Article Last Updated: Monday, December 29, 2003 - 5:39:33 AM PST
By Rebecca Vesely, STAFF WRITER
PATIENTS WHO find themselves at the hospital on New Year's Day probably won't notice anything different from the day before, except the usual hectic atmosphere of a hospital around the holidays. But for California nurses and hospitals, Jan. 1 marks the start of a statewide experiment -- the first in the nation -- on whether more nurses caring for fewer patients means less staff burnout and better patient outcomes.
On Thursday, a state law requiring hospitals to meet minimum nurse-to-patient ratios goes into effect.
Signed in 1999 by former Gov. Gray Davis, AB 394, known as the Safe Staffing Law, sets minimum nurse-to-patient ratios on all hospital units. The ratios range from one nurse per patient (1:1) to one nurse for eight patients (1:8), depending on the unit.
Some units, such as the intensive care unit, or ICU, have had minimum ratios for years. But in areas of the hospital where most patients are treated -- medical/surgical and the emergency department, for instance -- ratios will be newly enforced.
Unions representing nurses championed the ratios, citing studies that show a primary reason for the current worldwide nursing shortage is low pay, poor benefits, and, most of all, too many patients to care for on each shift. "Ratios go a long way to improve working conditions and protect patients," said Glenda Canfield, California policy director for SEIU Nurse Alliance, representing 35,000 registered nurses (RNs) and licensed vocational nurses (LVNs) in the state.
A 1998 survey of more than10,000 nurses nationwide, published in the Journal of the American Medical Association, found that each additional patient per nurse was associated with a7 percent increase in the likelihood of dying within 30 days of admission. Each additional patient was associated in a 23 percent increase in the odds of burnout.
Hospitals in the state, however, have by and large fought the ratios, arguing the rules are too inflexible and too difficult to meet amid a nursing shortage. California ranks 49th among 50 states in nurses on a per capita basis.
"We are absolutely entering into uncharted territory in California," said Jan Emerson, vice president of external affairs at the California HealthCare Association, a lobbying group for hospitals. "There is no flexibility, and that is the single most onerous and difficult aspect of the law."
In the ER, for instance, one nurse must care for a maximum of four patients at each time starting Jan. 1 -- regardless of how many patients are waiting and their acuity. If a nurse goes on a bathroom break, another nurse must be located to care for those four patients or the hospital will be in violation of the law. Hospitals out of compliance could lose their accreditation or MediCal or Medicare reimbursements.
"We have a dilemma," Emerson said. "Which law are we going to break? Do we turn people away from the ER or do we break the ratio law?"
Such arguments evoke little sympathy from nurses.
"My first question is when did the hospitals start working on this?" Canfield said. "Kaiser is a very good example. They had less than a 2 percent nurse vacancy rate a year ago. If Kaiser can do it, anyone can do it."
The California Nurses Association, which also represents Kaiser Permanente Northern California nurses, cites Kaiser as an example of how the nursing shortage can be overcome by good recruiting methods.
Over the past two years, Kaiser of Northern California has hired about3,500 nurses in preparation to meet the ratios, and now employs 13,300 nurses in the region.
"Yes, there is a nursing shortage, but on the other hand, ratios improve work environment and attract more nurses to the profession," said Pamela Johnson, associate director of operations for patient care services for Kaiser Northern California.
Registered nurses with no experience start at Kaiser at $33.74 an hour, according to their union contract. The average salary for an RN at Kaiser is$82,000, Johnson said. Their shifts can't be canceled, and they get excellent retirement benefits. In 2003, Kaiser spent $3.6 million in nurse education, including partnerships with nursing schools.
Even with this kind of planning, though, Johnson said meeting the 1:4 ratio in the ER won't be easy.
"That will be a challenging issue," Johnson said. "The demands of patients change and the number of patients change so frequently."
A lack of flexibility also will be a challenge for the select hospitals with trauma units, where the ratio will be one nurse to every patient.
At Eden Medical Center in Castro Valley, which has the only trauma center serving south and east Alameda County, multiple trauma cases can come in at the same time.
"On a Saturday night, that happens quite a bit," said Rose Corcoran, vice president of patient care services at the hospital.
In the past, a critical care nurse would "float" -- or be pulled -- from the critical care unit to work on any additional trauma patient. But with mandatory nurse ratios of 1:2 on critical care, Eden would be breaking the ratio on one unit to make it on another. So instead of floating nurses, Eden and other hospitals will likely need more nurses on standby in case trauma cases come in.
Overall, nurse unions said that Eden is staffed appropriately to meet the ratios.
Private hospitals in the Bay Area said they will be able to meet the ratios with registry and traveling nurses -- temporary nurses hired day to day or for a tour of up to three months from other states.
But financially strapped public hospitals could have a harder time of it. The Alameda County Medical Center, including Highland and Fairmont hospitals, has a $71 million deficit. As of November, the medical center had more than 100 nurse vacancies.
Ellen Waxenberg, the former chief nurse executive for the medical center, quit in November in part out of frustration of an inability to hire new nurses -- or even track recruiting and hiring statistics. Not one nurse was hired in November, she said in a interview, and she feared patient safety would be compromised.
"These sorts of delays (in hiring) are very unwise and erode our competitive position among hospitals, all of which are desperate for more nursing help," Waxenberg wrote in her resignation letter.
Susan Spoelma, the medical center's interim director of nursing, said all units are prepared to meet the new ratios, adding that last week the medical center launched a new computer system to track nurse staffing. "I can't say what Ellen's experience was," she said. "We feel we will meet the ratios, even with the law as stringent as it is."
The main issue isn't the numbers, said Gina Henning, manager specialist at the state Department of Health Services, who worked to develop the ratios, but what level of care the patient should receive.
"The whole key to this is the requirement that hospitals have an acuity system, that they staff according to a patient's need," Henning said. "If a patient needs one-to-one care, they should get it."
The California Nurses Association, representing RNs, has been especially critical of Alta Bates Summit in Oakland and Berkeley, and San Leandro Hospital. The union said these hospitals are meeting the ratios by assigning LVNs, who have a lower skill set than RNs, to do the job of RNs. Stanford University and Lucile Packard Hospital also have come under fire from unions for allegedly not creating a good care mix among nurses.
Alta Bates Summit officials point out that LVNs are allowed to be assigned patients, provided patient needs are within the LVN scope of practice. The state mandates that LVNs can make up a maximum of 50 percent of nursing care at any time. There about 300,000 RNs in the state, and about 70,000 LVNs.
"There is no evidence that having that (50/50 mix) requirement in place compromises patient care," said Henning from the State Department of Health Services.
Nurse unions plan to monitor hospitals closely for any violations of the new law, and recommend that patients do so as well.
"I would really hope the public asks their nurse, 'How many patients do you have besides me?'" Canfield said.
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