HomeMy WebLinkAboutMINUTES - 06081999 - D2 TO: BOARD OF St�'PER�'I5�R5
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Contra
FROM: Supervisor Donna Gerber Costa
County
DATE: „une 8, 1999
SUSJFCT: Siuipport Posit ion on AB394
SnCIFIC R$DUEST(S)OR RECOMMENDATION($)i SAOMOUND AND JUSTIFICATION
Recommendation:
1. Support AS 394 by sending a letter to Assemblymember Sheila Kuehl.
2. Include a request that psychiatric technicians working in inpatient psychiatric
units is clearly identified in the bill in order to clarify how the staffing requirements
include this classification.
Background:
On May 11, 1999 representatives from the California Nurses Association
requested that the Board support AS 394, The Board referred the matter to the
Joint Conference Committee for review and recommendation. However,
Supervisor DeSaulnier was not present so Supervisor Gerber solely makes this
recommendation.
On May 20,1999 the Joint Conference Committee met, including Health Service
Staff on the committee, reviewed and discussed the bill. The committee
reviewed the specifics of the bill and compared its requirements to the County's
current staffing and policies. It was acknowledged that the Contra Costa
Regional Medical Center already provides nursing staff at the same levels or
above the required minimums in the bill. In addition, the other provisions of the
bill were felt to be consistent with policies of the Medical Center. Frank Fuglisi,
Hospital Administrator, stated that he was philosophically opposed to staffing
minimums and had some questions about the effect on psychiatric technicians.
However, he agreed that passage of the bill would not require a change in
current practices of the Hospital.
a �
C:ONTtNUED ON ATTAC"tENT: .y- YES SIONATURE: .
-RECOMMENDATION Of COUNTY ADMINISTRATO; _Fk1COMMtN0ATtON cif 0OAA0 COWMMT11
APPROVE OTHER
NA
AC"tiON Of SCJM11tD ON June 8 , _,1999
Amf.-tED AS vwco I'MEAfv=ZL OnI mA
The following people commented on the matter: Francisco U ante, California Nurse's Assoc., 2000,
Franklin Street, Oakland; Claudine Thomas, 1463 Date Street,Martinez; ?Mary K. Rayl, California
'Nurse's Assoc., 1311 Rosemary Lane, Concord.
All persons desiring to speak having been heard, the Board APPROVED the recommendations set
forth above.
VOTE Of SUPERVISORS
t HERESY CERT1rY THAT?N14 4 A TRUE
1X U ANIMOUS(AltWW #Ty + AND CORRECT CO"Of AN A>~T*N TAKEN
AYMI , 111 -2 AND IRM90 ON THE WINUTU CN TM SOARD
ASSENTt AS AIN: Of SUP MSORS ON TM DATE SKO".
C ATTESTED j"e 8 y,_
PHIL BATCHELOR,CLERK OF THE 8WO OF
SUPERVISORS AND CC?UNTY ADMINIMATOR
EY C>tPUTY
LAW MIMI
A copy of AB 394 is attached. In summary, it provides for the following:
1. Prohibits an acute care hospital from assigning an unlicensed person
to perform nursing functions in lieu of a registered nurse.
2. Prohibits an acute care hospital from allowing unlicensed personnel
under the direct clinical supervision of a registered nurse to perform certain
functions such as administration of medication, intravenous therapy, tube
feedings, inserting catheters, tracheal suctioning, assessment of patient
conditions etc.
3. Requires hospitals to provide minimum nurse to patient ratios.
Additional staffing to be based upon condition of individual patients determined
by patient classification systems. These minimums include RNs and LVNs
depending upon the clinical unit.
4. requires adoption of written policies and procedures for training and
orientation of nursing staff.
6. requires that RNs, shall be orientated to the unit and competent to
Provide care before being assigned to a clinical area.
6. Exemptions may be approved by the DHS to rural acute care hospitals
as long as they do not jeopardize health, safety and well being of patients.
7. Requires that the provisions of the legislation be subject to existing
provision or regulation regarding the scope of nursing practice.
Discussion.
In the late 1970's, due to problems with fatalities in California's Hospitals, the
legislature began considering proposals from nurses for minimum staffing levels.
Although opposed by the hospital industry, minimum staffing levels for some
clinical areas such as Intensive Care Units were adopted and have been in place
ever since. Basically, there is a requirement that there be no more than 2
patients per nurse. This is a minimum and additional staff are to be assigned
(such as 1.1) when necessary based upon the patient's condition.
Periodically the Hospital and HMC) industry have attempted to abolish these
staffing standards, but have not succeeded. The remaining clinicalareas of a
hospital have no minimums and nurses complain that they often have to take
care of too many patients. This has resulted in working conditions that have
often driven nurses out of the profession causing workforce shortages that have
driven up the cost of nursing and caused operational problems despite the
adequate numbers of nurses licensed by California.
"Managed Care" (rationing) and capitation of payment (fixed dollars per month
per patient) byrip vate HMOs has exacerbated the problem as hospitals/HMOs
respond by attempting to cut costs by de-skilling and fragmenting patient care
(i.e. assigning tasks to cheaper employees and removing licensed nurses from
the bedside) thus jeopardizing the quality of patient care. This tread is coupled
with the increased acuity (seriousness of illness) of hospital patients as hospitals
limit the length of stay and admission of patients to control costs. Thus, hospital
patients are more acutely ill while staffing expertise and numbers have been
reduced. The result has been documented in every media outlet in California
and nationally. Generally, the quality of care has been jeopardized and
California now ranks last nationally in number of RNs per patient
California has led the nation in implementation of HMOs and "managed care" and
as a result is on the cutting edge of the consequences. While the economics of a
deregulated health care system have made it the number one (ahead of
technology) profit industry in the country, there has been little counter balance to
protect patients. AB 394 is a mechanism to provide that balance on behalf of
California patients and their families (who often have to provide nursing to their
family members). These staffing minimums would extend standards to parts of
the hospital where there are none. This would reduce the shuffling of patients
from one unit to another.
They would be clear and therefore enforceable. They would level the playing
field so that market place competition would not disadvantage hospitals like our
Regional Medical Center by driving standards to the bottom while increasing
liability for patient outcomes. They would encourage competition based upon
quality of care. Most importantly, AB 394 would result in protection of care for
patients and safer working conditions for nurses. For these reasons, AB 394 is
recommended as good public policy consistent with the County's public health
mission.
Also attached is a letter from CNA clarifying what the current staffing is compared
to the requirements of minimum staffing in the legislation. Please nate that the
Hospital meets or exceeds the standards. In addition, the nurses employed by
the County submitted a petition urging the Board to support AB 394.
It should be noted that industry's argument that thea would be inadequate
numbers of RN's and LAN's available to meet staffing minimums is being
addressed by other legislation, to increase training for specialized nurses, as well
as multiple efforts by nursing organizations and educational institutions,
California Association of Public Hospitals position is neutral.
California Hospital Association and Kaiser Oppose.
CAUFORNIA L63GiSLAT€3R.&-1999-2M REOULAR SESSION
A,%IElMLY BILL No. 394
Introduced by Assembly Members Kuehl
(Coauthors: Assembly Members Dutra,Gallegos,and
V laraigosa)
(Coauthors: Senators Burton and l scutia)
Febnniry 11, 1999
An act to add Section 2725.3 to the Business and Profession.s
Cade, and to add Section 1276,4 to the Huth and Safety Code,
relating to health care.
AB 394, as introduced, Kuehl. Health facilities. nursing
staff,
Existing law provides for the licensing, registration, and
regulation of nurses, and sets forth the scope of practice.
'Phis bill would prohibit a general acute care hospital, an
,acute psychiatric hospital, and a special hospital, as deftrted,
from assigning an unlicensed person to perform nursing
functions in lieu of a registered nurse, or from allowing
unlicensed personnel under the direct clinical supervision of
a registered nurse:to perfonn certain functions.
Existing law prohibits operation of a health facility, as
defined, without a license issued by the State Department of
Health Services and provides for the issuance of licenses and
for the regulation of health facilities and sets forth the sees
to be provided therein. Wdffid or repeated violation of these
provisions is a crime.
MAY-19--1999 11:36 925 335 1099 P.02
AB 394 --- —
This bill would require general acute care hospitals, acute
psychiatric hospitals, and special hospitals to provide certain
minimum nurse-to-patient ratios, and to adapt written
policies and procedures for training and orientation of nursing
std.
By changing the definition of an existing crime this bill
would impose a state-mandated local,program.
Th:r California Constitution requires the state to reimburse
local agencies and school districts for certain costs mandated
by the state. Statutory provisions establish procedures for
making that reimbursement.
This bill would provide that no reimbursement is required
by this act for a specified reason.
Vote: majority. Appropriation: no. Fiscal committee: yes.
State-mandated local program: yes.
The people of the Mate of California do enact as follows:
I SECTION 1. The Legislature finds and declares all of
2 the following:
3 (a) Health care services are becoming complex and it
4 is iacreasingly difficult for patients to access integrated
5 services.
b (b) {duality of patient care is jeopardized because of
7 staffing changes implemented in response to managed
8 carp.
9 (c) To ensure the adequate protection of patients in
10 acute care settings, it is essential that qualified register
II nurses and other licensed nuns be accessible and
12 available to meet the needs of patients.
13 (d) The basic principles of staffing in the acute care
14 setting should be based on the patient's care needs, the
15 severity of condition, services needed, and the
lb complexity surrounding those services.
17 Sly'. 2. Section 2725.3 is added to the Business and
18 Professions Code,to read:
19 2725.3. (a) A health facility licensed pursuant to
20 subdivision (a), (b), or (f), of Section 1250 of the Health
21 and Safety Code shall not assign unlicensed personnel to
22 perform nursing functions in .lieu of a registered nurse
ss
MAY-13-1999 11:37 925 335 1098 P.03
-3— A.B 394
1 and may not allow unlicensed personnel to perform
2 moons under the direct clinical supervision of a
3 registered nurse that require a substantial amount of
4 scientific knowledge and technical sills, including, but
S not limited to,airy of the fallowing.
6 (1) Administration of medication.
7 (2) Venipuncture or intravenous therapy.
g (3) Pmntmvl or tube feedings.
9 (4) Invasive procedures including inserting
10 nasogastric tubes, inserting catheters, or tracheal
11 suctioning.
12 (5) Assessment of patient condition.
13 (6) Educating.- patients and their families concerning
14 the patient's health care problems, including
15 postdischarge care.
16 (7) Moderate complexity laboratory tests.
17 (b) This section shall not preclude any person from
18 performing any act or function that he or she is
19 authorized to perform pursuant to Division 2
20 (commencing with Section 500).
21 SEC. 3. Section 1.276.4 is added to the Health and
22 Safety Code,to read:
23 1.276.4. (a) A health facility licensed pursuant to
24 subdivision (a), (b), or (f) of Section 1250 shalt allocate
25 sufficient numbers of registered nurses so as to provide a
26 nurse-to-patient ratio as follows;
27 (1) One: registered nurse to two patients to staff
28 critical care units, burn units, tabor and delivery,
29 postanesthesia units, and critical patients in emergency
30 departments requiring care in an intensive care or
31 critical care sem. The ratio of one registered nurse to
32 two critical care patients temporarily held in the
33 emergency departments shall be in addition to the
34 regularly scheduled emergency room staff.
3 (2) There shall be sufficient ming personnel so that
36 one registered nurse is not serving as circulating assistant
37 for mom than one operating room.
3g ( ) (ane licensed nurse to three patients to staff
39 pediatric and step-down/int mediate care units.
99
m,RY--19-1999 11:37 925 335 1098 P.04
AB 394 —4-
1
4-1 (4) One licensed nurse to four patients to staff
2 specialty care and telemetry.
3 (5) the licensed nurse to six patients to staff general
4 medical ears units that include subacute care and
5 transitional impatient care units.
6 (b) "These ratios shall constitute the minimum number
7 of registered and licensed nurses that shall be allocated..
8 Additional staff shalll be assigned in accordance with a
9 documented patient classification system for
10 determining nursing care requirements, including the
11 severity of the illness, the need for specialized equipment
12 and technology, the complexity of clinical judgment
13 needed to design, implement, and evaluate the patient
14 care plans and the ability for self-care, and the licensure
15 of the personnel required for cane.
16 (o) "Critical care unit" as used in this section means a
17 unit that is established to safeguard and protect patients
18 whose severity of medical conditions requires continuous
19 monitoring and complex intervention: by licensed
20 registered nurses.
21 (d) All health facilities licensed under subdivision (a),
22 (b), or (f) or Section 1250 shall adopt written policies and
23 procedures for training and orientation of nursing staff.
24 (e:) No registered nurse shall be assigned to a nursing
25 unit or clinical arca unless that noise has first received
26 orientation in that clinical area sufficient to provide
27 competent care to patients in that area, and. has
28 demonstrated current competence in providing care in
9 that area.
30 (f) The written policies and procedures for orientation
31 of nursing staff shall require that all temporary personnel
32 shall receive the same amount and type of orientation as
33 is required for permanent staff,
34 (g) Requests for waivers to this section that do not
35 jeopardize the heath, sarfety, and well-being of patients
36 affected and that are needed for increased operational
37 efficiency may be granted by the departrwnt to rural
38 general acute care hospitals meeting the criteria set forth
39 in paragraph(2)of subdivision(a) of Section 1250.
MAY-19-1999 11:37 925 335 1099 P.05
.�. AB 394
1 (h) In cue of conflict between this section and any
2 provision or regulation defining the scope of nursing
3 practice, the scope of practice provisions shah control.
4 SEC. 4. No reimbursement is rewired by this act
5 pursuant to Section 6 of ,Article XM B of the California
6 Constitution because the only costs that may be incurred
7 by a local agency or school district 'willl be incurred
g because this act creates a new crime or id=dM
eliminates a crime or infraction, or changes the penalty
10 for a crime or infraction, within the meaning of Section
11 13556 of the Government Code, or changes the definition
12 of a crime within the meaning of Section 6 of Article
13 M B of the California Constitution.
0
T 'AL P.06
P.06
�'?PY-19-5.99'9 11:38
925 335 10599 97i
CALIFORNIA
NURSES
ASSOCIAMN
Sh*ng 7bmorraw'r Health Carne
www.ednurw..org
May 17, 1999
Donna Gerber
Berard of Supervisors
Contra Costa.County
Dear Donna:
The safe staffing bill AB394 outlines minimurn nurse-patient ratios. We have asked the
Berard of Supervisors to endorse this staffing bill which would take an enormous step in
guaranteeing safe staffing and preventing cutbacks against nursing staff that lead to a
decrease in quality and safe care.
Some questions have arisen regarding the current staffing at Contra Costa Regional
Medical Center. Here are the xninimurn ratios hospitals would have to comply with:
Medical Surgical: One nurse for every six patients(CCRMC.One to 4-5)
Specialty Care and Telemetry: One Nurse to four patients(CCRMC.One to 3-4)
Labor&DefiverylPACUICrftft;ad patients to ER., One nurse to two patients(CCRMC.One to 2)
OR: One nurse circulating for each OR(CCRMC.same)
Pediatric: One nurse to three patients(CCRMC.same)
As it stands,CCRMC is basically in compliance with the proposed bill. There have been
incidents where these ratios were not maintained, but those incidents occur infrequently.
I have included a"questions and answers"fact sheet in case you have more questions
regarding the bill. Please call me if you or any of the Heard members have any questions
at(510)273-2277.
Sin
Francisco U arte
Labor Representative
7 CNA OAKLANn M CNA SACRAMENTO -0 CNA SAN JOSE C CNA FRESNO Q CNA SANTA MONfCA 0 CNA SAN 1361: -0
TMADQUAMZ ERS 1100 lash,Ste 205 101,Race S=et M Box 27317 3350 Ocean P"Dfvd 3611 5th Ar Ste a
2000 FsankUa St.Si*:3011 Saermatto,CA 45634 Sit Jog--.CA 95 i26 Ffemo.CA 931M Ste 3115 San 19iep,CA 42103
Oakland.CA iA4612 (916)446-5UZ1 (409)920-0290 (204)201-9571 SWIM Monica,to 905 (514)299-313;
(S 10)2,73-22un Fix(916)436-6314 fax(iMAJ 5:20-0362 Fax(209)261-9572 (310)66"369 Fax(614)2919-15543
F"(53(1)wl-1535 Fax(310)664-5375
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MEMCALUCMIA
Nurm
AssMATION
Questions and Answers about AB 394,the Safe Staffing bill
What does AB 394 do?
AB 394 would require minimum nurse to patient staffing ratios for all acute cam
facilities.It would also limit the inappropriate use of unlicensed personnel in all.
California hospitals.
Why is AB 394 needed?
California rates last in the U.S.in the per capita proportion of registered nurses(RNs)to
patients,Unsafe staffing levels in California hospitals are placing patients at risk and
prompting beleaguered nurses to leave hospital.nursing.AB 394 would reverse the trend.
Numerous studies document a direct link between nursing care and patient safety. for
example,a study by the Agency for Health Care Policy and Research fast December
reported that one additional hour of RN care cuts a patient's risk of a urinary tract
infection by nearly 10%and the risk ofpneumonia by 8%.
Doesn't California presently have a nursing shortage?
The current shortage is the result of a decade of downsizing and deskilling as the hospital
industry has become dominated by corporate chains more focused on market goals than
in ensuring patient safety.California has more than 284,000 registered nines and tens of
thousands of licensed vocational nurses. Thousands have been laid off Hospitals have
also cut specialty arra training programs to prepare new graduate and generalist nurses to
work in opemtion rooms,labor and delivery,emergency departments,and critical care
units,areas where the greatest shortages have occurred.Many Beed nurses are now
working in temporary position or for registry agencies where they can choose to work i
hospitals that have safer conditions. Others have left hospital nursing due to inadequate
staffing or other safety concerns.
With the shortage, won't AB 394 make it more difficult for hospitals to hire sufficient
nursing staffl
No. AB 394 will reverse the deterioration of safe staffing standards in hospitals,
providing more protection for patients and encouraging more nurses to return to hospital
nursing.Additionally,CNA.is sponsoring,complementary legislation,including AB 389
would provide funding for 6-8 week programs in our community colleges to train RNs to
work in specialty care areas where the shortages are greatest,including critical care,
obstetrics,pediatrics,neonatal intensive care,and operating rooms.
t
J -01--:999 35:56 134% P,05
K%at are the current staffing regulations?
In the early 1980s,the California legislature required specific staffing ratios for licensed
nines to patients for intensive care units due to a need to assure patient safety in critical
care hospital wards.No specific ratios exist for other hospital.areas. Hospitals are simply
required to establish patient classification or"acuity" systems to determine staffing needs.
Don't patient classification systems assure that hospitals are appropriately staffed?
No. Patient classification systems currently in use are commercial products that use
secret,proprietary methods for determining how many staff will be assigned. The
systems typically permit manipulation of staffing and the mix of licensed and unlicensed
staff to meet financial targets,rather than individual patient care heeds.The system are
typically concerned with the fiscal costs of patient care,not just the clinical validity of
identified patient needs.RNs frequently report that individual patient illness is often
ignored,and staffing decisions are made on the basis of patient census tied to budgetary
considerations.
Doesn't the state ensure that hospitals are using these systems to ensure safe staffing?
Enforcement by the state Department of Health Services is inconsistent. Frequently,the
presence on gaper of a system is deemed to be sufficient to conform to state
requirements. The divergent mature of the commercial patient classification systems,the
ability of hospitals to manipulate the data,and the private criteria the hospitals use for
determining patient illness make it extremely difficult to maintain uniform enforcement.
Only in intensive care units,which have specific minimum nurse to patient ratios, do
DHS inspectors address complaints of inadequate staffing,consistently.
Won't staffing ratios limit the flexibility hospitals need?
Marty hospitals abuse the flexibility they now have,posing a risk to patients.An example
is St.Joseph Hospital in Orange where after newborn baby was sent home with the wrong
parents in February, 1999, the hospital admitted it's postpartum unit has been under
staffers for six months and that it has fair to follow its own staffing system. This highly
publicized incident shows that even in a hospital with a patient classification system,
current regulations are inadequate.
One-fourth of RINs responding to a 1997 ,survey by the California Board of Registered.
Nursing expressed dissatisfaction with inadequate staffing,increased workload, and said
there are not enough RNs for the number of patients they are assigned.
How were the ratios in AR 394 deterrrmined?
The specific ratios are based on unit by unit CNA surveys of RNs who provide care for
patients in California.hospitals every day of the year. The ratios are, in fact,moderate. A
number of California hospitals already meet or emceed the standards in AB 394,
2
JUN-01-1999 15:57 98% P.06
Won't AB 394 cost California hospitals hundreds of millions of dollars
Cost projections made by the California hospital industry are wildly inflated,used on
inaccurate projections of current pay scales for registered nurses and licensed vocational
nurses. Ironically,the projections made by the industry demonstrate their,assumption that
their own hospitals are dangerously under staffed. In fact, a number of hospitals,
especially children`s hospitals,already meet the minimum standards established d in AB
394 and will incur no additional cost under the bill.
Additionally,hospitals will accrue cost savings as a result of safe staffing levels.
Numerous studies have demonstrated that appropriate staffing levels not only lead to
improved patient outcomes,but also actually reduce casts by cutting in hospital mortality
rates, infection rates, lengths of stabs, and patient re-admissions. Finally,assurance of
safe staffing standards will assist hospitals in maintaining regular RN staffing cutting
enormous resources now spent our hiring agencies to provide temporary and even out of
state nurses who have little or no familiarity with the community's hospitals,patients,and
other staff`and state regulatory requirements.
Won It AB 394 lead to service gaps by requiring hospitals to lay r,,ff unlicensed aides and
replace them with licensed nurses?
Hospitals who make this argument are conceding that they have hired unlicensed staff to
displace licensed professional caregivers. That abuse is one of the reasons why AD 394 is
needed. DHS inspectors at a Sauna Rosa hospital last year,for example,found incidents
of an unlicensed technician suturing tissue,cutting bone,closing;wounds,pounding
metallic devices into bane, and placing clamps in the operating room.Safe hospital care
rrequuir% adequate levels of all personnel.AB 394 merely requires that unlicensed
personnel perform hospital nursing case duties as authorized by state law,under the direct
clinical supervision of a registered nurse.
Which legislators sponsored AB 394?
AB 394 is authored by Asscmblyrnember Sheila Kuehl. Co-authors of the bill include
Sete President Pro-Tem.John Burton,Assembly Speaker Antonio Villaraigosa, Sen.
Martha 1"scutia who chairs the Senate Health Committee, and Assemblymernber Martin
Uallegos,chair of the Assembly Health Committee_
3
.�UN-O i--i 999 15!57 93�: P..07
FACT SHEET ON R.Ns AND SAFE STAFFLN -- 1999
a California is at or near the bottom in the United States in patient access to registered
nursing care, according to the 1998 Dartmouth .Atlas of Health Cure, published by the
American Hospital Association and the source of much of its data. All but one of 24 listed
statistical areas in California,fall below the national average in RNs, and eight regions are among
the worst in the nation. Bronx and Manhattan, N. Y, Detroit, and New deans have more than
twice the average of RNs to patients than Contra Costa,San Jose, Santa Rosa, Santa Cruz, San
Mateo, and Palm. Springs.
u Following an incident in February, 1999 at St. Joseph Hospital in Orange,where a newborn
baby was sent home with the wrong parents,the hospital admitted that its postpartum care
unit has been understaffed for six months. The hospital conceded it has not followed its own
internal staffing standards and requirements.
u St.John's Medical Center in Oxnard shut dawn a 31-bed unit in March, 1999 because
of an inability to maintain safe nursing care levels. The closure occurred despite record
numbers of patients at the hospital.
u California's Department of Health Services cited Columbia Good Samaritan Hospital in
San Jose in February, 1999 for numerous unsafe staffing violations.
The hospital"failed to take all reasonable steps to conform with state taw" to meet safe
staffing rations in Coronary Intensive Care "over an extended period sof time."
' Failure by the hospital administration"over an extended period of time to assure a staffing
plan was implemented for each patient care unit bid on patient cage needs. Such failure
has, and does plane Medical Surgical Intensive Care Unit pediatric patients at ongoing
risk/jeopardy."
Failure to observe physician orders and provide appropriate levels of patient care in
MSIC due to an "insufficient number of MSIC nurses" with required pediatric intensive
care.Moreover,the hospital's CEO and chief of nursing operations "have been aware of the
existing deficit of nurses with PIC skills for at least 2 years."
u One extra hour of registered nursing care per surgical patient per day cuts a patient's risk
of contracting a urinary tract infection by nearly 10% and the risk of pneumonia by 8%.
That's according to a study in December, 1998 by the Agency for Health Cam Policy and
Research,an arm of the U.S. Health and Haman Services Department. The researchers looked.
at 506 hospitals in 10 states, including California, using,American Hospital Association data.
a Numerous studies in the 1990s and early 1990s,a period in which RNs typically comprised
at least 80% of nursing staffs, documented a direct correlation between safe RN staffing
levels on tower mortality rates and other positive patient outcomes. Among the findings,
analyzed by Patricia Prescott, RN, Ph.D., in,Nursing Economics in 1993:
-/ Thirteen studies -- including one that looked at 8,593 high risk surgical patients in 17
JUN-01-1999 � P.08
hospitals, another at 5,030 patients front 13 hospitals, and another at 42,773 patients --
shored hospitals with higher RN to patient ratios had fuer deaths:
V One study of 700 seniors documented that patients in shorter staged units had higher re-
hospitalization rates after discharge.
Several studies linked greater RN to patient ratios to increased patient satisfaction,
quality of life after discharge,knowledge and compliance in treatment, and fuer in
hospital complications.
Virtually all the studies demonstrated decreased casts and safer shorter patient stays
associated with safer RN staffing levels.
u Kaiser Permanente was cited three titres in the summer of 1998 by the California
Depart hent of Health Services for the unsafe and illegal use of unlicensed staff`on
patients during surgery. DHS inspectors at Kaiser Santa Rosa found incidents of an
unlicensed technician suturing tissue, cutting bone, closing wounds,pounding metallic
devices into bone, and placing clamps.(Santa Rosa Press Democrat August 18, 1998). In
one case, an unlicensed orthopedic assistant was seen placing a retractor directly in a total hip
wound, an action, the DHS citation noted, 'Is dangerous since a person other than a surgeon
might not know where the nerves are and where to place the retractor. A retractor(an
instrument used to hold back tissue)could cause nerve damage if improperly placed,
especially during total hip surgery.,.
a Eight of ten hospitals that have launched restructuring programs have cut Rhys and other
staff, according to a Cornell University Study, using American Hospital Association data,
published in Hospitals & Health Networks magazine July 20, 1998.
u In a 1996: national survey of 7,500 RNs by Boston College School of Nursing Assistant
Professor Judith Shindul-Rothschild,RN,p`h.D,,60% noted a reduction in the number of RNs
providing direct care,40%reported substitution of unlicensed personnel for RNs. The study
found disturbing increases in unexpected patient re-admissions, complications, medication
errors,wound infections,patient injuries, and patient deaths.Two of five RNs said they would
not recommend a family member receive care in their facility.
u Under staffing has put their patients at risk,say 76% of hospital-based RNs responding to
a survey by RN magazine published in February 1999. Two of five said they encounter a
dangerous short staffing situation on a weekly basis, 13% say it happens every day, 24%
say it occurs once a month. 82% said that short staffing has forced them to provide care with
which they are not satisfied. Nearly 40% said their hospital has hired Unlicensed Assistive
Personnel(UAP)to perform nursing care duties; 55°1 of those respondents say the UAPs get
three weeks or less of training.
u Two-thirds of California RNs responding to a 1997 surrey by California Board of
Registered Nursing reported working forced overtime. One-fourth of the 4,000 respondents
voiced dissatisfaction with inadequate stag,increased workload and said there are not enough
RNs for the number of patients they are assigned.
J�?t- 1-1999 15:58 P.09
u An internal mento at Mercy Healthcare Sacramento in July,1998 documented an"ever-
increasing number of vacancles" that it could not fill. A major problem identified was the
voluntary departure of hundreds of RNs. in exit interviews, many said they were leaving due
to staffing that was `unsafe; too mach required; not enough staff."
o Centers for Disease Control and Prevention in Atlanta studies.have limed improved nurse
to patient ratios and lower hospital outbreaks of bloodstream infections.
a A March/April 1998 report in Nursing Economics"Linking Outcomes to lees'Roles in Health
Care" found "outcomes associated with nurses' independent role functions included the
prevention of complications,(positive)clinical outcomes, (patient) knowledge of diseases
and treatments,satisfaction and cast outcomes."
0 A 1994 Gallup poll found that two-thirds of Americans surveyed believe a reduction in R'Is
on a hospital floor mould have a negative effect on the quality of care provided. 840/0 said
they would choose a hospital that had a smaller nurse to patient ratio over a tamer ratios.
u A survey of RNs at Sutter Roseville hospital in 1997 found that in medical and surgical
units where restructuring was Implemented three years earlier, 86"1` of the nurses
experienced a decline in the duality of came on their unit, 68% said their unit was usually
understaffed.,94%said they had less direct contact with patients,and 95% said their unit.newer
or rarely staffs on the basis of patient illness as required by law.
o A study in Switzerland, reprinted in the journal Critical Care Medicine in November 1995,
documented a connection between better RN to patient ratios and weaning some of the
sickest intensive care unit patients from mechanical respirators. Patients with severe
respiratory illnesses were able to forego respirators, and return home, sooner.
u A 1994 study by Linda Aikm Ph.D., and her University of Pennsylvania School of Nursing
colleagues found that magnet hospitals that empower Rids to adequately use their
professional skills had a 7.7% lower mortality rates than did hospitals which did not place
the same emphasis on nursing care.
n The percentage of U.S. medical care workers doing mostly paperwork skyrocketed from
18 to 27% of total health employment whine the proportion of nursing and physician
personnel fell from 51% to 44%, over the past 25 years, according to an article in the
February, 1996 issue of the Journal ofPublic Health.
u Unmarried poor mothers regularly visited by licensed nurses were less likely to have
substance abuse problems,entanglements with police,or other problems, according to a 15
year study by the University of Colorado published in the Journal of the American Medical
Association in 1997.
JUN-01-1999 15:59 ?. 10
u Joint federal and state investigations of four Kaiser Permanente hospitals in Contra Costa
and Alameda counties In 1997, prompted by a series of patient deaths, complaints about
inadequate care,and delays in transfers to other facilities documented repeated problems with
inadequate RN staffing. Findings included.
EIS waits "increased by the failure of the hospital to provide nursing staff to care for
patients who required admission."The Quality Assurance Director told investigators, "If
there are no staff,them are no beds."
Short staffing in Labor and Delivery, including failure to meet the hospital's oven stated
staffing criteria„posing"a significant potential danger to mothers and babies. Patients
requiring out to one monitoring are aot getting it"
RNs expected at one hospital to provide care for 115-152%of their patient assignment, "a
physical impossibility."At 150%that would mean they would have to provide 12 hours of
care during an 8-hour shift.
ci Kaiser Pente's Northern California nurse recruitment manager tori Nie Week in February
1998 that"the recruitment infrastructure was demolished during downsizing,and vire had
several years of not providing opportunities to new grads, it's bind of like nature, you can't
reproduce during a drought."Ateordi Dg to a duly 28, 1998 internal memo,Kaiser cut its RN
staff by 14% in Northern California prior to seeking new hires.
a A survey by a contractually established RN professional practice committee at Columbia/HCA
Good Samaritan Hospital in San Nose in 1997 documented a sharp rise in the filing of
reports by RNs who were objecting to assignments that were unsafe to the nurse, her
paflcnt,or both.Most of the reports concemmed short staffing,and a substantial number involved
the use of inappropriate or inexperienced personnel.
u When a New York hospital began running advertisements in 1996 that promoted the fact
it had shifted to a 92%RN nursing staff it was swarmed with favorable public responses.
The ad cautioned readers"don't assume your nurse is a real nurse."
u An analysis by Rd's at Children's Hospital Medical Center in Oakland in 1995 found that
In the two years following a 20% replacement of RNs with unlicensed staff'in hospital
infection rates more than doubled in general medical wits. In intensive care units,which have
nursing to patient ratios,the number of infections for that same period decreased.
o 1n testimony to the Institute of-Medicine's Committee on Adequacy of Nursing Staffing in 1994,
CNA's Director of Nursing Practice & Patient Advocacy Hedy Dumpel'provided numerous
detailed incidents by patients and RSIs in which unsafe staffing had led to patient harm or
"near misses."As the incidents document,many of the"near misses"have become tragic
outcomes.
March 26, 1999
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