Friday, June 18, 2004
Patient-nurse ratio debated as quality issue
Many hospitals won't give figures
By Elizabeth Lynch
The number of patients compared to the number of nurses on duty should be part of the criteria people use to select a hospital for care, an advocacy group said.
But hospital management argues the nurse-to-patient ratio is not a true indication of the quality of care a patient receives.
The debate has risen out of the nationwide nursing shortage.
Only one of six hospitals in the nine-county Hudson Valley region were able to provide callers with the ratio of nurses to patients, a recent survey by New York State Patient Safety Advocates found. The group is a coalition of pediatricians, the American Heart Association, the New York State Nurses Association and the New York State Trial Lawyers Association, among others.
Nyack Hospital in Rockland County received a 'B' grade because it was able to provide the ratio of patients to nurses within five minutes. The others surveyed -- Orange Regional Medical Center, Putnam Hospital Center, Benedictine Hospital in Kingston, Kingston Hospital and Sound Shore Medical Center of Westchester -- received an "F" because they did not provide the information.
Staffing ratios are a key piece of information patients should have when they are selecting a hospital, said Nancy Webber, spokeswoman for New York State Patient Safety Advocates.
Not all participated
There are many more hospitals in the Hudson Valley region, but only six were included in the survey. Statewide, 50 of the 93 hospitals surveyed were unable to provide the ratio statistics.
The ratio of patients to nurses should be one piece of information available to people deciding which hospital to choose for a procedure, Webber said.
''This is information they need to have,'' Webber said. Inadequate nursing care has been linked to complications such as bed sores, pneumonia and blood infections, she said.
Others said knowing the ratio is not useful if it is the only piece of information used.
''I don't see how it's meaningful information,'' said Monica Mahaffey, spokeswoman for the New York State Healthcare Association. ''How sick are the patients? What's the level of acuity? That's what you need to know. What really matters is the care that is required and the care that is being delivered.''
When her mother was hospitalized recently, Susan Puccillo of LaGrange felt she needed to stay overnight because her mother suffers from dementia.
''The nursing service itself was wonderful,'' Puccillo said. ''But I needed to be with her.''
City of Poughkeepsie resident Lorraine Bent has been bringing her daughter to St. Francis Hospital to see her primary care doctor for the last five years.
''The nurses are good,'' she said.
Town of Poughkeepsie resident William Miller said his doctor's recommendation is more important in his choice of a hospital than a nurse's workload.
But Yonkers resident Kenny Krasnow and his wife Ellen said the nurse-to-patient ratio is one piece of information they would use to select a hospital. Just as important would be the skill of the nurses, as well as the specialized services the hospital offered.
''It's the level of care, rather than just how many patients per nurse,'' Kenny Krasnow said. ''The number is just part of it. The majority of people understand hospitals are short-staffed as it is.''
Bills in state Legislature
Two bills are pending in the state Legislature. One would require hospitals to make staffing ratios and patient outcomes public, such as the rate of pneumonia cases. The other would mandate minimum nurse-to-patient ratios.
''While it appears to be a quick fix, we strongly believe that staffing ratios are not the appropriate solution'' to the nationwide nursing shortage, said Arthur Weintraub, president of the Northern Metropolitan Hospital Association. ''Staffing ratios are an imperfect measure of direct care.''
A 2004 report by the Institute of Medicine titled ''Keeping Patients Safe: Transforming the Work Environment of Nurses'' found: ''Nurse staffing levels, the knowledge and skill level of nursing staff, the extent to which workers collaborate in sharing their knowledge and skills all affect patient outcomes and safety.''
The report recommended the federal Department of Health and Human Services create a system to allow public access to nurse staffing at hospitals and nursing homes.
Staffing part of accreditation
Staffing levels are one element hospitals provide as part of their three-year review for accreditation by the Joint Commission on Accreditation of Healthcare Organizations. The staffing levels are set by the hospitals and not the agency, spokeswoman Charlene Hill said. The commission is a nonprofit organization that accredits more than 16,000 health care organizations.
''What patients need to consider are outcomes. ... It's more complex than just the number,'' Hill said.
The commission requires hospitals to compare patient rates of pneumonia, falls and length of stay with staffing issues such as turnover, overtime and the number of unfilled jobs. Those three measures are indicative of the care a patient receives, Hill said.
Suzanne McLaughlin, chief nursing officer at St. Francis Hospital, said staffing plans at the Poughkeepsie hospital are determined by the number of patients, how sick they are, the physical layout of the unit, support services for the nurses and the technology available to support the nurses.
''When a patient is asking about a pure ratio, what they don't ask is how many other kinds of people are around to save steps for the nurses,'' McLaughlin said. ''You don't want the nurse to do stuff that a lesser-skilled person could do possibly better.''
The hospital has a goal of one nurse, working with one patient-care partner, for every six patients in its medical-surgical wards. Staffing is adjusted each shift based on the patients' needs, McLaughlin said.
None of the hospitals part of HealthQuest -- Vassar Brothers Medical Center, Northern Dutchess Hospital or Putnam Hospital Center -- would release their nurse-to-patient ratios, said Mark Kochanowski, vice president of human resources.
''Our reluctance is that people interpret this data based on what interests they have and it's not our primary driver,'' he said.
The goal of the hospitals, he said, is to find the right mix of staff to support patient needs. Even if two patients have the same diagnosis, they may require different support.
At Vassar Brothers Medical Center, Margaret Cusumano, vice president for patient care services, said the hospital would not give a ratio because staffing levels are complicated.
''That could be used out of context,'' she said. ''It's an apples-to-oranges comparison.''
Cusumano said even having the same ratio of nurses in two hospitals' intensive care units wouldn't give a true picture of the care provided. As a patient ''you might compromise your own care because you don't have all the information you need,'' she said.
New York State Patient Safety Advocates is supporting legislation that would require hospitals to provide nursing ratio to the public, as well as make public the number of patient complications.
''The more information the better,'' Webber said. ''During a nursing shortage, it's probably even more important for the public to know what's going on.''