Spotlight Case

1. Spotlight Case Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care

2. Source and Credits • This presentation is based on the August 2009 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME/CEU credit is available • Commentary by: Victoria Rich, RN,PhD, University of Pennsylvania School of Nursing • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Mary A. Blegen, RN, PhD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand the context for and processes that hospitals use to design nurse staffing plans • Describe the licensing and regulatory constraints that shape staffing plans • Appreciate system capacities for covering sudden changes and overload situations

4. A 68-year-old man was admitted to the ICU with COPD exacerbation and atrial fibrillation with rapid ventricular response. Alert and oriented but frail, the patient was markedly short of breath and only able to speak in short sentences. Providers were concerned that he might require mechanical ventilation. In the ICU that night, two nurses had called in sick, and only one patient care assistant was scheduled for this weekend shift. Due to short staffing and inability to locate a last-minute replacement, each existing nurse was assigned three patients rather than the usual two. Case: Nurse Staffing Ratios

5. When RNs working on hospital units become ill or otherwise unable to work their assigned shifts, the patient-to-nurse ratio may suddenly increase When number of patients assigned to an RN increases there can be more complications, higher morbidity, more errors, and higher costs of care Shortages of RNs: Impact on Care See Notes for references.

6. Reports from IOM, NQF, and ANA have emphasized importance of adequate nurse staffing to provide safe, high quality care Several state and national groups are collecting standardized measures of nurse staffing, including: National Database of Nursing Quality Indicators (NDNQI) Collaborative Alliance for Nursing Outcomes (CalNOC) Efforts to Standardize RN Staffing See Notes for references.

7. Initiatives for Nurse Staffing • 12 states and the District of Columbia have legislation or regulations to directly address nurse staffing levels • 15 states have restrictions on mandatory overtime See Notes for references.

8. The American Nurses Association’s Nationwide State Legislative Agenda NURSE STAFFING PLANS AND RATIOS ME* WA MT ND VT NH MN NY OR MA WI CT RI ID SD MI WY PA NJ IA NE OH MD DE NV IN IL wv UT DC VA CO CA MO KS KY NC TN SC OK AR AZ NM GA AL MS AK TX LA FL Enacted legislation/adopted regulations to date: (12 states plus DC) CA, CT, DC*, IL, ME*, NJ, NV, OH, OR, RI, TX,, VT, WA * legislation was either waived or modified from that which was enacted Introduced in 2008-9; (17 states): AZ, CA, CT, FL, IL, MA, MI, MN, MO, NV, NH, NJ, NY, OR, PA, TX, WV HI June 2009

9. The American Nurses Association’s Nationwide State Legislative Agenda PROHIBITION OF MANDATORY OVERTIME ME WA MT ND VT NY NH MN OR MA WI ID SD CT RI MI WY PA IA NJ NE OH MD NV DE IN IL UT wv VA DC CO CA KY MO KS NC TN SC OK AR AZ NM GA AL MS AK TX LA FL Enacted legislation/adopted regulation to date 15 states; (12 states): CT, IL, MD, MN, NH, NJ, NY, OR, PA, RI, WA, and WV. ( 3 states) have provisions in regulations: CA, MO and TX Introduced legislation in 2008-9; (11 states): AK, IL, MA, NC, OH, VT, WA, & WI; MI, NY, TX included in staffing bills. HI March 2009

10. Directives for Nurse Staffing • State nursing license boards, The Joint Commission, and the Centers for Medicare & Medicaid Services (CMS) all have standards designed to help assure adequate nurse staffing

11. Hospital nursing departments develop a staffing plan for each budgeting cycle Planning involves nurse leaders, staff nurses, physicians, hospital administrators, financial officers, patients, and families The plans take into account patient volume and acuity, regulations, benchmarks, and nursing skill mix and experience Hospital Staffing Plans

12. Nursing care units plan monthly staffing and scheduling templates based on their budget Primary criteria Patient acuity and volume Skills, competencies, and experience of nurses on unit Recommended patient-to-nurse ratios: 4-5 patients: 1 RN on medical/surgical units 3-4 patients: 1 RN on intermediate units 1-2 patients: 1 RN on intensive care units Staffing Patient Care Units See Notes for references.

13. The nurse implemented the initial orders as the patient was stabilized on a diltiazem drip for his atrial fibrillation. The patient’s respiratory status stabilized: he avoided the need for non-invasive ventilatory support and intubation. He began to transition to intermittent, rather than continuous, nebulizer treatments. Case: Nurse Staffing Ratios (2)

14. Case: Nurse Staffing Ratios (3) Within 30 minutes, a second patient was transferred from the ED with hemodynamic instability from a massive pulmonary embolism. Since the patient with COPD appeared to be improving rapidly, and the other nurses were caring for more critically ill patients, the same nurse volunteered to admit the new patient. 14

15. While the nurse was tending to orders for the new admission, the COPD patient began urgently insisting for help to get up to go the bathroom, rather than using the bedpan. The nurse quickly assisted the patient to the toilet and called for a patient care assistant to transfer the patient back to his hospital bed. The nurse then rushed to the bedside of the acutely ill patient with the pulmonary embolism. Case: Nurse Staffing Ratios (4)

16. Case: Nurse Staffing Ratios (5) Approximately 5 minutes later, the patient care assistant arrived at the COPD patient’s toilet and found him slumped on the floor in the bathroom, with his oxygen detached from his face. The patient was unresponsive and cyanotic. A code blue was called. Despite extensive resuscitation attempts, the previously “stable” ICU patient was pronounced dead. 16

17. Unplanned Staffing Deficits • Danger points for shortages are weekend shifts and times of high ED census • Nurse unit leaders must anticipate changing staffing needs and assess at least 4-8 hours prior to next shift See Notes for references.

18. What Went Wrong? • In the case presented, it appears that nursing staff members were not supported to make difficult decisions that would have protected the patient and themselves • It also appears that the unit and hospital did not have a back-up plan to fill positions left empty by illness

19. It is vital that staff nurses on units have a voice in staffing decisions and unit work flow This is true both in developing the unit staffing plans and in hour-by-hour decisions made on the unit Empowering Staff Nurses See Notes for references.

20. Three resources should be in place: Centralized staffing office to assist unit leaders to adjust daily staffing Shift coordinator who can adjust staffing across units for each shift Resource pool of RNs who can be flexible in their working hours to adjust for slack times and busy times Responding to Last-Minute Staffing Changes See Notes for references.

21. Take-Home Points Best Practice Options for Nurse Staffing Ratios Include: • Conduct failure mode effect analysis on nurse staffing for each unit to develop strategies for when staffing levels are not adequate • Create an internal resource pool for flexibility and census adjustments • Communicate all action plans to staff nurses on unit as well as interdisciplinary and administrative stakeholders

22. Take-Home Points (2) • Administer annual nurse satisfaction survey to assess whether nurses find staffing plan safe and adequate • Empower staff nurses to identify solutions for staffing issues. Involve staff nurses in staffing decisions made for budgetary purposes • Benchmark staffing ratios annually with other facilities and correlate with data about patient outcomes, adverse events, and root causes • Evaluate patient satisfaction feedback closely and correlate with nurse staff plan 22