Urgent Letter to California State Legislature

June 14, 2012

Dear California State Legislature,

The proposed budget language to suspend the nurse-to-patient ratios for every patient on every unit in the acute care hospitals for the entire period that nurses are away from their patient assignment for meal and rest breaks undermines patient safety in every hospital setting. Intensive care units, neonatal intensive care units, pediatric units and all other medical-surgical and oncology units where patients receive critical acute care nursing services would find that their RN' s patient care assignment would be doubled during a significant portion of each shift.

The proposed budget language means that on a medical-surgical unit where two RNs each have an assignment with the maximum number of patients per RN (5 patients), for two hours out of every eight hour shift, an RN would be required to provide care for 10 patients each. In effect, during one quarter of the shift an RN would be required to provide care for 10 acutely ill hospitalized patients. That is double the number of patients that the DHS found was consistent with safe patient care. Patients will see delays in care impacting pain management and severely reducing RNs ability to provide protective surveillance of patients in the acute care setting increasing the likelihood that there will be increased "failure to rescue" patients, a significant contribution to inpatient deaths.1

The requirement that minimum ratio standards be in place at all times including meals and breaks has been in place for nearly 40 years in the ICUs, Neonatal Intensive Care Units and the Operating Room. Just before implementation of the nurse-to-patient ratios in the remainder of hospital units in 2004, the California Hospital Association filed a lawsuit claiming that the Department of Health Services (DHS) "at all times" interpretation was inconsistent with the language of the regulation and was not clearly stated as a requirement during the lengthy rulemaking process. Superior Court Judge Gail Ohanesian ruled that the California Hospital Association's (CHA) was aware of the requirement with respect to maintaining the minimum nurse-to-patient ratios at all times, including meal and rest breaks and that it was the only reasonable interpretation of the nurse-to-patient regulation. Judge Ohanesian stated that "[a]ny other interpretation would make the nurse-to-patient ratios meaningless."2 [Emphasis added] She went further in characterizing CHA's arguments against meal and break replacement as " ... an attack on the ratios themselves. "3

During the years that followed implementation of the ratios a seminal study of the first in the nation California ratios compared patient outcomes and staffing levels of California hospitals to those of two other states, New Jersey and Pennsylvania. The study determined that there would have been 13.9% fewer death of surgical patients in New Jersey and 10.6 % fewer deaths in Pennsylvania if these state's had staffed according to the ratio standards in California.4

In 2007 a 539 page technical review of 96 studies related to nurse to patient ratios staffing between 2000 and 20065 also noted:

"Higher registered nurse staffing was associated with less hospital-related mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other adverse events. The effect of increased registered nurse staffing on patients safety was strong and consistent in intensive care units and in surgical patients. Greater registered nurse hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter lengths of stay." (emphasis added)

This proposed language would be a major set back in the progress made in California as a result of the first in the nation nurse-to-patient ratios and, as Judge Ohanesian so wisely observed, would be an attack of the ratios themselves.



Bonnie Castillo

Director, Government Relations


Cc: Governor Jerry Brown


1 : Clarke SP and Aiken LH Failure To Rescue: Needless Deaths Are Prime Examples of the Need for More Nurses at the Bedside, American Journal of Nursing, 1 03(1 ), Jan 2003 pp.42-47

2 : CHA v DHS, Superior Court of Sacramento, No. 03CS01814, May 24, 2004, p. 5

3 : Ibid, p.8

4 : Linda H. Aiken, et. allmplications of the California Nurse Staffing Mandate for Other States, 2010., p.l

5 : Robert L. Kane, MD et. al., Nurse Staffing and Quality of Patient Care, AHRQ Publication No. 07-EOOS, 2007 {539 pages).


Please visit our page on Safe RN-to-Patient Ratios page.

Read California Labor Federation's Lettter to the Governor.