More nurses, less death

By Stacey Burling
Philadelphia Inquirer
April 20, 2010

Ten to 13 percent fewer surgical patients in New Jersey and Pennsylvania would die if hospitals in those states had as many nurses as California law requires, according to a University of Pennsylvania study published Tuesday.

The study of 1.1 million patients in 2005 and 2006 found that the nurse-to-patient ratios mandated in California could have saved the lives of 468 patients in New Jersey and Pennsylvania over a two-year period.

Linda Aiken, who led the study and directs the Center for Health Outcomes and Policy Research at Penn, said improved nurse staffing likely could save "many thousands a year" nationally.

The study was based on reports to states of deaths within 30 days of surgery and surveys completed by 22,336 nurses. It was published in the journal Health Services Research. Aiken said 18 states, including Pennsylvania, were considering legislation on nurse-staffing levels.

She decided to compare California to other states rather than look at what happened in California before and after the law so that people would see this as a broader issue. "What happens in California," she said, "is relevant for other parts of the country."

California became the first, and only, state to enforce minimum nurse-to-patient standards in 2004. For example, it says one nurse can be responsible for no more than five patients on a medical-surgical unit and two in an intensive-care unit.

Aiken's study found that, on average, nurses in California medical-surgical units cared for two fewer patients than nurses in New Jersey and 1.7 fewer than in Pennsylvania. It also found that nurses in California liked their jobs better and were less likely to feel burned out, an important finding because of the projected shortage of nurses.

Bills have been introduced in Pennsylvania that would either set minimum ratios or require hospitals to establish committees that would develop a "safe staffing plan" for nurses. New Jersey last year began requiring hospitals to report staffing ratios to the Department of Health and Senior Services.

Nurse-to-patient ratios are among the issues dividing 1,500 striking workers and their administrators at Temple University Hospital.

The strikers, who are nurses and allied professionals represented by PASNAP, the Pennsylvania Association of Staff Nurses and Allied Professionals, have proposed staffing requirements similar to those in California.

Patricia Eakin, PASNAP's president, said nurses often encountered staffing levels at Temple they considered "unsafe." The union has only one contract that includes staffing ratios, at Mercy Suburban Hospital in East Norriton.

When nurses have to care for too many patients, they may not be able to deliver pain drugs on time or keep a close enough eye on patients with troubling symptoms, Eakin said. It can take 90 minutes to stabilize one patient whose heart stops. "Then you're behind on everything else," she said.

Sandy Gomberg, interim chief executive officer at Temple, said the hospital would not agree to required ratios. She said staffing was too complex - a mixture of patient needs, nurse skills, available technology, and unit geography - to reduce to one number. "Quality patient care cannot be boiled down to a math problem," said Gomberg, who is a nurse.

Aiken said the new study followed decades of research showing that patient outcomes were better when nurses cared for fewer patients.

She said many hospitals in Pennsylvania and New Jersey already met California's nursing requirements. "Some hospitals are quite good and some hospitals really have unsafe staffing by the standards of California," she said. Her report did not identify specific hospitals.

Aline Holmes, senior vice president for clinical affairs for the New Jersey Hospital Association, said two-thirds of hospitals in New Jersey had medical-surgical unit nurse-to-patient ratios of 1 to 5.5 or less. She said previous studies had not shown that California's mandates led to better patient outcomes. She thinks hospitals should determine staffing based on how sick patients are.

Hospital Staffing

Number of nurses to patients as mandated by California legislature.

Unit Type ratio

Medical-surgical 1:5
Pediatric 1:4
Intensive-care units 1:2
Oncology 1:5
Labor/delivery 1:3

SOURCE: Health Services Research