Staffing Ratios & APRN Practice

Mohamad Ata, MS RNRush University Medical Center

02/01/2015

Does this Sound Familiar?

• “Bob is low-censused, but Jane just called in sick. Now we’re expecting three new admissions and that patient is coding.”– You, the RN, are forced to put in extra work– You fall behind, leave late, or make a mistake– Then you’re blamed for not being efficient

• Before long, the RN is written up and is looking for a new job… where the same thing happens

US Legislation

• California is the only state with comprehensive patient to nurse (PTN) staffing laws that apply to all units

• Other states require hospitals to have staffing committees responsible for staffing– IL, CT, NV, OH, OR, TX, WA

• Others considering legislation: DC, NY, TX, FL, IA, MN

• (Nurse Staffing Plans & Ratios, 2014)

Significance of the Issue

• Reports showed that each patient added to RN workload led to an increase in mortality by 7%, following common surgeries

• Research also shows that increased RN levels led to a decrease in mortality in patients who had an acute MI

• Mortality reductions associated with increased PTN were most significant in hospitals that were already severely understaffed

• Reduced workload led to higher staff retention and lower turnover– Leads to decrease in overhead and training costs

• (Aiken, et al. 2010)

Is it Cost-Effective Legislation?

• Hospitals complain about being already squeezed and adding another nurse increases costs

• 8:1 PTN was associated with the lowest cost, but highest in mortality. Every decrease in patient increment by one, led to lower mortality, but higher costs

• Cost associated with saving one life when PTN reduced to 7:1 was over $45,000. Cost associated with saving one life when PTN reduced to 4:1 was over $140,000.

• Research shows that lower PTN ratios does NOT save money, but costs less than any other patient safety intervention

– For example, thrombolytic therapy or a PAP testing costs exorbitantly more ($180,000 per life saved and $430,000 per life saved, respectively) than reducing staffing costs

– If a hospital decided, for economic reasons, to stop providing thrombolytic therapy or PAP testing, physicians would never refer to that hospital.

– Lower PTN is a patient safety intervention, and when compared to other safety interventions is actually still more cost effective.

• (Rothberg, et al. 2005)

The Quality of Care

• Physicians agree that deficient nursing staffing results in decreased quality of care

• Staffing shortages led to RN burnout in 40% of hospitals– Job dissatisfaction in hospitals is 4x higher than the average US

worker– 1/5 nurses intend to leave their job

• Increased emotional exhaustion and increased job dissatisfaction in nurses correlated with increased PTN

• 168 hospitals in Pennsylvania found:– RNs in hospitals with 8:1 PTN were 2.29x more likely than 4:1

ratio to show emotional exhaustion and 1.75x more likely to be dissatisfied

• (Aiken, et al. 2002)

NJ S. 1257- PTN in New Jersey

• Synopsis: New Jersey state assembly bill, introduced January 30, 2012, which institutes minimum RN staff standards for hospitals and other healthcare facilities

• Highlights:– 5:1 PTN medical-surgical units– 4:1 PTN stepdown, telemetry, or immediate care– 1:1 PTN for trauma services in the ED– 1:6 PTN psychiatry units– Facilities must utilize a staffing system to ensure appropriate staffing

• Desired outcome: – Improved quality of care and improved patient safety via

improved PTN ratios– This bill would be associated with improving access to care and

the costs mentioned earlier that are associated with PTN issues• (S. 1257, 2012)

S. 382- Improving Access to Care: APRN Scope

• Synopsis: Senate bill, introduced February 26, 2013, amends title XVIII (Medicare) to broaden PA, NP, & CNS scope of practice

• Highlights:– These clinicians can supervise cardiac, intensive cardiac, and

pulmonary rehabilitation programs

• Desired outcome:– This bill would increase access to care for all patients, but

especially in rural areas, and addresses primary care shortage– The bill would widen the scope of APRNs, giving them more

knowledge, more autonomy, and more respect in the healthcare industry

• (S. 382, 2013)

Reference ListA bill to amend title XVIII of the social security act to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary

rehabilitation programs, S. 382, 113 th Cong. § 1 (2013)

Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA: The Journal of the American Medical Association, 288(16), 1987-1993.

Aiken, L., Sloane, D., Cimiotti, J., Clarke, S., Flynn, L., Seago, J., ... Smith, H. (2010). Implications Of The California Nurse Staffing Mandate For Other States. Health Services Research, 904-

921.

Establishes minimum registered professional nurse staffing standards for hospitals and ambulatory surgery facilities and certain DHS facilities. S. 1257, 112 th Cong. (2012)

Nurse Staffing Plans & Ratios. (2014, December 1). Retrieved February 1, 2015, from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative- Agenda-Reports/State-StaffingPlansRatios

Rothberg, M., Abraham, I., Lindenauer, P., & Rose, D. (2005). Improving Nurse-to-Patient Staffing Ratios As A Cost-Effective Safety Intervention. Medical Care, 43(8), 785-791.

Reference ListA bill to amend title XVIII of the social security act to allow physician assistants, nurse practitioners, and clinical nurse specialists to supervise cardiac, intensive cardiac, and pulmonary

rehabilitation programs, S. 382, 113 th Cong. § 1 (2013)

Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA: The Journal of the American Medical Association, 288(16), 1987-1993.

Aiken, L., Sloane, D., Cimiotti, J., Clarke, S., Flynn, L., Seago, J., ... Smith, H. (2010). Implications Of The California Nurse Staffing Mandate For Other States. Health Services Research, 904-

921.

Establishes minimum registered professional nurse staffing standards for hospitals and ambulatory surgery facilities and certain DHS facilities. S. 1257, 112 th Cong. (2012)

Nurse Staffing Plans & Ratios. (2014, December 1). Retrieved February 1, 2015, from http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative- Agenda-Reports/State-StaffingPlansRatios

Rothberg, M., Abraham, I., Lindenauer, P., & Rose, D. (2005). Improving Nurse-to-Patient Staffing Ratios As A Cost-Effective Safety Intervention. Medical Care, 43(8), 785-791.