Risky Ratio

Legislation to remedy unsafe nurse-to-patient ratios could be dead. Some patients could soon follow.  

By Angie Hargot

Jackson Memorial Hospital is one of few South Florida facilities with safe staffing levels for its 3,700 nurses. File photo

Martha Baker sat in a large, sparsely populated conference room at the Miami Beach Resort and Spa in January and talked frankly about a South Florida nursing shortage that could claim lives.

People could die, said Baker, a 29-year nurse and the SEIU Healthcare of Florida Local 1991 president — not because the medicines they need don’t exist, not because the procedures to save them are too complicated or risky, and not because they just couldn’t be saved.

They could die because health care workers are overworked, suffer from injuries caused by unsafe working conditions and lack fail-safes at understaffed hospitals. They could die because there aren’t enough nurses to monitor them, or because of errors in medication dosing that a second pair of eyes could have caught.

“Twenty-four percent of [medical] errors are caused by understaffing,” Baker said at a conference of the Registered Nursing Association of Ontario, an organization recognized across the world as the authority on safe hospital staffing levels. Nationally, “98,000 people die every year from preventable causes.”

Baker — a registered nurse since 1979 who is currently a nurse manager at the Trauma Intensive Care Unit at Jackson Memorial Hospital — and the SEIU base their concerns on a 2002 American Medical Association study that found a “7 percent increase in the chance of death for each patient over [a 1-to-4 ratio] that is assigned to a nurse on a medical or surgical recovery floor of a hospital.”

It’s no secret that South Florida hospitals are experiencing a shortage of nurses. The results of a survey released that same month by the Florida Center for Nursing confirms what many in the health care industry already know: With just 37 percent of the health care institutions willing to respond, there were at least 5,000 nursing vacancies across the state, which means Florida hospitals have an average of 30 vacant registered nursing positions.

In recent months, hospitals have been scrambling to entice qualified applicants with signing bonuses, down payments on homes, education reimbursements and attractive salaries, benefits and schedules. But with a waning pool of qualified nursing graduates, those incentives may not immediately solve the problem.

However, Baker supports additional solutions now facing state lawmakers — measures that would mandate safe staffing levels and safer working conditions and enable patients to know if their hospitals are safely staffed.

“Eighteen percent of nurses leave the bedside because of lower back injury,” Baker said. “No one human being should have to lift 50 pounds.”

Needless Deaths

Baker spoke about a Mount Sinai Medical Center nurse who was fired from the Miami Beach hospital for speaking up about the problem after refusing to accept an assignment in what she said was an understaffed telemetry department, which monitors patients with life-threatening conditions that affect their heart rates.

While a safe staffing ratio would have been roughly 1-to-3, the ward was perilously staffed at a 1-to-15 ratio, the nurse said.

Baker chronicled the SEIU’s fight for public transparency of hospitals’ nurse-to-patient ratios. But many area hospitals responded to recent requests for their nurse-to-patient ratios with prepared statements, if they replied at all.

Although a hospital, public or private, is under no legal obligation to divulge their staffing levels, Baker, along with an extensive network of area nurses and union personnel, seeks to change that.

With 18 percent of deaths caused by such preventable medical errors as misdosing medications, the implications can be terrifying in the midst of a shortage.

Even if preventable deaths increased by 5 percent, “if there’s four more patients per nurse, that’s a 20 percent increase in deaths,” Baker said. “You have patients falling, breaking a hip; you have missing or the wrong medication, or not enough time to point out an allergy.

“Eighty-four percent of medication errors are caught by nurses,” she said. “They are the last caregivers before a patient gets whatever they’re getting.”

Legislating Care

So, Baker headed to Tallahassee on April 7 with 100 other nurses to push for a bill before a House health care committee that would create safer working conditions for nurses. The Safe Patient Lifting Bill, sponsored by Rep. Jimmy Patronis and Sen. Mike Fasano to create standards for how much heavy lifting a nurse should be responsible for, passed unanimously in the Senate on March 13.

Lifting patients is a major, yet preventable, cause of on-the-job back injuries and nurse turnover, Baker said. However, “the safe lifting bill was pulled because of political reasons,” she said.

Two other bills designed to make hospitals safer for both patients and nurses also could help solve the nursing shortage problem.

One bill currently stalled in the House Committee on Health Innovation would require hospitals to make their staffing levels available to patients.

The Decision-Making in Health Care Bill, also called the Patient’s Right-to-Know Act, would require hospitals and other health care facilities “to publish and disseminate information concerning violations of federal regulations, complaints made to regulatory agencies, and nurse staffing levels and turnover rates.” It also would require them to “calculate and make available upon request hospital staffing levels and staffing schedules” and “require that records and methods used to determine staffing levels be made available to public.”

The House Committee on Health Innovation, which was scheduled to discuss the bill on March 14, “temporarily deferred” it.

“We’ve been told that the bill is going nowhere because they don’t want to spend money this year” to monitor compliance with it, Baker said. “There’s such a long path ahead of it, because it is so stacked politically.”

The bureaucratic red tape has hindered the effort so much that the group appreciates even being heard in committee.

“If hospitals can’t get their head around the 1-to-4 ratio, then they need to start telling the public about the staffing levels in their hospitals,” Baker said. “There’s a wealth of data out there about what staffing levels are safe. The nurses and the administrations disagree. We’re asking them to report their numbers.”

Many South Florida nurses have consistently told Baker that their hospitals have staffing ratios of 1-to-8, 1-to-10 or as high 1-to-12 and 1-to-15, when 1-to-4 is considered safe.

“We’ve collected nightmare stories,” Baker said. “A typical ICU unit has a safe 1-to-1 ratio. One nurse said her hospital’s was 1-to-8.”

Safety in Numbers

Another bill, also stalled in the state House Committee on Health Innovation, would create the Safe Staffing for Quality Care Act, which would require hospitals throughout the state to maintain safe staffing levels.

A similar bill was enacted in California in October 1999 amid a rash of hospital closings. The landmark legislation made California the first state to require safe hospital staffing.

“The hospitals said hospitals were closing because of mandatory ratios,” Baker said, “which is propaganda and spin. They closed because they were the subject of Medicare fraud.”

Baker said many hospitals and even chief nursing officers — senior nursing managers who often oversee hundreds or even thousands of employees and answer to the hospital’s chief financial officer — are opposed to the measure.

Indeed, many Miami-Dade County hospitals didn’t want to reveal their nurse-to-patient ratios for this story.

Asked about staffing levels, Mount Sinai Public Relations Manager Pamela Gadinsky responded that the Miami Beach hospital “offers its nurses competitive salaries, signing bonuses and retention bonuses. In addition, Mount Sinai Medical Center is mission-driven with a culture of caring. One of six statutory teaching hospitals in Florida, [Mount Sinai] values education and training,” and provides on-site housing for nurses, an on-site day care center, and an on-site satellite learning center for kindergarten through third-graders as part of a public school partnership with Miami-Dade County Public Schools.

Baptist Hospital, South Miami Hospital, Aventura Medical Center, North Shore Medical Center, Mercy Hospital and Cedars Medical Center were unwilling to volunteer their staffing and ratio numbers.

However, Jackson Memorial Hospital, the institution where Baker works, is generally regarded as one that safely staffs its 3,700 nurses. “Our staffing levels vary by unit,” said Kathryn Griffin, Jackson’s central staffing office administrator. “In general, the ratio can be 1-to-3 or 1-to-4. On the medical surgical floors, the ratio can be 1-to-5, and in the ICU, the norm is 1-to-1 or 1-to-2 because these patients can be super-critical. Staffing is based on needs. Our patients can be very sick; they come to us because their needs are specialized.”

Ultimately, though, funding will play a huge role in getting the bills passed, according to state House Minority Leader Rep. Dan Gelber.

In the wake of statewide budget slashing, lawmakers are “cutting $200 million out of nursing home care alone,” Gelber said. “It’s going to impact care in a very horrible way. The elderly won’t be turned as often, resulting in bedsores. If they’re incontinent, they won’t have their diapers changed as often. It’s shameful.”

Comments? E-mail angie@miamisunpost.com