many charge nurses were afraid to ask, and supervisors often vetoed their requests.

"We can communicate with the administrators a lot easier, and they're willing to listen," Jackie Hanson, who runs a 54-bed medical unit at Southdale. "If we feel we have to close a unit, they'll close the unit."

In the past, the message was often quite the opposite, said Jane Ekerberg, a charge nurse at Southdale's intensive care unit. "They wanted us to make room, no matter what," she said.

Some say that still happens at times; and that nurses themselves feel torn about turning anyone away. "We're very aware of the fact that there's a patient that needs to come into the hospital," said Pat Swenson, a charge nurse at Abbott. "It's not that we don't want to take care of [them]. It's that we have concerns about how well we're taking care of the patients that we have."

Control issue

For some doctors, it's been a tough adjustment. "Physicians love to grumble," said Dr. Stephen Remole, the chief of cardiology at Mercy. "And here they are seeing some of their precious control moving over to the nursing staff."

At Mercy, he said, some colleagues worried that the closures would make it tougher to admit patients, and undercut their ability to get patient referrals. Yet "we all want what's right for the patient," he said. "I don't want my patient transferred to a unit that just took six admissions and can't handle it."

In practice, he said, the delays have been minimal. "We can almost always find a place to put them within a couple of hours," he said. "You're going to have crunch times where you've got to do some creative shuffling."

To hospital administrators, the answer isn't just hiring more nurses -- because the nurses shortage is getting worse. In late 2001 -- after Twin Cities nurses won 20-percent pay hikes over three years, there were 3,260 openings for registered nurses in Minnesota, according to a state job vacancy study. That's up from 2,900 nurse vacancies the year before.

The big push now is efficiency -- finding ways to move people in and out of the hospital more quickly, to free up beds. That's prompted hospitals to re-invent themselves in subtle ways.

At Mercy, for example, heart specialists have changed their morning routine to check on their healthiest, rather than sickest, patients first, so that they can send people home earlier and make room for new admissions. At the same time, says administrator Wilde, Mercy is considering creating a temporary holding area to house overflow patients for up to four hours.

If that kind of thing helps control the flow of patients, then the nurses say they're all for it.

"Patients don't get the benefit when you have to turn them away," said Carrie Mortrud, a nurse and union representative at Abbott. And hospitals lose money, too, she said. "It behooves all of us to work on this situation."

[fedupnurse]

It is about DAMN TIME on this one folks! I don't know about you guys but we use this "patient classification" system called Medicus. We are a 24 bed ICU. Even if we have 30 patients over the course of a 24 hour period, we can only count 24. If I hear the suits say "It offers a snapshot" of what is happening on the unit one more time, I may just go postal. Finally, my hope is being restored with the contracted right these nurses have to close beds based on ACTUAL ACUITY!!! Congratulations to all who worked so hard on this contract ON BOTH SIDES! I congratulate the suits too because they agreed to it. I jus don't buy that a patient is better off being held in another area when the unit they are headed for is falling apart at the seams!

I give all of you involved in this precedent a tremendous amount of credit and I hope to be able to say that we have followed in your foot steps soon!

[Cascadians]

The word about this safety valve must spread!

May this necessary ability appear in all contracts very soon.

[moonshadeau, ADN, BSN, MSN, RN, APN, NP, CNS]

This isn't new. My little hospital does this. Every four hours each unit is required to update the "board" that shows four colors. Green means that the unit can take patients without difficulty related to staffing and acuity. Yellow means that patients can be admitted but staffing and acuity are a factor. Orange means that staffing and acuity are a problem and that few admits can be taken safely. Red means stop and the unit is "Crazy". On the board is other information such as capping. What a unit is capped to and when the capping will be over. The house supervisor is in charge of placing patients appropriately to need and staffing. The charge nurses of each unit play a vital role in capping. Our charge nurses really have no other function than to be the go to person. They still have their own patients as well. The charge nurse figures out staffing and the color board and communicates this to the supervisor. Sometimes shifting of patients has to be done to accomadate needs of incoming patients. But the program works really well.

My unit, a telemetry unit is one of the highest turnover units and also most demanded since only two floor units have the capablity of monitoring heart patients. This weekend we had five nurses which meant that we could essentially go up to 30 patients in the unit. However, we kept our numbers down because the nurse went down to four on Memorial day. The shift coordinator works to keep our admits down with that in mind though we were not officially capped on Sat or Sunday.

Capping prevents you from having to take more patients than safely could be handled. When the whole hosptial is full we are placed on Cardiac and Trauma bypass.

It is easier to cap on the weekends than it is on the weekdays though due to administration being around.

[mattsmom81]

I'm nonunion and as a charge nurse I have said 'NO' many times to admissions. There is no contractual agreement as such, only my Nurse Practice Act which states I have a duty to decline assignments I cannot do safely. So I tell the supes and the ER I am not accepting admissions, if I don't have staff to care for them. :)

The ER director hates my guts...LOL! But I sleep well at night.

[fedupnurse]

I am Union, Mattsmom, and I could get fired for that! Isn't that sad? They don't usually put me in charge anymore because I do cause a huge stink. I even made a supervisor come up and make an assignment. That night she did close beds. Another night I refused charge due to the horrific staffing and the refusal of the night supervisor to close the 4 open beds that were left. 2 of the 4 had patients slated to come in. I had 5 RN's with

Thanks!

[l.rae]

My hospital doese this all the time. I read thru this thread pretty fast and I don't think I saw anyone mention how this affects the ER where many patients can get stuck. My Hospital is non-union, they try to staff our ER by census.....idiots! Anyway, since we are the smaller satellight hosp, seems we cand almost never meet their criteria for diversion or re-rout....and we are VERY busy in spite of our size. A lot of bars around, right off the interstate, several ECF's too. It is not uncommon for the ER to be full, and then have 3-4 squads roll in in five minutes. I once had an unresponsive pt. arrive by squad and not one empty bed....which part of the reason was we were holding several patients because floors had closed. I'm allfor patient safety etc. but our ER is never considered.......They expect us to stack them on the walls....and don't even mention the triage area is full. After 3am we have 3 nurses and sometimes 1 tech. because that is the "low census" time...what a crock... How about it????? Are your ER's allowed to close as easily as the floors?? Our's sure isn't......LR

[MPHkatie]

The ER doors never close, of course because it would violate EMTALA. We can close to Trauma - when all our ICU beds are filled, but we still must take everyone who arrives without the benefit of EMS.... Same problem here with units closed, or no nurse to take pt upstairs, lots of holding, etc. Patients complain, stuff doesn't really get done to move their treatment ahead etc. I think it's just the chronic nrsg shortage, I mean, I don't want to send someone to the floor when there aren't enough RN's, but then I am also really unable to care for those patients as well as the new ones that continue to come in....SO I wonder, where will these patients go.

[fedupnurse]

There really is no easy answer! How many of your ER patients should really be going to a clinic? In our ER we have a very large indigent population and if they don't feel like going to the clinic during hours they go to the ER. We have them stacked up in the ER too but not because of closed beds! All of our beds have been full much of the time of late. We go on divert and it means nothing, the squads still bring people in left and right. Critical care divert also means nothing. Our ER does have an admitting room where pts waiting for beds are held until a bed becomes available but we still have the piled high in the halls on a fairly regular basis. Does anyone else think if we got rid of managed care people wouldn't be getting so sick?????

[-jt]

Thousands of RNs had to go on strike for 3 weeks to obtain that right to stop admissions on their unit until they have enough staff called in to handle them. I dont think the suits had any choice but to agree to that safe staffing plan because that strike was not going to end until it did - and imagine having all those hospitals in one area having RN strikes at the same time.

Hopefully, because these nurses went the distance, no other nurses will have to go thru all that to get the same right to make the decision to temp close a unit to admissions until it has safe staffing numbers. The Minnesota nurses did the hard part - sticking to their guns, having the courage & fortitude to do what they had to do - strike - to have more control over the safety of their pts, & their own licenses. They have set a precedent that can become the standard & so it will be easier for the rest of us to obtain the same right. And thats how the fight of one unionized group of nurses improves things for all nurses.

We all really have a lot to thank the RNs of the Minnesota Nurses Assoc for because we may all be able to follow in their footsteps & obtain these same rights now, and we may not have to strike to do it - because they did it for us.

[-jt]

May this necessary ability appear in all contracts very soon.>

Nothing appears in contracts by itself. It will appear in other contracts only if the nurses are willing & committed to do what it takes to get it. The Minnesota NA nurses were & did. It was BIG news all over the place last year. It was the reason for their strike - safe staffing & nurses control of it. They were awarded at the UAN annual convention last year for their strength.

Mandatory OT was not an issue in their strike - it was all about this safe staffing measure - because Minnesota Nurses Association contracts already banned Mandatory OT years ago.

I think this article is an update to evaluate how well the historic agreement is working out. The hospital sure is singing a different tune about it now than they did when the nurses were demanding it & being forced to strike for it. For anyone who missed it & wants to see what happened & how the RNs won this safety valve, just do a search here on Minnesota nurses. A lot of info was posted while it was happening.

[mattsmom81]

You guys are right, this is a tough problem and standing up to the suits and saying 'NO' is risky, I know.

Obviously, I have exhausted all my options, my staff and I have maxed assignments (2-3 depending on acuity in ICU) and 5-6 each me on PCU. These staffing guidelines are written in our policy manuals and our supervisors understand me when I say I can't safely take any more. I don't abuse this privilege (plus I've been a supervisor and that probably helps my trustability)

I am usually past the safe point already when I say 'no more' and if the ER medical director bucks me I call my director and she either comes in herself, or supports me in closing the unit....isn't it sad we have to work like this?

Nobody likes to get fired, but I think you would have a very interesting case against that hospital, Nancy....fired for taking seriously your duty under the law of your nurse practice act? The public stir you could cause would be even more interesting....as this stuff makes news today. Any nurse attorneys out there? I'd LOVE to read your comments!!

I was fired once for breaking hospital policy....it was a complicated scenario and in retrospect I would do the same as I believe I saved a life by doing so. To me, the decision was: break a policy or follow policy to the letter and harm a patient/patients as a result?

I lost the job, but I still had a LICENSE, my conscience was clear, and I found a better job.:) Later, I worked in a SICU where it became policy to never refuse patients and we were expected to work way unsafe every day. I quit.

I know this stuff isn't easy...the best advice I can give is follow your consciences, guys. Some facilities will push and push and push like nurses have no limit...but we are only human, aren't we?

(((HUGS))) to everyone out there trying to do a good job under such poor conditions today.