Nursing ratio curtails ER's efficiency
Some in need of immediate help are waiting longer or aren't being seen, medical center says
By Rebecca Vesely, STAFF WRITER, Oakland Tribune
Article Last Updated: Monday, March 29, 2004 - 3:27:17 AM PST

In the narrow hallways of Highland Hospital's emergency department in Oakland, patients lay waiting on gurneys while medical staff maneuvered around them on a recent Monday morning.

As usual, the ER was a beehive of activity. One of the busiest in the region, Highland's ER is on track to have 80,000 patient visits this year and treats the very sick, poor and uninsured.

Since January, however, nurses said they have a little more breathing room -- thanks to a state staffing law that mandates nurse-to-patient ratios in all California hospitals. Under the law, ER nurses can only be assigned four patients each.

"It's nice to have the time to help a patient with a phone call or get them an extra blanket," said Grace Del Valle, a registered nurse working at Highland's ER for the past five years. "You can't efficiently care for 10 to 12 patients at a time."

Like other nurses interviewed at Highland, Del Valle sings the praises of the new staffing law -- the first in the nation -- but she added it does have a downside:At a crowded, urban hospital, a low nurse-to-patient ratio may not be practical.

"It's a great law," she added, "but it didn't consider the ER in terms of acuity."

Or, as Dr. Barry Simon, director of Highland's emergency department put it: "It's like nurses showing up at the scene of an accident and there are 10 patients who need immediate treatment and we say, sorry, we can only care for four." At Highland and other hospitals, the push and pull between urgent patient care and a law intended to curtail nurse burnout are still at odds three months after the law went into effect.

Last month, officials at the Alameda County Medical Cen-ter, which includes Highland, sent a letter of complaint to the state Department of Health Services on the matter.

"Waits in triage have increased, and we have seen up to double the number of patients leaving without being seen," wrote Dr. Jim Mittelberger, president of the medical staff.

"These delays clearly put patients at risk of adverse consequences while waiting, and it is likely that many of the patients that leave ultimately will require medical attention with their presenting problem in a more advanced state," Mittelberger wrote in the letter.

State officials have since met with the medical center's directors to hear concerns, said Barbara Klutz, deputy director of licensing and certification at the Department of Health Services.

A little-known clause in the law does allow hospitals to be temporarily out of compliance if an unexpected influx of patients comes in -- a provision designed for ERs, Klutz said.

"This law is an adjustment for hospitals," he said. "A lot have come up with excellent ways of managing patient flow differently."

The California HealthCare Association, a trade group representing hospitals, contends that 40 percent of hospitals statewide have to go on ER diversion at least once each week because they are at the maximum number of patients per nurse. And patients often can't be moved out of the ER without violating the ratio law by overassigning patients to nurses on other units.

"Patients are getting stacked up in the ER on a regular basis," said hospital association spokes-woman Jan Emerson.

But the union representing the majority of registered nurses in the state -- the California Nurses Association -- said hospitals are manipulating the issue.

"To pin ER overcrowding on the safe staffing law is outrageous," said the union's spokesman Chuck Idelson. "There have been ambulance diversions and ER overcrowding for years."

The state Department of Health Services has received 46 complaints about the ratios as of March 23. Only two hospitals have been cited for deficiencies -- Kindred Hospital of the Bay Area in San Leandro and Riverside County Regional Medical Center.

Kindred Hospital was cited for failing to maintain the minimum ratio of one nurse per six patients on the medical surgical floor, in six out of 10 shifts reviewed in early January.

Kindred officials declined comment for this article, and referred all questions to their trade group, the California HealthCare Association. Accord-ing to the statement of deficiencies, Kindred was not cited for any negative patient outcomes, and its plan of correction included hiring more temporary nurses from agencies.

Emerson said nine out of 10 of its 350 member hospitals are out of compliance with the law at some time each week.

Compliance failures are largely due to the "at all times" provision of the law that doesn't allow flexibility for break times, Emerson said.

The association is suing the state over the provision. As the law stands, a nurse with four patients in the ER can't cover for a fellow nurse while on a bathroom or meal break because that would double the nurse's load -- if only temporarily -- to eight patients.

The case will be heard on May 14 in Sacramento County Superior Court.

Highland's interim director of nursing, Susan Spoelma, said the "at all times" requirement is "very difficult" for staff to juggle. Sometimes nurses take breaks before they are ready because that's when other nurses can fill in, nurses interviewed said.

But nurses see a positive side. April Oldenburg, a Highland ER nurse for nearly five years, said peace of mind that another nurse isn't being overloaded with too many patients makes breaks more restful.

"In some ways you go home feeling less exhausted," Oldenburg said.

This was the primary reason for the law. Studies showed understaffing contributed to nurse fatigue, which in turn compromised patient care.

For Oldenburg and her colleagues, the law allows time for patients -- many for whom the ER is their only access to the health care system.

"We can sit down and have a conversation with a patient and get to know them," Oldenburg explained. "They trust us and they talk to us in a way they don't talk to others. That's why we're nurses."

Contact Rebecca Vesely at rvesely@angnewspapers.com.