7/1/03 UPDATE: Calif Nurse Ratios info here

the california nurses association today welcomed the release of the final regulations to establish new minimum registered nurse staffing ratios that all hospitals must meet by january 1, 2004 as a significant step towards improving patient care conditions in california hospitals and protecting patient safety.

"a new era is dawning in which all california families should expect safer standards in california hospitals," said kay mcvay, rn, president of the 50,000-member cna which sponsored the safe staffing law and worked for 10 years to enact it. "the finish line is finally near. every patient should be able to demand and count on receiving the registered nursing care they need, when they need it."

in the package approved by gov. gray davis and the department of health services, state officials made critical decisions on some hotly contested issues regarding implementation of the cna-sponsored law, the first such law in the nation which has been a model for rns and legislators in other states. among key decisions in the plan:

proposals by the hospital industry to erode the ratios in emergency rooms, post-surgical recovery units, and for evening, night, and weekend shifts, were all rejected. state officials also rebuffed hospital efforts for further delays in implementation.

phased-in, improved ratios (fewer patients to nurses) in three hospital areas. as of 2008, ratios will be lowered in step down units, typically housing patients just transferred from critical or intensive care, telemetry, where patients are on monitors, and other specialty care units, such as oncology and rehab. cna was the only organization to present scientific data - based on 22 million patient discharge records, the drg designations and patient acuity - along with thousands of rn testimonials to make the case for these reductions.

assurances that hospitals must adhere to scope of practice laws to protect patient safety. no rn may be assigned, or be responsible for more patients than the specified ratios. the regulations clarify the respective roles of rns and lvns, make it apparent that rns and lvns are not inter-changeable, and require that additional nurses must be assigned, as needed, by severity of patient illness.

hospitals are required to document staffing assignments, including the licensure of the direct caregiver for every patient for every unit for every shift, and keep the records for one year, steps that will help the state monitor and assure compliance with the law.

mcvay noted that many cna-represented hospitals have already hired hundreds of additional rns in preparation for implementing the law, and as a result of unprecedented cna gains in compensation, retirement security, and workplace improvements intended to enhance retention of current experienced rns and recruitment of new rns.

cna, which has campaigned since 1992 to enact safe rn staffing ratios, will work with rns across the state to monitor enforcement of the law and encourage hospital compliance. cna has also sponsored a new bill, ab 253, to help assure compliance.

introduced by assembly introduced by assembly member darrell steinberg (d-sacramento), the bill authorizes state health officials to conduct unannounced inspections, and provides for fines of up to $5,000 a day, on hospitals that continue to maintain unsafe rn staffing after final implementation of the ratio law.

the specific ratios by hospital unit, and more background on the law, are available on the cna website, http://www.calnurse.org http://www.calnurse.org/>.

Home Health Columnist / Guide · Jul 2, 2003

The Ratios1

Intensive/Critical Care ..........1:2

Neo-natal Intensive Care......1:2

Operating Room....................1:1

Post-anesthesia recovery.....1:2

Labor and Delivery................1:2

Antepartum..........................1:4

Postpartum couplets.............1:4

Postpartum women only.........1:6

Pediatrics.............................1:4

Emergency Room..................1:4

ICU patients in the ER..........1:2

Trauma patients in the ER....1:1

Step Down Initial..................1:4

Step Down in 2008...............1:3

Telemetry Initial....................1:5

Telemetry in 2008.................1:4

Medical/Surgical Initial...........1:6

Medical/Surgical in 2005........1:5

Other Specialty Care Initial....1:5

Other Specialty Care in 2008...1:4

Psychiatric............................1:6

All ratios are minimums. Hospitals

must increase staffing as needed by

patient acuity.

1 Charge RNs and managers are not counted in

the ratios.

2 RN license only.

3 Triage or Base Radio RNs shall not be included in

the ratios. Every ER must have an RN, with

experience in emergency care, on duty at all times.

4 Such as Oncology and Rehab.

oramar · Jul 2, 2003

This is really amazing, when you think how dark everything looked 5 years ago. I got tears in my eyes. Hope floats!

Desert Rat · Jul 2, 2003

These ratios specify that the charge RN is not to be counted in the staffing ratio, but what about other ancillary personnel? Our small ICU has a great pt/RN ratio, but we are it. No CNAs, no secretaries...We answer phones, take off orders, do traffic control with visitors...the whole nine yards. You can imagine the HIPPA nightmares when you and your only co-worker are doing patient care, leaving the station unguarded.

Our administrators say the California idea (and hospitals locally who advertise good nurse/patient ratios) are actually making the RN do more work because they are getting rid of CNAs and secretaries. Who can clarify this for me?

rebelwaclause, ASN, RN · Jul 2, 2003

I still ask...If an RN is "covering" (Yeah...right) an LVN, and the LVN has 8 patients...What will the RN's ratio be then?

pickledpepperRN · Jul 2, 2003

http://www.applications.dhs.ca.gov/pressreleases/store/pressreleases/03-47.html

STATE HEALTH DEPARTMENT RELEASES REVISED

NURSE-TO-PATIENT RATIOS FOR PUBLIC COMMENT

SACRAMENTO - The California Department of Health Services

(CDHS) today released for public comment revised nurse-to-patient

ratio regulations for general acute care hospitals. The ratios will be the

first of their kind in the nation.

"The high interest in this issue is reflected in the fact that CDHS

received more than 24,000 letters from organizations and individuals

across the state during the initial public comment period," noted State

Health Director Diana M. Bontá, R.N., Dr.P.H. "In signing the

legislation that led to the development of these ratios, Gov. Gray Davis

demonstrated his commitment to quality patient care and recognition

of the key role nurses play in providing that care."

While most of the revisions are technical in nature or clarifications to

make the regulations more clear, ratios for step-down, step-down

telemetry, telemetry and specialty care units were changed in

response to comments received during the initial public comment

period in late 2002 (chart attached). The ratios would be implemented

in stages beginning in 2005 to enable hospitals, especially those in

rural areas, to develop strategies to meet the new ratios.

In 1999, Gov. Gray Davis signed AB 394, which required CDHS to

establish minimum nurse-to-patient ratios by licensed nurse

classification and by hospital unit for the state's general acute care

hospitals.

The proposed ratios are based on a complex number of factors,

including information collected by state regulators during

unannounced visits to 80 acute care hospitals and 10 state-operated

hospitals that began in May 2001. CDHS used data from the on-site

hospital visits to determine the licensed nurse-to-patient ratios in the

nursing units at the hospitals.

The proposed ratios also reflect the results of a literature search, an

analysis of data from the state Office of Statewide Health Planning

and Development, comments from professional organizations and over

24,000 letters received from individuals across the state.

Only intensive and critical care, acute respiratory care, coronary care,

well-baby nursery, neonatal intensive care unit and operating rooms

currently have minimum ratios. The proposed ratios cover all other

areas of a hospital, including medical/surgical units. The proposed

ratios vary from 1:1 for trauma patients to 1:6 (reduced one year later

to 1:5) in medical/surgical units.

The regulations are expected to take effect Jan. 1, 2004. Five years

after their adoption, CDHS will evaluate the regulations and provide a

report to the Legislature, as required by law.

The draft regulations, research findings and information about the

process for submitting comments are available on CDHS' Web site at

http://www.dhs.ca.gov

CDHS will summarize all comments received and provide a formal

response to each one. The regulatory package, including the

responses, will be submitted to the Office of Administrative Law for

approval. After approval, the regulatory package, including the

responses, will be published on the CDHS Web site.

The deadline for public comments is 5 p.m. July 17. Written

comments can be submitted via fax at (916) 440-7714, e-mail at

mailto:[email protected] or

through the "Making Comments" link on the CDHS' Web site at

http://www.dhs.ca.gov/regulation. Comments can also be mailed to the

Office of Regulations, Department of Health Services, MS 0015, P.O.

Box 942732, Sacramento CA 94234-7320. (Please note that CDHS

has moved to a new location in the East End Complex in Sacramento

and that the U.S. Postal Service requires the use of a post office box

for the delivery of mailed items.

Hospital Unit

CDHS Proposal

10/18/02

Revised CDHS

Proposal

07/01/03

Intensive/Critical Care Unit

1:2*

Operating Room

1:1*

Neonatal ICU

1:2*

Well-Baby Nursery

1:8*

Postpartum

(When multiple births, the number of

newborns plus the number of mothers shall

never exceed 8 per nurse)

1:8 (1:4 couplets)

1:6 (mothers only)

1:8 (1:4 couplets)

1:6 (mothers only)

Antepartum 1:4

Labor and Delivery

1:2

Post Anesthesia Care Unit

1:2

Emergency Departments

(Triage, Base Radio, and other specialty

nurses are to be added as additional workforce

and not included in the ratio)

1:4

Critical Care Patients

1:2

Critical Trauma

Patients 1:1

1:4

Critical Care

Patients 1:2

Critical Trauma

Patients 1:1

Burn Units (considered a CCU)

1:2

Pediatrics Units

1:4

Behavioral Health Psychiatric Units

1:6

Step-Down and Step-Down/Telemetry Units

1:4

1:3 on 01/01/08

Specialty Care (Oncology) Units

1:5

1:4 on 01/01/08

Telemetry Units

1:5

1:4 on 01/01/08

Medical, Surgical and Medical/Surgical Units

1:6

1:5 on 01/01/05

1:6

1:5 on 01/01/05

Mixed Units

1:6

1:5 on 01/01/05

1:6

1:5 on 01/01/05

Desert Rat · Jul 2, 2003

Sounds good on paper, but I agree with rebel..so you are covering for LVN/SNT etc, what is your ratio then? Are they really going to cut out other staff to keep the licensed ratio?

pickledpepperRN · Jul 2, 2003

Originally posted by Desert Rat
Sounds good on paper, but I agree with rebel..so you are covering for LVN/SNT etc, what is your ratio then? Are they really going to cut out other staff to keep the licensed ratio?

Simple answer is NO!

Complex answer is that the RNs, other hospital staff, and the public (patients & visitors) will have to help enforce the ratios. U dom't expect most facilities to comply unless forced by their staff or the DHS. Who would stay at a poorly staffed hospital when a safely staffed one is nearby?

For answers to many questions soch as why laying off other workers will not be acceptable click the PDF files on the links:

http://www.calnurse.org/

http://www.calnurse.org/cna/press/7103.html

California Nurses Assn. Applauds Final RN Ratios Plan

Hospital Industry Proposals to Erode Ratios Rejected by State

The California Nurses Association today welcomed the release of the final regulations to establish new

minimum registered nurse staffing ratios that all hospitals must meet by January 1, 2004 as a

significant step towards improving patient care conditions in California hospitals and protecting patient

safety.

"A new era is dawning in which all California families should expect safer standards in California

hospitals," said Kay McVay, RN, president of the 50,000-member CNA which sponsored the Safe

Staffing Law and worked for 10 years to enact it. "The finish line is finally near. Every patient should be

able to demand and count on receiving the registered nursing care they need, when they need it."

In the package approved by Gov. Gray Davis and the Department of Health Services, state officials

made critical decisions on some hotly contested issues regarding implementation of the

CNA-sponsored law, the first such law in the nation which has been a model for RNs and legislators in

other states. Among key decisions in the plan:

Proposals by the hospital industry to erode the ratios in Emergency Rooms, Post-Surgical

Recovery units, and for evening, night, and weekend shifts, were all rejected. State officials also

rebuffed hospital efforts for further delays in implementation.

Phased-in, improved ratios (fewer patients to nurses) in three hospital areas. As of 2008, ratios

will be lowered in Step Down units, typically housing patients just transferred from critical or

intensive care, Telemetry, where patients are on monitors, and other specialty care units, such

as Oncology and Rehab. CNA was the only organization to present scientific data - based on

22 million patient discharge records, the DRG designations and patient acuity - along with

thousands of RN testimonials to make the case for these reductions.

Assurances that hospitals must adhere to scope of practice laws to protect patient safety. No

RN may be assigned, or be responsible for more patients than the specified ratios. The

regulations clarify the respective roles of RNs and LVNs, make it apparent that RNs and LVNs

are not inter-changeable, and require that additional nurses must be assigned, as needed, by

severity of patient illness.

Hospitals are required to document staffing assignments, including the licensure of the direct

caregiver for every patient for every unit for every shift, and keep the records for one year, steps

that will help the state monitor and assure compliance with the law.

McVay noted that many CNA-represented hospitals have already hired hundreds of additional RNs in

preparation for implementing the law, and as a result of unprecedented CNA gains in compensation,

retirement security, and workplace improvements intended to enhance retention of current experienced

RNs and recruitment of new RNs.

CNA, which has campaigned since 1992 to enact safe RN staffing ratios, will work with RNs across

the state to monitor enforcement of the law and encourage hospital compliance. CNA has also

sponsored a new bill, AB 253, to help assure compliance.

Introduced by Assembly introduced by Assembly member Darrell Steinberg (D-Sacramento), the bill

authorizes state health officials to conduct unannounced inspections, and provides for fines of up to

$5,000 a day, on hospitals that continue to maintain unsafe RN staffing after final implementation of

the ratio law.

For the specific ratios by hospital unit Click here.

For the specific ratios by hospital unit and more background on the law, Click Here

Fact Sheet on RN Staffing Ratio Law

California is the first state in the U.S. to establish minimum RN-to-patient ratios for hospitals. The

ratios are based on AB 394, sponsored by the California Nurses Association and signed by Gov. Gray

Davis in October, 1999.

Today's announcement of the final regulations to implement AB 394 culminates a 10-year campaign

by CNA to improve RN staffing in California hospitals to protect patient safety, and reverse the effects

of a decade of hospital restructuring that eroded patient care conditions and produced a hospital

nursing shortage.

All hospitals must be staffing with the minimum ratios as of January 1, 2004. Many CNA represented

hospitals have already hired hundreds of additional RNs in preparation for implementing the law, and

as a result of unprecedented CNA gains in compensation, retirement security, and workplace

improvements intended to enhance retention of current experienced RNs and recruitment of new RNs.

What the Law Does

AB 394 establishes specific numerical nurse-to-patient ratios for acute care, acute psychiatric and

specialty hospitals in California. The ratios are the maximum number of patients that may be assigned

to an RN during one shift. The law requires additional RNs be assigned based on a documented

patient classification system that measures patient needs and nursing care, including severity of

illness and complexity of clinical judgment.

AB 394 also restricts the unsafe assignment of unlicensed staff and the unsafe assignment of nursing

staff to hospital clinical areas where they do not have demonstrated competency, training, and

orientation.

The specific ratios:

AB 394 required the state Department of Health Services to establish the specific ratios for specific

hospital units. In 2002, the DHS issued the proposed regulation to implement AB 394, including the

specific ratios for every hospital unit, and held public hearings.

On July 1, 2003, Gov. Davis and the DHS issued the final regulations incorporating extensive

testimony presented during the hearings and public comment, including from 500 CNA RNs who

testified in the hearings, and nearly 25,000 RNs whose letters were submitted by CNA to the DHS.

Why the Law was needed

The purpose of the law was to address the growing crisis in patient care in California hospitals caused

by managed care and market based decisions on hospital care that resulted in California having

among the worst RN staffing in the nation and a growing exodus of RNs out of hospitals creating a

serious nursing shortage.

CNA campaigned for 10 years to get the law enacted, including the largest gatherings of RNs in

California history, major rallies drawing thousands of RNs to the Capitol.

California's law was the first (and still only) ratio law in the nation. It is the single most effective

response to protecting patient safety in hospitals and reducing the nursing shortage. The California law

is considered a national, even international model, and has generated extensive attention from the

national media and RN organizations around the world.

How the ratios will protect patients

Safe RN staffing is the single most essential element to safe patient care in hospitals. In the last year

alone:

JCAHO, the Joint Commission on Accreditation of Hospital Organizations, announced that

inadequate staffing precipitated one-fourth of all sentinel events - unexpected occurrences that

led to patient deaths, injuries, or permanent loss of function - reported to JCAHO the past five

years

A New England Journal of Medicine study documented that improved RN-to-patient ratios

reduces rates of pneumonia, urinary infections, shock, cardiac arrest, gastrointestinal bleeding,

and other adverse outcomes. No similar links were found for LVNs or other nursing staff.

Research in the Journal of the American Medical Association found that up to 20,000 patient

deaths each year can be linked to preventable patient deaths. For each additional patient

assigned to an RN the likelihood of death within 30 days increased by 7 percent. Four

additional patients increased the risk of death by 31%. No similar findings were associated with

improved ratios for LVNs or other staff.

Where will the RNs come from to meet the ratios?

DHS has projected that California will need 5,000 RNs to meet the ratios that go into effect in

January. That is the same number of RNs who graduate every year from California's 72 schools

of nursing.

The approach of the ratios is already having an effect on overcoming the nursing shortage. In

the past fiscal year, the number of RNs increased by 4% -- the largest increase since 1989,

reports the Board of Registered Nurses. The number of exam applicants increased by 18% and

the ratio of RNs entering and exiting the state continues to make a dramatic change with 1,664

more RNs coming into the state than leaving.

In the three years since the law was signed, according to BRN data, applications for RN

licenses from new graduates and from RNs outside California, has grown from 22,372

applications in fiscal year 1999-2000 to 27,551 in fiscal year 2000-2001 to 32,368 in fiscal year

2001-2002.

In Victoria, Australia, ratios were enacted in 2001. By February 2002, the full-time RN

workforce had increased by 16.5 percent.

The real key to meeting the ratios is for hospitals to hang on to the RNs they already have.

Many CNA-represented hospitals have taken big strides by enacting significant improvements,

though collective bargaining with CNA, in retirement security, compensation, and improved

patient care conditions.

More background information is available at http://www.calnurse.org

July 1, 2003

Desert Rat · Jul 2, 2003

That's great. Too bad I'm in Arizona. We've got a long way to go.

pickledpepperRN · Jul 2, 2003

You have a way to go as do we. We do have a head start but some Arizona nurses have begun. California nurses will help our neighbors (at least some of us)!

http://cna.igc.org/saznc/

Southern Arizona Nurses Coalition - California Nurses

Association

For Justice in Health Care

Mission Statement:

The Southern Arizona Nurses Coalition is a grassroots, community-based

organization of direct-care nurses and supporters seeking justice in

healthcare. Founded in August 2001, the coalition promotes the

organization and representation of direct-care nurses to improve working

conditions, patient care, nurse retention and healthcare justice in the

community.

The coalition recently affiliated with the California Nurses Association, a

professional organization and union with an outstanding record of

advocacy for nurses and patients.

SAZNC-CNA promotes and protects the legal and human right to organize

and bargain collectively. Without contract protection, nurses are unable

to vigorously advocate for themselves or their patients without

jeopardizing their job security.

Membership

The membership-based coalition currently comprises nurses from many

Tucson-area hospital facility, including the following:

Northwest Medical Center

University Medical Center

St. Mary's Hospital

St. Joseph's Hospital

El Dorado Hospital

Tucson Heart Hospital

Tucson Medical Center

Kino Community Hospital.

Members also include nursing students and nurses in public health,

long-term care, and behavioral and home health.

***Direct-Care Nurses***

Help Change ICU Ratios from 1:3 to a Safer 1:2