New Staffing ratios

[pickledpepperRN]

I missed the editorial these letters to NurseWeek are responding to.

http://www.nurseweek.com/news/respond/

Necessary protection

I thought Carol Bradley made some good points in her column, "Trump Card," about regulations being a problem in meeting health care needs flexibly.

But until regular staff nurses have a powerful voice at every hospital, I believe that staffing ratios will be a necessary protection for health safety. And that day may be long in coming.

GARY CORUM

Redding

In the 1930s, our country endured a devastating depression with extremely high unemployment, bank failures and a devaluation of our currency. The incumbent president, Herbert Hoover, was an advocate of laissez-faire, believing that the government had no business intervening in an essentially private-sector economic problem. The voting public disagreed with him, electing Roosevelt, who developed a number of strategies to combat the Depression. The effectiveness of these new agencies and public assistance models were varied. But he took the responsibility to try to fix the problem.

We see this same mentality in organizations like the California Nurses Association, which took the lead in developing nurse staffing ratios. Why? Because the health care industry was decidedly against any such intervention. Hospitals want to make money. They don't necessarily care about patients or about nurses. Their goal was to make the most amount of money with the least amount of overhead. So, they began diluting RN staffing with LVNs, certified nursing assistants and other unlicensed personnel.

Bradley fashions herself as the advocate of quality patient care against nasty politics. Then she firmly sides with the hospitals and bureaucracies that continue to evade any viable solution. It is one thing to say you are in favor of quality patient care and another to align yourself with the agencies that abdicate their responsibility and seek profit at any cost.

The value of increased RN ratios was confirmed by a study funded by the National Institutes of Health and published in the Journal of the American Medical Association, showing a decrease in patient mortality being linked directly to more RNs. A similar study conducted by the Harvard School of Public Health confirmed that more RNs led to lower mortality, fewer infections and fewer patients suffering upper GI bleeding and shock.

The CNA should be applauded for standing in the gap and making a valiant effort at stopping this dilution of nursing care. Unfortunately, nurse staffing ratios are a bit like price fixing. It isn't the best solution, but the business/hospital community is doing nothing to fix the problem. They are an externally imposed limitation that is absolutely necessary in the face of inaction and greed on the part of hospitals. Time will tell if they work or not.

In the meantime, it may give the public pause to know that when they must endure a hospital stay, they will be cared for by registered nurses and not by housekeepers, food service workers or security guards wearing stethoscopes.

RICHARD MALLYON, RN

Lancaster

Effective Jan. 1, California will be the first state in the nation to implement nurse-to-patient ratios in all units of licensed acute care general hospitals. These regulations that Carol Bradley characterizes as part of California's "suffocating degree of regulation," requiring the development of "operational strategies to implement," represent the culmination of a decade of patient and RN advocacy by members of the California Nurses Association in addressing the deplorable decline in the quality of patient care services following implementation of an earlier innovative "operational strategy."

That innovation was ironically referred to by corporate health care consultants as "patient-focused care," although it was neither focused nor friendly. If registered nurses are wary of the next wave of innovative operational strategies proposed by self-appointed "nurse leaders," it is because they have not forgotten the heartless, degrading treatment that they and their patients experienced during the last decade.

The lesson learned during what was referred to as "process redesign" is that the only voice heard by profit-seeking health care corporations and the "nurse leaders" they employed was the collective voice of thousands of CNA members firmly and unapologetically resisting compromises in the quality of patient care.

Nurse-to-patient ratios have been in effect in California since 1975 in critical care units and in the operating room. Implementing the same approach to minimum safe staffing throughout the remaining units in the acute care facilities does not require innovation or the development of new "operational strategies."

The California Department of Health Services received unprecedented support for the staffing ratio regulations by California registered nurses who recognize that "basic principles of quality patient care" require the presence of a registered nurse. Minimum nurse-to-patient ratios provide a much-needed safety net for hospitalized California health care consumers.

VICKI BERMUDEZ, RN

regulatory policy specialist

California Nurses Association

Sacramento

[sjoe]

"For instance, fines are only $50 per patient where violations occur. "

Exactly the point I was going to make, but spacenurse beat me to it. All the foregoing discussion is simply a waste of time with microscopic fines such as this. Logic and "studies" will simply be ignored.

(BTW the state legislature declined to pass a new bill in the past couple of weeks that would have raised this fine substantially. Score another one for big healthcare's lobbyists.)

[pickledpepperRN]

Long Beach Press Telegram

Safe nurse staffing ratios is good for California's health

Patients in Long Beach, San Pedro and the rest of California can soon rest assured that when they are admitted to a hospital, a registered nurse will be at their bedside to care for and advocate for them.

Saturday, October 11, 2003 - {BYLINE}By Jan. 1, all hospitals must be in compliance with the state law that mandates safe RN staffing ratios, the number of patients assigned to each nurse, for all hospital units in all California acute care facilities. Many hospitals, including Long Beach Memorial and San Pedro hospitals, have already hired hundreds of RNs to fill these ratios, and that is good for patients. But this has not always been the case.

The California Nurses Association (CNA) sponsored this law to reverse the degradation of patient care conditions caused by years of managed care and corporate business practices that put hospital profits ahead of patient safety.

As bedside nurses we were outraged to see the money the hospitals received in reimbursement from Medicare and other reimbursement sources squandered and misused to fund record executive compensation, numerous outside high paid consultants, failed computers systems, and other nonessential items while direct patient care was cut.

RNs who work in these hospitals are required by law to be patient advocates. We could no longer sit back and allow patient care to be compromised and see lives lost. CNA, joined by RNs and patients across the state, campaigned for years to pass the safe staffing law in 1999 and it continues to have broad public support.

A September poll found 77 percent of likely voters think strong standards are necessary to protect patients, including clear rules on safe nurse-to-patient ratios.

Repeated studies have documented that there is a decrease in medical errors, complications, and patient mortality when staffing ratios are required by law and not subject to the whims of hospital administrators. The staffing ratio law will save thousands of patients' lives and will also save community hospitals money by improving patient outcomes, and cutting patient stays and re-admissions.

Rather than continue efforts to overthrow the law, as proposed by several administrators in a Press-Telegram commentary (SundayForum, Oct. 5), the hospitals owe it to their patients to work with us for the benefit of our community.

Hospital administrators' complaints that safe staffing is an unfunded mandate fail to meet the credibility test. California has approved more funding for nurse education and training programs than the federal government. The Davis Administration last year initiated a $60 million Nurse Workforce Initiative. One beneficiary, with the support of CNA, was Long Beach Memorial, which was awarded a $2.5 million grant to train ancillary workers to upgrade their skills to become RNs.

CNA is also tackling the nursing shortage with programs to reverse a disastrous turnover of RNs from our hospitals, the worst in decades. CNA has negotiated professional wages, benefits and pension packages that, accompanied with new safe staffing standards, finally make nursing an attractive profession once again. Long Beach Memorial, which hosts nursing students in training from Long Beach City College, again provides a case study. In the class just prior to the landmark CNA contract at Memorial last year, only one City College student returned to Memorial as a staff RN. From the graduating class last summer, following our agreement, 175 RNs came to Memorial, of whom 100 were new nurses.

Since these ratios have begun to be implemented, we are witnessing unprecedented increases in the number of people signing up for nursing school programs and reentering the profession they were forced out of by corporate greed. Retention also produces substantial savings for the hospitals. Hospitals spend about $42,000 to replace each general medical and surgical unit RN, and $64,000 to replace each specialty RN, according to one recent national study, and spend billions every year on temporary agencies, all expenses that will be reduced by assuring hospitals can keep their present workforce at the bedside.

Public safety standards are not a new concept. We have ratios for airline pilots and daycare centers, and minimum regulations for clean air and water. Hospital patients deserve no less protection. With the help of the new staffing ratio law, our community has our promise that we will stand by our patients to ensure that their care is never compromised.

Margie Keenan, RN, Long Beach Memorial

Mary Bailey, RN, Long Beach Memorial

Rise Barrows, RN, St. Mary Medical Center

Ronnell Wilson, RN, St. Mary Medical Center

Nancy Giallombardo, RN, Little Company of Mary-San Pedro Hospital

Lora Smith, RN, Little Company of Mary-San Pedro Hospital

[sharann, BSN, RN]

Thanks for the update Spacenurse

[pickledpepperRN]

Originally posted by sharann

Thanks for the update Spacenurse

You are very welcome!

Here are the scheduled classes. Continental breakfast, lunch, learning, networking and humor. Plus 6 CEs.

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

[pickledpepperRN]

I'll just leave the link.

http://www.applications.dhs.ca.gov/regulations/search.asp?REGID=R-37-01&advanced=yes&c2=@filewrite&o2=%3E&q1=&EMERGENCY=&submit1=Begin+Search

(1) Amend Section 70217 to read:

Section 70217. Nursing Service Staff.

(a) Hospitals shall provide staffing by licensed nurses, which includes registered nurses, licensed vocational nurses, within the scope of their licensure in accordance with the following nurse-to-patient ratios. Licensed nurse means a registered nurse, licensed vocational nurse and, in psychiatric units only, a licensed psychiatric technician. Staffing for care not requiring a licensed nurse is not included within these ratios and shall be determined pursuant to the patient classification system.

No hospital shall assign a licensed nurse to a nursing unit or clinical area unless that hospital determines that the licensed nurse has demonstrated current competence in providing care in that area, and has also received orientation to that hospital's clinical area sufficient to provide competent care to patients in that area. The policies and procedures of the hospital shall contain the hospital's criteria for making this determination.

Licensed nurse Nurse-to-patient ratios represent the maximum number of patients that shall be assigned to one licensed nurse during one shift at any one time. "Assigned" means the licensed nurse has responsibility for the provision of care to a particular patient within his/her scope of practice. There shall be no averaging of the number of patients and the total number of licensed nurses on the unit during any one shift nor over any period of time. Only licensed nurses providing direct patient care shall be included in the ratios.

Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses, and other licensed nurses not having a specific patient care assignment, shall not be included in the calculation of the licensed nurse-to-patient ratio only when those licensed nurses are engaged in providing direct patient care. When a Nurse Administrator, Nurse Supervisor, Nurse Manager, Charge Nurse or other licensed nurse is engaged in activities other than direct patient care, that nurse shall not be included in the ratio. Nurse Administrators, Nurse Supervisors, Nurse Managers, and Charge Nurses who have demonstrated current competence to the hospital in providing care on a particular unit may relieve licensed nurses during breaks, meals, and other routine, expected absences from the unit.

Licensed vocational nurses may constitute up to 50 percent of the licensed nurses assigned to patient care on any unit, except where registered nurses are required pursuant to the patient classification system or this section. Only registered nurses shall be assigned to for Intensive Care Newborn Nursery Service Units, which specifically requires one registered nurse to two or fewer intensive care infants,. or where registered nurses are required pursuant to the patient classification system. In the Emergency Department, only registered nurses shall be assigned to triage patients and only registered nurses shall be assigned to critical trauma patients.

Nothing in this section shall prohibits a licensed nurse from assisting with specific tasks providing care within the scope of his or her practice to for a patient assigned to another nurse. "Assist" means that licensed nurses may provide patient care beyond their patient assignments if the tasks performed are specific and time-limited.

[pickledpepperRN]

http://www.calnurse.org/102103/safestaffqa.html

RN Staffing Ratios - It's the Law

Questions and Answers about California's RN-to-patient staffing ratios, as required by the California Nurses Association sponsored Safe Staffing Law, AB 394.

Send in your additional questions. Answers, provided by CNA's nursing practice, regulatory, collective bargaining, and legal experts, will be posted here.

Email us your questions by clicking here

Q. When do the ratios go into effect?

A. All hospitals must be staffing with the new ratios by January 1, 2004. Hospitals that are not staffing by the ratios on that day are breaking the law.

Q. Are these RN ratios?

A. Based on patient acuity and scope of practice laws, in accordance with a Patient Classification System, no RN can be assigned responsibility for more patients than the specific ratio at any time, under any circumstances.

Q. What if more RNs are needed because of sicker patients?

A. Once the minimum ratios are in place, additional staffing must be assigned based on a hospital's Patient Classification System.

Q. Can hospitals use LVNs in the ratio count?

A. Under law, LVNs are authorized to practice only under the direction of an RN or licensed physician.

Q. What duties can LVNs perform under AB 394?

A. Data collection and other nursing care tasks may be assigned to the LVN, but validation of that data and incorporation into a plan of care remains the responsibility of the RN. JCAHO defines "data" as uninterpreted observation of facts. Only an RN can assess a patient.

Q. What if hospitals lay off ancillary staff?

A. The ratios are premised on DHS surveys of existing hospital staffing patterns, including the percentage of LVNs and other nursing staff. It is CNA's position that any hospitals that cut non-RN nursing staff must hire additional RNs to assure safe patient care.

Q. Can RN assignments be averaged?

A. The ratios are the maximum number of patients assigned to any one RN at all times during a shift.

Q. Are charge nurses out of the ratio count?

A. If the charge nurse has no direct patient care assignment, she/he may not be counted in the ratios. Charge nurses, whose competencies have been validated, may provide break relief so other RNs in the unit will not have additional patients exceeding the ratios.

[CV CNS CCRN]

Can anyone out there tell me FOR SURE if, when a patient has orders written and on the chart for transfer from an ICU to a general or tele floor, but thhere are no beds available on the tele unit, if the ration for that patient will remain the same while they are still housed in thhe ICU, regardless of the fact that their charge code should have been downgraded to reflect a change (improvement in status) and their care should have been downgraded as well. I hope no one is continuing to treat these patients awaiting transfer as ICU status patients while they await a clean room on the floor. Anyway, if anyone has a reference to the policy which address this, I would be very greatful. Thanks.

[RNKPCE]

CV CNS CCRN

We have a unit in our hospital that use to be a CCU and now is only open when ICU is full. They may at times have tele patients but since they are licensed for ICU the nurses can't ever have more than 2 patients each. Even if all the patients would be considered medical or tele they would have to be staffed 2 pt per nurse.

At some point some bureaucratic group was contacted ( I think whoever is in charge of licensing beds- possible dept of health) and the hospital got fined because at one point the nurses were getting more than 2 patient each, even though they were ICU patients.

[pickledpepperRN]

Originally posted by CV CNS CCRN

Can anyone out there tell me FOR SURE if, when a patient has orders written and on the chart for transfer from an ICU to a general or tele floor, but thhere are no beds available on the tele unit, if the ration for that patient will remain the same while they are still housed in thhe ICU, regardless of the fact that their charge code should have been downgraded to reflect a change (improvement in status) and their care should have been downgraded as well. I hope no one is continuing to treat these patients awaiting transfer as ICU status patients while they await a clean room on the floor. Anyway, if anyone has a reference to the policy which address this, I would be very greatful. Thanks.

I have known of hospitals in this situation that applied for and received "progran flexibility" or a "waiver" which is for a specific period of time with clearly outlined conditions.

Presumably the descriptions of units in the links near the start of this post would determine what staffing and equipment is required.

One hospital had a closed ICU that was temporarily allowed to function as a telemetry unit during the flu season. that was about three years ago. We were very assertive in communicatine to the doctors that this was NOT and ICU. If a patient needed ICU level care a transfer was in order.

[RNKPCE]

I think they are looking into that Program flexability option. I agree that it would be very important that the docs know that it isn't an ICU. We already get heavier patients than we should at times just because we are a tele unit. We will get patients that have no real reason to be on tele but they are too heavy for the regular floor. It is very frustrating.

[pickledpepperRN]

Originally posted by batmik

I think they are looking into that Program flexability option. I agree that it would be very important that the docs know that it isn't an ICU. We already get heavier patients than we should at times just because we are a tele unit. We will get patients that have no real reason to be on tele but they are too heavy for the regular floor. It is very frustrating.

Cut & paste from the DHS site:

...

(9)The licensed nurse-to-patient ratio in a step-down unit shall be 1:4 or fewer at any time all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times. A "step down unit" is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support. Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care. "Artificial life support" is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged. "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.