Battle for Ratios at Tufts Medical Center

Work intensification has become one of the major problems in advanced market economies. It is an especially serious problem in health care. At a time of increased preoccupation with cost control and profit maximization, demand for health-care services is growing dramatically. In such a context the pressure for doing more with less becomes overwhelming and irresistible. Nurses have learned that managers who might otherwise have fought to give patients more nursing care and nurses more support on the job find it impossible to resist the pressure to cut, cut, cut. We saw this in the 1990s, when after a decade of denying that nursing cuts were rampant and that this compromised patient safety, Massachusetts General’s Chief Nursing Officer Jeanette Ives Erickson, candidly confessed on an NPR documentary that “we couldn’t cut them fast enough.” That is precisely what is happening in hospitals all over the country and here in Massachusetts.

Over the past decade over 60 studies have documented the connection between nurse staffing and patient mortality, thus failure to rescue and adverse patient outcomes. In my book Safety in Numbers: Nurse to Patient Ratios and the Future of Health Care, my co-authors and I analyzed over 60 studies. Since its publication more studies have come out and have documented this connection. In 2008, an article in the New England Journal of Medicine explored how long it takes caregivers to respond to patients with ventricular arrhythmias. The study looked at 6789 patiens who had a cardiac arrest due to ventricular arrhythmia or pulseless ventricular tachycardia at 369 US hospitals. After identifying these patients, researchers looked to see overall median time to defribilation. Turns out delayed defibrillation (more than two minutes to defibrillation) occurred in an amazing 2045 patients. Of those who had delayed attention, fewer survived to hospital discharge.

We know that patients who are defibrillated immediately – here literally seconds count– do better. These are the recommended guidelines. Yet 30.1% of patients in this study didn’t get care that conforms to the guidelines. Why not? Researchers found a number of things that affected quality of care: if patients were black, if they had a non-cardiac admitting diagnosis, if they were in a small hospital and – most importantly – if they developed problems at night or on the weekend. In commenting on the study, observers noted that the worst time to have a cardiac arrest in a hospital was when units had less staff – i.e. nursing staff on them. If a patient is not hooked up to a cardiac monitor that screams out an alert, they can get into trouble. Nurses are so busy they don’t have time to keep their eyes on the patient enough of the time and thus can’t detect problems and respond to them. This is the classic definition of failure to rescue and another example of why having enough nurses in hospitals – at all times– is so critical.

Then came a study of MRSA in the Lancet that was even more interesting and disturbing. Here again researchers studied one of the most important infection control interventions – hand-washing to prevent one of the worst hospital borne infections. The article made clear that under-staffing and overcrowding are breeding grounds for MRSA. Hospitals that are too worried about rushing patients in and out of their units and that are trying to save money by hiring less nursing and other staff put patients at clear risk for this dreadful infection. The places the study targeted were Australia, where there has been a 40% decreased in public hospital beds, and the UK, Canada, the USA and the Netherlands. In the UK bed reductions have been accompanied by higher patient admissions. Patients are rushed through the system but with less nurses to care for them. When this happens, the indicators for the need for hand washing go up while staff actually wash their hands less. “Transmission of MRSA and other (Hospital Acquired Infection) HAI-causing organisms has been shown to be greater during periods of understaffing, defined by a low health-care worker to patient ratio…” What is more, when health care workers have too many patients, the study showed they washed their hands less because too much hand-washing caused skin- irritation even with new gels. Perhaps the most interesting finding was that too many patients and too few staff leads to what is identified as “organizational fatigue, “ – “which related to overburdening of staff and facilities during periods of high bed occupancy and workload.” It’s what nurses constantly tell me. Yes, they know they should wash their hands but after eight hours on the job, rushing from patient to patient, they just don’t all the time. They are too wiped out to wipe up. So once again, we have proof from all over the world that not having enough nurses and other care providers who have enough time and decent patient loads kills patients and demoralizes nurses.

@font-face { font-family: “Courier New”; }@font-face { font-family: “Times”; }@font-face { font-family: “Cambria”; }p.MsoNormal, li.MsoNormal, div.MsoNormal { margin: 0in 0in 0.0001pt; line-height: 24pt; font-size: 12pt; font-family: “Times New Roman”; }h1 { margin: 0in 0in 0.0001pt; font-size: 24pt; font-family: “Times New Roman”; }span.Heading1Char { font-family: Times; font-weight: bold; }div.Section1 { page: Section1; }

Finally,on March of 2011, the New England Journal of medicine published yet another study documenting the connection between nurse staffing and patient mortality entitled just that Nurse Staffing and Inpatient Hospital Mortality. Again the conclusion of this retrospective observational study funded by the Agency for Healthcare Research and Quality. staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.

Again the conclusion of this retrospective observational study funded by the Agency for Healthcare Research and Quality. staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.

In 1999, we learned that almost 100,000 patients die a year in American hospitals. That’s four times the amount of people who have died in the recent Japanese tsunami, and it happens every year. Recent studies have documented that since the famous IOM study to Err is Human was released in 1999, there has been little progress in reducing harm in American hospitals. In Mid April, of 2010, the Agency for Healthcare Research and Quality, released a report that compared rates of bloodstream infections between 2009 and 2010. The 2010 rate of bloodstream infections, the agency reported, increased by 8 percent in one year, while, in the same time period, catheter associated urinary tract infections had likewise increased (by 4 percent). There was good news, e.g., pneumonias were down.

Perhaps the reason why we are seeing so little progress despite a rash of patient safety innovations has to do with the fact that, all of these innovations depend on having enough bodies at the bedside. If there is not enough staff on the ward to take care of patients, they will not be able to respond to cardiac crises, they will not be able to clean their hands, they will , not be able get off the ward to attend a meeting or take advantage of educational opportunities that would improve patient safety . If there are not enough physical bodies, there will not be enough minds to innovate care at the bedside. Nor will there be enough voices raised to support–or suggest alternatives to–them. If they are taking care of six or seven or eight patients, nurses can’t take the ten or fifteen minutes needed to do the rounds with physicians and convey the critical information on which decisions about medical treatment and nursing interventions should be made. Without this kind of interaction, it is impossible for nurses to become full participants as well as fully respected members of the interdisciplinary team. Without enough nurses, both patients and nurses suffer unnecessarily. I have watched that professionally and experienced it personally as a patient who had the misfortune to be taken care of at night, and on a holiday weekend in a shortstaffed hospital and I am still suffering from a preventable complication that was a result.

Ellen Zane, CEO of Tufts Medical Center insists that she will not jeopardize the financial survival of her hospital by instituting safe nurse staffing ratios. She claims it will cost her hospital $33 million to staff up. My question – one she and all administrators should be forced to answer is : if they can’t afford ratios nurses propose what can they afford? If they can’t afford the appropriate ratios, how can they afford to spend millions on high priced consultants and $4 million on replacement nurses. Indeed, one question for Tufts is how much money has been spent during Zane’s tenure on hospital consultants, like Six Sigma, unnuecessay and replicative medical equipment and futile care? Zane says she is against nurse- to- patient ratios and wants complete management flexibility. Well, guess what, she already has them. In fact, the biggest secret in health care is that we already have total managerial flexibility in Massachusetts and this has, in fact, produced nurse to patient ratios – as in get away with whatever you can ratios.

Ask any nurse manager, and she will tell you that she receives a quarterly budget for her unit. (She does not receive a daily budget that allows her to add more nurses. In fact, nurses are constantly being told they have to leave the unit and go home if a patient is not in the bed) .Knowing how many beds are on the unit, she must allocate that money to pay for staff. This therefore ends up producing a certain number of nurses per a certain number of beds with patients in them. Whether you call it nursing hours per patient day, a staffing grid or ratios, ratios is what it is. In fact, since spending god knows how much to hire Six Sigma, the hospital has produced staffing grids that distinctly document that they have determined nurse-to-patient ratios per unit. These grids also document that, in many instances, the ratios of patients to nurse are going up not down.

The issue here is not whether we have ratios in our hospitals. The issue is whether we want to give hospital executives and managers unfettered discretion to come up with the ratio of patients each nurse will care for, or whether we want to make that process transparent and develop a mechanism to hold hospitals accountable for those decisions.

Although there is no scientific study documenting the perfect number of nurses on particular units, the evidence that better nurse staffing improves patient health is incontrovertible. We may not know what the perfect nurse-to-patient ratio is, but we certainly know what it isn’t. Nurses all over the country are fighting to protect their patients. As a patient, I certainly hope they win.

Leave a Comment