New Staffing ratios

[Cmyst]

This is fascinating, and I consider myself to be more aware of the proposed changes than most RNs I've spoken with. An insulin drip will mean classification as a step-down patient? ???

The Med/Surg floor that I work on most of the time gets these occasionally, and truthfully they take a great deal of time and care and *should be* a higher acuity -- so, does that mean if I'm assigned a patient on an insulin drip, that my caseload of *all* patients should be no more than the number for a stepdown unit?

And what about "Tele" units (same floor, which is officially the Med/Surg garbage dump of the hospital) that require the RNs to be Tele certified (BCM) and have ACLS, but do not have on-site monitor techs? This one has a monitor room, unmanned and largely ignored, and the monitor techs are in another seperate facility miles away but they do monitor the patients and call us if they note a problem. Also, we must run strips and interpret them at routine times, and we also *should* be doing so whenever they call -- but we're usually too busy to do anything but assess the patient and deal with the problem, which thankfully is usually minor. Is this considered a "Tele" unit, under the new law?

Lastly, and not meaning at all to slight LVNs, but on the noc shift on this floor the LVNs usually act as primary nurses and RNs must "cover" their patients. LVNs are not allowed to call MDs, or give any IV meds. They are not allowed to write the shift summary that we must write on all patients in the chart. They can assess, but we must also assess and then co-sign. Our LVNs are wonderful, skilled, intelligent nurses -- but ultimately, the RNs are legally responsible and often we are giving multiple IV meds and assessing and calling MDs on patients that were not our "primary" patients and who are taking up most of our time. As it stands, a license is a license for staffing -- but not for responsibility and liability. Do we count these patients into our ratios? And if so, how then will we justify having LVNs providing primary care, since they are "licensed" nurses and should therefore be figured into the ratios?

Thanks for the great info!

[pickledpepperRN]

Cmyst:

Boy you do raise a lot of good questions. I am far from expert. I do attend a CNA class every year.

On the tele ratios when mixed with med surg patients I know the DHS visited my hospital a few years ago. We were surprised they cited the hospital for having telemetry patients in the ICU staffed as tele. The telemetry floor was full. We had 1:2 or 1:1 for our ICU patients and 1 RN for 4 telemetry patients. SO I think that each bed needs to be licensed according to the unit. A unit with monitored patients would then be staffed as tele unless such as drips or ventilators made ot a step down unit.

My DH just came in, I'll get back to the computer later.

[sharann, BSN, RN]

I asked one of our p.m supervisors what the hospital was doing to prepare for "January 2004". He said they would institute the new ratios in November, and have hired alot of new nurses. He also hinted that unit secretaries and some aides would be let go.... Sound like we are in for it no matter what.

[pickledpepperRN]

The CNA interperts the following to mean the % of non nurse or unlicensed staff must remain the same or better than before the ratios. The ratios are meant to improve patient care. Clearly decreasing the number od secretaries and/or aides will NOT improve care.

From the STATEMENT OF REASONS:

"In order to clarify that a hospital cannot reduce overall staffing by assigning licensed nurses to duties customarily and appropriately performed by unlicensed staff, it is stated that staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system. At 22 CCR 70053.2 and 70217(b), the PCS is defined as a system that is established to determine the amount of nursing care needed by each unit, on each shift, and for each level of licensed and unlicensed staff. Setting a minimum level of staffing for licensed nurses is not intended to alter the current requirement of the PCS to determine needed staffing levels for licensed and unlicensed staff. "

And regarding Insulin, Dopamine, and other drips that require monitoring and assessment mor frequently than possible when assigned to 5 or 6 patients the CNA (Author of AB 394) believes this constitutes technical support.

Of course just as traffic laws are not always followed we expect some hospitals to do all they can to circumvent the letter and spirot of the law. Mesanwhile they will promote their quality of care!

""Technical support" is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, and or mechanical ventilation, for the immediate amelioration or remediation of severe pathology for those patients requiring less care than intensive care, but more than that which is available from medical/surgical care. "

[pickledpepperRN]

Link to scheduled classes. I am sure there will be more announced soon.

http://www.calnurse.org/cna/ce/

[Cmyst]

So, am I hearing you right that the CNA's interpretation of the law is that if pt's are tele-monitored, or on insulin drips, that constitutes a level of technical support that is more accurately deemed to be "step-down"?

I am only too happy to have all the ACLS, BCM, Conscious Sedation, 12 Lead EKG, etc. courses that this basically Med/Surg floor requires. The problem is that all those courses do not really make me a competent Tele nurse. This floor is 90% straight Med/Surg. Of course, I would love it if they'd staff us at the Tele ratio. Many is the night I have been overwhelmed, exhausted, and demoralized by caring for just 4 patients (well under the ratio that will take effect in January) -- much less the usual 5 or 6, and covering 1 or 2 more (which legally are still my patients).

And as for the LVNs, where do they come into the staffing ratios? If I have 5 patients, and am covering 2 or 3, is that in violation of the ratios come January?

Another question: What types of tasks are rightfully ancillary tasks? Up until about six months ago, the NAs did vital signs and blood glucose checks. Then, what we were *told* was that too many mistakes were being made and they wanted the nurses to do their own vital signs. And that the BG checks, being invasive, legally couldn't be performed by the NAs. I really feel torn by this issue. On the one hand, I think UAPs can be a real danger to patient care if they do not understand the rationales behind their tasks, or take their responsibilities seriously. On the other hand, nurses have so much to do that it really hurts to take on more and more -- and in truth, there is only so much that one human being can do.

[pickledpepperRN]

A certified nursing assistant may not do glucose testing (no UAP may), They are trained and tested to take accurate vital signs, but need the registered nurse who has assessed the patient to give specific instructions on what to report. Alternately the RN could take the vitals when performing the initial assessment and being sure to check the subsequent ones routinely taken by the CNA.

As to your question, "And as for the LVNs, where do they come into the staffing ratios? If I have 5 patients, and am covering 2 or 3, is that in violation of the ratios come January?"

I wish it were a violation. Many nurses wrote and testified at DHS hearings, but they state, "LVNs may constitue up to 50% of licensed nursing staff."

The rational is to allow units to continue team nursing.

There are a lot of references to "within their scope of practice"

The patient classification system (PCS) will be important.

The CNA advised that LVNs be assigned to the RN not to the patient. That is team nursing and the DHS does mention that.

Remember the ratios are meant to be the floor, not the ceiling. For a unit on the rare day all the patients are low acuity they may be safe. Usually the acuity is medium to high. That should call for more licensed and unlicensed staff.

This is a beginning. First the hospitals have to accept the ratios, and the PCS = acuity. It will be up to the nursing staff, families, and patients to enforce by reporting violations to the DHS. The number is in the front of the phone book under State of California Government Department of Health Services (something like that).

[Going80INA55]

My question is this. The ratio is 1:5 on telemetry. Does it remain 1:5 once the tele box comes off or does the ratio change to a med/surg ratio?

[Cmyst]

Ok, I'm not trying to beat this to death, just to make sure of what I'm hearing because I am most likely to be the nurse giving advice to other nurses about this on night shifts at the hospital I work at.

So, if the law allows up to 50% of staffing to be LVNs, then in actual practice instead of a maximum of 6 patients on the Med/Surg floor I could, in fact, end up with 9? ? ? My own interpretation is that I can be *responsible* for no more than 6, which would include those I am "covering". Is this what the law intends?

It seems like the new law is saying that *any* licensed nurse, RN or LVN, on a Med/Surg floor can have no more than 6 patients?

For an RN, that would mean a total of 6, including those that are being "covered" (which is really team nursing with split teams)?

This issue is very, very important to clarify. If we don't, it is entirely likely that more LVNs will be hired due to the RN shortage and the desire of most LVNs to leave SNFs. RNs might end up with much greater patient loads than the law intends, and SNFs that are already hurting for nurses will be in terrible trouble.

On the LVN side of the equation, this would be a godsend for the LVNs working days, who are currently working as medication/treatment nurses and are splitting the entire floor of up to 38 patients between 2 LVNs. If I'm hearing your explanations of the intention of the law correctly, then the LVNs would be limited to 6 patients on Med/Surg as well.

And there are to be no differences in staffing between days and nocs, correct?

I've been thinking that my hospital staffs close to the ratio, but maybe they don't....... and I am now having trouble believing that they will change the status quo around here by January, because if they were going to do so they would have implemented some changes by now.

[Genista, BSN, RN]

I think the ratios are a step in the right direction.However, be forwarned that the hospitals will rob Peter to pay Paul to meet the ratios. Case in point: my current patient load is 1:5-6, which sounds dreamy.However, that usually means no nurses aid (or one for the whole floor for maybe only 3-4 hrs)...and usually no unit secretary.The charge nurse does the desk along with a full assignment. So, I already have the current med/surg ratios. I can tell you, many days this isn't adequate staffing. We have a ways to go with those ratios. 5-6 patients is a heavy load when 4 out them are total feeds, diabetics, TPN, isolation, drawing labs, wound care, the phone ringing off the hook, and charts piled to the rafters waiting to be entered into the computer.With such a low nurse patient ratio, they think we don't need UAPs, so you've got NOBODY to delegate to. The call lights are always blazing, and I am always running. Acuity is NOT taken into account where I work. I personally think the ratios could be even lower!!!

[pickledpepperRN]

"And there are to be no differences in staffing between days and nocs, correct? " CORRECT.

That is the good news.

"I think the ratios are a step in the right direction.However, be forwarned that the hospitals will rob Peter to pay Paul to meet the ratios."

I am afraid of that too. It will take a strong united nursing staff to accomplish a reasonable PCS that increase staffing to meet the needs of the patients.

Remember the ratios are the minimum. They must be maintained at all times, all shifts and during breaks, and what a friend calls "road trips" to radiology and other tests.

Check the links to the DHS and read the revised law and the Statement of Reasons. Try to attend a class. If you do in the Los Angeles area I may see you there.

Please don't think me an expert. Just a nurse activist like thousands of others who worked to get this law.

[pickledpepperRN]

http://www.oaklandtribune.com/Stories/0,1413,82~1726~1637852,00.html

Oakland Tribune

Chan's abstention draws nurses' ire

Hundreds of nurses protest Chan

By Rebecca Vesely

STAFF WRITER

Wednesday, September 17, 2003 - Hundreds of nurses descended on the Oakland offices of Assembly Majority Leader Wilma Chan, D-Oakland, on Tuesday to protest her decision to abstain from voting on a bill that would have fined hospitals for violating new nurse staffing ratios.

Carrying placards that read "Wilma Chan equals politics over patients" and "Wilma Chan, enemy of RNs," members of the California Nurses Association stormed into her office and filled the building's atrium with echoes of angry chants and shouts.

At issue was AB 253, by Assemblyman Darrell Steinberg, D-Sacramento, which would have fined hospitals up to $5,000 a day for breaking new nurse-to-patient ratios going into effect in January. The legislation failed in a 29-33 vote last week with 19 abstaining, including Chan.

As it stands, the state has few means to crack down on hospitals that staff below the new ratios mandating how many nurses must be on duty per shift to care for patients. For instance, fines are only $50 per patient where violations occur. The ratios vary depending on specialty.

The nurses said they believe Chan, who originally backed the bill, abstained from voting on it because the CNA endorsed incumbent state Sen. Don Perata, D-Oakland, in his bid for another term. Chan has sought a decision from the courts on whether Perata would be violating the state's term limits by running again.

"She'll move forward in the political arena on the backs of patients," said CNA president Kay McVay.

Rachel Richman, Chan's chief of staff, spoke to the nurses on behalf of Chan, who was on vacation.

"If you look at Wilma's votes on health care, she's always been supportive of patient rights," Richman said. "We've always looked at what is the issue, not the politics."

Richman said Chan pulled her support of the bill because "she had concerns that she hoped would be worked out but they weren't."

Chan did support SB 1005, by Sen. Joe Dunn, D-Garden Grove, that also would have fined hospitals for legal violations, Richman said.

That bill failed as well and, in the final hours of the legislative session, no agreement could be made to combine the two bills and get the votes needed to pass the measure.

The nurses were rallying for universal health care at the Ron Dellums Federal Building in downtown Oakland when they decided to storm Chan's office nearby. The rally was part of CNA's centennial celebration in Oakland, and drew more than 1,000 nurses from around the state and other countries.

Many nurses said they felt betrayed by Chan.

"I can't support Wilma Chan," said Pat Strickland, a nurse at Summit Medical Center in Oakland. "I can't recommend that other nurses support her. We're devastated."