10.09.2003

Department of Public Health Public Hearing
On DON for Lahey Clinic Hospital – Project # 4-3A58
Massachusetts Nurses Association Testimony
October 9, 2003

Testimony Provided by:
Karen Higgins, RN, President
Massachusetts Nurses Association

Good morning. My name is Karen Higgins. I am the president of the Massachusetts Nurses Association, an organization that represents more than 22,000 registered nurses and health professionals in the Commonwealth, working in more than 85 health care facilities across the Commonwealth.

I, like the overwhelming majority of MNA members, am a practicing staff nurse working on the frontlines of the health care system. As frontline nurses, we spend more time with patients and probably have a greater understanding of how the current health care system operates more than any other provider group. I can tell you that the nurses of Massachusetts have been witness to a dramatic and alarming deterioration in the quality and safety of health care in our state in recent years, as we have watched the state embrace a free market, deregulated system that has allowed for far too little oversight and regulation of the health care system.

As the Department of Public Health considers a determination of need for a major expansion of the services at the Lahey Clinic, we have come here tonight to offer our insights and recommendations to assist you in your deliberations.

Specifically, we are here to strongly recommend that as you consider this and any future expansion of patient care services in the health care system that you factor in a component that has been too often overlooked or ignored – registered nurse-to-patient ratios. We urge you to consider the status of ratios and their impact on this facility's and future applicants' ability to deliver safe care within the expanded cadre of services being proposed.

These comments are offered at a time when Massachusetts finds itself in the midst of a severe nursing crisis. Poor staffing conditions have forced RNs to leave the bedside. Let me emphasize that I am not talking about a shortage of nurses that has caused a crisis in care. Instead, I am talking about a crisis in the quality of our nursing care caused by an industry-driven penchant for creating inadequate and dangerous staffing conditions for nurses. These conditions have forced thousands of our nurses to the sidelines out of fear for their license and frustration over their inability to practice nursing the way they were educated to practice their chosen profession.

Lahey might propose and obtain funding to build a new patient tower of 36- med/surg beds, 24 ICU beds, four OR suites, but our question is, what guarantee is there that they will be able to attract nurses to staff these beds, and if they do staff these beds, what guarantee is there that these beds will be staffed with an RN-to-patient ratio that will provide the level of care promised by this institutions?

The impact of nurse staffing on the quality and safety of care cannot be overstated.

No less an authority than the Journal of the American Medical Association found that the higher the patient-to-nurse ratio, the more likely there will be a death or serious complication. Each additional patient above four that a nurse is caring for produces a 7% increase in mortality. If a nurse is caring for eight patients instead of four, there is a 31% increase in the risk of death.

Keep in mind that many of the nurses in Massachusetts and nurses we have talked to at the Lahey Clinic today report that they are regularly being assigned ratios that fall into this dangerous range, and the majority is working with ratios above what would be considered appropriate, according to this study.

Allow me to put this in perspective. Consider that according to UNOS (the United Network for Organ Sharing), a liver transplant program is required to maintain an 80% survival rate, and failure to meet that survival rate would trigger an audit and subject that program to losing its Medicare funding. But we have clear documentation that at many of our hospitals, we have nurses regularly assigned eight patients or more, resulting in a deplorable 69% survival rate for those patients undergoing the most basic types of surgery, and nothing has been done about it. I would ask what would the DPH Division of Health Care Quality do if it found that one of our state's transplant or open heart surgery programs had a 30% mortality rate?

And this is just one of many studies.

The New England Journal of Medicine last year released a study of six million patients in 11 states, including Massachusetts warning that patients without adequate nursing attention are more likely to die or suffer serious complications. The more nurses per patient, the better the care.

And the Joint Commission on the Accreditation of Health Care Organizations, which is charged with auditing the safety of our hospitals, issued a report in 2002 disclosing that 25% of the patient deaths and serious injuries it investigated in recent years were directly attributed to nurses having too many patients to care for.

Now some might argue that the studies I cite are national studies and don't apply to our much touted medical mecca here in the Commonwealth. But here in Massachusetts, a recent survey by Opinion Dynamics, a respected independent research firm provided localized evidence of the dangers of understaffing in our state's hospitals.

• 87 percent of nurses report having too many patients to care for safely.
• 2 in 3 nurses report an increase in medication errors due to understaffing;
• 2 in 3 nurses report an increase in complications due to understaffing;
• 1 in 2 nurses percent report readmission of patients due to understaffing;
• 1 in 2 nurses report injury and harm to patients do to understaffing;
• 1 in 2 nurses report that poor staffing leads to longer stays for patients, which cost more; and
• Most alarming of all, nearly one in three nurses (29 percent) report patient deaths directly attributable to having too many patients to care for.

I hope I have made my point – registered nurse staffing not only matters, it is a matter of life and death. You can have the nicest building, the most expensive supplies and the world's greatest surgeons and physicians, but if you don't have registered nurses with a ratio of patients that allows them to apply their skills and experience to the care of the patient, none of these other factors matter. I would also point out that there are many existing beds in the system right now that go unused every day because there are no nurses currently willing to work in those hospitals. This in fact, is a major cause of the ER diversion problem we now face.

So we are asking you to consider this fact as you consider this and other applications for the expansion or introduction of new services by health care providers.

Specific to this case, we would suggest you ask for the following:

• Data on current staffing levels, and we're not talking about FTEs here. You need to know and to survey to find out the daily RN to patient ratio and skill mix on the floors at Lahey today.
• You should also ask for access to any patient care data, including mortality and morbidity, records of medication errors and patient falls, etc. Hospitals are now required by JCAHO to provide and track some of this data as part of their accreditation process. You need to get your hands on that data.
• You should ask for projections on staffing ratios for the new units as proposed, as well as the proposed skill mix for these floors. You should also ask if there is a patient classification system in place that will mandate improvements in staffing based on the acuity level of the patients on these floors.

It is important to note that we have been told by a number of nurses from this facility that Lahey was one of the facilities in the 1990's that implemented nursing care models that replaced RNs with lesser skilled unlicensed personnel. This practice proved to be extremely dangerous to patients and has been widely discredited by the nursing research. Again, we have also received disturbing reports about the current RN-to-patient ratios at this facility.

Now it may be the case that under current law and the existing DON regulations that your agency is prevented from considering these factors in making your decision. I'm sure you are aware that our organization is working hard to pass legislation – H. 1282, An Act to Ensure Quality Patient Care and Safe Registered Nurse Staffing -- which would mandate by law specific RN-to-patient ratios for all acute care hospital units and departments, as well as a call for a standardized patient classification system that will mandate improvements in staffing based on acuity and other factors. It will also serve as a vehicle for restoring nurses' confidence in the health care system and entice the many thousands of nurses in our state who left the bedside to return to the bedside.

In the meantime, it is up to you, those who are in charge of monitoring and protecting the public health to do whatever you can protect patients in our hospitals from conditions that place them at unnecessary risk. Failure to do so is not only a mistake in the application of public policy; it is truly a matter of life and death.