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the regulations will require too much money and personnel to implement, and
apparently are stunned by the California Department
of Health Services' recent increase in its projected
annual costs by more than 20 percent.
Meanwhile, the California Nurses Association-the strongest
supporter of staffing ratios-claims the ratios will
save hospital operators money in the long run. The Association
of California Nurse Leaders is taking the middle ground,
supporting the regulations in general, but requesting
some specific clarifications before they are implemented
in 2004.
"The California Department of Health Services
has really done a stellar job in taking input from everyone
and rolling a product out," said Patricia McFarland,
MS, RN, the ACNL's executive director. McFarland cautioned,
however, that state regulators will need to assess the
effect of ratios on patient outcomes, and that they
are not taking into account an anticipated explosion
in the state's nursing shortage by the end of the decade.
"We're all worried that the collision between
the nursing shortage and the ratios will create widespread
ripples," said Jennifer Jacoby, MSN, RN, vice president
for patient care services and chief nursing officer
for the five San Diego-area Sharp Memorial Hospitals.
Although Jacoby believes the ratios for the most part
have been logically drafted, she is concerned that many
hospitals caught between federal and state regulations
may have to reduce the number of beds available to accommodate
them, even though Sharp Memorial's hospitals have seen
an almost 11 percent increase in patient admissions
in the past five years.
All sides are expected to air their views on the regulations
through written comments and three public hearings scheduled
Nov. 15 in Los Angeles, Nov. 19 in San Francisco and
Dec. 4 in Fresno.
As it stands, California will require an initial ratio
of one nurse for every six patients in medical/surgical
units, reduced to a 1-to-5 ratio after one year. Now,
about 75 percent of hospitals statewide meet the 1-to-6
ratio. Ratios in other units will range from 1-to-5
in telemetry; 1-to-4 in postpartum; and 1-to-2 in intensive
care, surgical recovery and other units requiring close
patient monitoring.
Ratios won't be implemented until the beginning of
2004-three years behind the original timetable when
the bill was signed into law in October 1999.
The California Department of Health Services' view
on how nursing ratios will affect health care delivery
statewide is sprinkled throughout the 60-plus pages
of regulations released in September. The DHS estimates
that costs will peak at $486.5 million per year in fiscal
2004-05, when the basic 1-to-5 ratio is implemented.
It also believes that hospitals could choose to close
selected units to meet the mandates, and cut non-nursing
jobs to accommodate the increase in nurse hiring required
to meet the ratios.
California's roughly 500 acute care hospitals appear
ready to fight the ratios as they now stand.
"A 1-to-6 and then a 1-to-5 ratio simply won't
be possible," said Jan Emerson, spokeswoman for
the California Healthcare Association, the state's leading
hospital lobby. The association has been a vocal critic
of the present ratios, which are essentially a middle
ground between the 1-to-3 basic ratio proposed by the
CNA and the 1-to-10 ratio proposed by the CHA.
The CHA also is critical of the perceived lack of flexibility
in other ratios. For example, Emerson said the mandated
1-to-4 ratio for emergency rooms may be unachievable
due to the inability to predict patient flow into the
emergency room. The 1-to-6 ratio in psychiatric units
would undermine the multidisciplinary approach toward
psychiatric care, she added.
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