Lower Nurse Staffing Proposed

Gov. Arnold Schwarzenegger’s administration on Thursday proposed scaling back some of the strict nurse-to-patient ratios imposed on California hospitals earlier this year, citing the heavy financial burden the rules have placed on medical centers.

The ratios have been the subject of much debate since the Legislature approved them in 1999. Nursing unions strongly support the law and believe the ratios are improving patient care.

But hospital administrators have complained about the cost of complying with the law, and a survey by a hospital group found that the vast majority of medical centers were not in compliance with the ratios.

The law, which took effect in January, sets standards for the maximum number of patients that each nurse is allowed to care for at all times, based on the severity of the patients’ illnesses. In the operating room, for example, each patient should have his or her own nurse. In a medical-surgical ward, one nurse may take care of six patients.

But Sandra Shewry, California’s director of health services, suggested that emergency departments be exempted from the ratios when they experience unexpected surges of patients. Moreover, she proposed that the state delay implementation of a second phase of the law, which requires that the nurse-to-patient ratio in medical-surgical wards drop to 1 to 5 next year.

“These changes provide common-sense flexibility for hospital emergency departments and clarify language in current regulations,” Shewry said. “Because we do not yet understand the impact of these groundbreaking ratios on the state’s fragile healthcare delivery system, we must move forward cautiously.”

Officials said they thought it was urgent to revise the rules.

Eleven hospitals have said nurse-to-patient staffing ratios contributed to their decisions to close or reduce services, the state said. And 68 hospitals throughout California have petitioned the state Health Services Department for more flexibility to deal with the ratios or asked for the ratios to be waived because they are small, rural facilities.

Shewry stressed that she believed the changes, which must be approved by the state Office of Administrative Law, would still ensure patient safety.

But two of the state’s largest nursing unions -- the California Nurses Assn. and Service Employees International Union -- criticized the plan.

“We’re furious,” said Deborah Burger, president of the California Nurses Assn. “The cavalier attitude that Gov. Schwarzenegger is taking on this is really showing that he’s more concerned with hospital profits than about the safety of all of us who are going to be patients.

“This law took 10 years to be scrutinized, evaluated, researched,” she said. “There was a delay of implementation from the time it was signed into law in 1999 to 2004 so we could take everybody’s issues into account, including the hospital industry. And now, in the ninth hour, they’re coming in and changing these ratios without public input.”

The state said a public hearing on the changes probably would be held in mid-January.

About 85% of the hospitals in the state do not meet the nurse-to-patient ratios, according to the California Healthcare Assn., which represents hospitals.

“We have had documented instances all over the state of reduced access to patient care because hospitals can’t comply with the regulations,” said Jan Emerson, a spokeswoman for the association. “This announcement is a step in the right direction.”

Emerson said hospitals don’t have the funds to hire enough nurses to meet the ratios while also treating uninsured patients and footing the bill for state-mandated seismic improvements to medical buildings. She also pointed out that many hospitals can’t recruit enough nurses because of a national shortage.

Dr. Thomas Garthwaite, director of Los Angeles County’s Department of Health Services, said he had mixed feelings about the proposal.

“It certainly makes managing the hospitals and keeping hospital beds open and therefore not backing up the emergency room ... a lot easier to accomplish,” he said.

But, he added, “I certainly want to meet the safe ratio for nurses. The reason there is a nurse-ratio law is that several studies show that patients do better when the nurses are not overstretched.”

County officials said they were complying with ratios the vast majority of the time at their five public hospitals. But to do so, they often employ expensive “traveling nurses.”

Union officials said that hospitals across the state were exaggerating the costs of hiring more nurses and that their own survey found a majority of hospitals were in compliance.

“Right now the quality has improved [at hospitals] and waiting times have decreased,” Burger said. “With rolling back those gains, people will have to wait longer for their care, have to leave without getting the care they need.”

Shewry’s proposal also would move up a planned assessment of the effect of the ratios so her department could have the results by early 2007. Additionally, it would clarify the “at all times” part of the staffing requirement so that nurses who were in the unit, but making phone calls or going to the restroom, would count toward the ratio.

Tracey Veal, a vice president at the Northridge Hospital Medical Center’s Sherman Way campus, said the proposed changes have come too late to help her facility. The Van Nuys hospital will close Nov. 19, in part because it could not find the money to pay for more nurses.

But, she said the proposal could benefit many other hospitals. “It will take the chokehold off a little,” she said.

Veal estimated that an average hospital that paid an additional $250,000 a month to try to meet the ratio could save $50,000 a month.