From the May 7, 2004 print edition
New nurse law fails to cause emergency
After dire warnings that new nurse-staffing rules could hamstring hospitals, state regulators received a total of 49 complaints that California hospitals had failed to meet nurse-to-patient staffing ratios in the first three months of the year. Citations were filed against two hospitals, neither one in the Sacramento area.
There were 60 requests for a waivers to deal with unexpected high numbers of patients or create new triage systems. Twenty-nine were denied, 23 waivers were approved and eight hospitals were told the request wasn't necessary.
Chaos does not reign, as some predicted. Ambulances aren't circling Sacramento, looking for a place with enough nurses to land. No hospital units have closed as a result of the law.
One hospital in Southern California did shut down as a result of financial problems and an inability to meet California's landmark staffing law, which took effect Jan. 1.
The rest of the 450-odd hospitals in the state scrambled to comply with the new rules. Most have not succeeded every minute of every day, but the California Nurses Association, the aggressive union behind the ratio law, seems generally pleased with the results.
"If you look at the enforcement numbers, it was a pretty simple and easy transition into the ratio law," said spokeswoman Jill Furillo. "Considering the way hospitals said it would be so disruptive and impossible to comply, we are pretty surprised."
"We're doing fairly well. I don't know about other institutions, but have no sense they are failing miserably," said Carol Robinson, associate director of patient-care services at the UC Davis Medical Center, the busiest hospital in the region. "At a given moment in time, we may be out of compliance, but it's such a fluid, moving situation. Staffing is actually better."
Hospitals' lawsuit is still pending: The landmark law requires a minimum nurse-to-patient ratio at all times for most hospital units. They range from 1 nurse per patient in trauma units to 1 nurse to 6 patients in a medical/surgery unit. Some ratios get tougher between now and full implementation of the law in 2008.
"Overall? We're not hearing anything dire," said Gina Henning, the staff specialist at the state Department of Health Services in charge of the ratio rules. The complaints the state has received don't allege that patients were harmed, she said.
A few months out, two sticky issues linger.
The trade group that represents California hospitals sued Dec. 30 to stop the state from enforcing the part of the new law that requires compliance during breaks and meals. The California Healthcare Association says it is impossible for hospitals to comply with the ratios "at all times." A hearing on the lawsuit will be held in Sacramento County Superior Court May 14.
There is also disagreement over the extent to which hospitals can use less-skilled licensed vocational nurses to meet the ratio law. The regulations say "licensed nurses," but the union that represents registered nurses says many patients are too sick to be looked after by LVNs on their own.
Despite the relatively few complaints, hospitals fear consequences. "Even though DHS is not actively enforcing 'at all times' -- that's why the numbers are so low -- that doesn't absolve hospitals," said Jan Emerson, spokeswoman for the healthcare association.
Medicare and Medi-Cal, government programs for the elderly and poor, can come in and audit hospitals retroactively, Emerson said. Part of the audit requirement is to show compliance with all laws. If a hospital doesn't obey the law, the government programs can deny payment retroactively.
In addition, trial attorneys can claim a problem with patient care and subpoena the staffing ratios as part of the hospital record, Emerson said. If hospitals don't meet the ''at all times" rule and something bad happens to a patient, lawyers can make a case for negligence -- and the $250,000 cap on medical malpractice awards wouldn't apply.
Other states are watching California carefully. Ratio bills are on the move in Pennsylvania and New York. Nevada rejected ratios. A vague bill was introduced and dumped in Missouri. A bill before Congress would create a task force to study nurses' work environment and patient safety.
Enforcement so far: A total of 49 complaints were filed with state regulators from Jan. 1 to March 31. The state investigated and filed two citations, one against Riverside County Regional Medical Center in Moreno Valley and the other against Kindred Hospital in San Leandro.
"All the healthcare facilities know the regulations, so we are not out there watching to make sure (compliance) takes place," said Norma Arceo, a spokeswoman for the state Department of Health Services. But regulators do respond to complaints.
Staff assignment sheets at Riverside County Regional Medical Center, summarized by the state, show there was 1 registered nurse and 1 certified nursing assistant to look after 9 patients in the medical/surgery unit on Jan. 14. Two registered nurses had eight patients each. The required ratio is 1 licensed nurse to 6 patients.
The chief nursing officer acknowledged the problem and the state signed off on a fix-it plan that includes daily monitoring, daily meetings to project staffing needs, and attempts to increase the pool of available nurses.
Records from Kindred Hospital in San Leandro show the facility failed to meet ratio rules in the medical/surgery unit for six out of 10 shifts from Jan. 3 through Jan. 5. In one instance, 3 registered nurses cared for 23 patients when they should have been responsible for no more than 18.
The hospital correction plan says that when sick calls compromise the work schedule, "all efforts" will be made to bring in supplemental staff or reassign managers to direct patient care on a temporary basis.
Wiggle room: The new law allows hospitals to request program flexibility in special circumstances, and rural hospitals with scarce staff resources can ask for a waiver if they can't satisfy the rules.
The state received 60 requests in the first quarter, including two from Sacramento-area hospitals. Twenty-three waivers were approved, 29 denied, and state regulators determined eight weren't needed.