Spotlight Case

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Spotlight Case

• Nurse Staffing Ratios
• The Crucible of Money, Policy, Research, and
  Patient Care

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Source and Credits

• This presentation is based on the August 2009
  AHRQ WebMM 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 WebMM Robert Wachter, MD
• Spotlight Editor Mary A. Blegen, RN, PhD
• Managing Editor Erin Hartman, MS

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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

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Case Nurse Staffing Ratios

• 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.

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Shortages of RNs Impact on Care

• 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

See Notes for references.
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Efforts to Standardize RN Staffing

• 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)

See Notes for references.
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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.
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The American Nurses Associations Nationwide
State Legislative Agenda
NURSE STAFFING PLANS AND RATIOS
WA
ME
MT
ND
VT
NH
MN
NY
OR
MA
WI
CT
RI
ID
SD
MI
WY
PA
IA
NJ
NE
OH
MD
DE
NV
IN
IL
UT
wv
DC
VA
CO
CA
MO
KS
KY
NC
TN
SC
OK
AR
NM
AZ
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
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The American Nurses Associations Nationwide
State Legislative Agenda
PROHIBITION OF MANDATORY OVERTIME
ME
WA
MT
ND
VT
NY
NH
MN
OR
MA
WI
ID
CT
RI
SD
MI
WY
PA
IA
NJ
NE
OH
MD
NV
DE
IN
IL
UT
wv
VA
DC
CO
CA
KY
KS
MO
NC
TN
SC
OK
AR
NM
AZ
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
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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

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Hospital Staffing Plans

• 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

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Staffing Patient Care Units

• 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

See Notes for references.
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Case Nurse Staffing Ratios (2)

• The nurse implemented the initial orders as the
  patient was stabilized on a diltiazem drip for
  his atrial fibrillation. The patients
  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.

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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.

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Case Nurse Staffing Ratios (4)

• 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.

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Case Nurse Staffing Ratios (5)

• Approximately 5 minutes later, the patient care
  assistant arrived at the COPD patients 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.

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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.
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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

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Empowering Staff Nurses

• 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

See Notes for references.
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Responding to Last-Minute Staffing Changes

• 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

See Notes for references.
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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

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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

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