The California Nurses Association last month announced its proposal for minimum nurse-to-patient ratios. CNA, the state's largest organization of registered nurses, said its proposal offers the prospect of dramatic improvements in patient safety and helping to resolve the state's shortfall of hospital nurses by restoring safe care standards in California hospitals.

Licensed nurse-to-patient ratios are required for all California hospitals under a CNA-sponsored law enacted in 1999. The final ratios, to be determined by the state Department of Health Services, are to go into effect in January, 2002. The Massachusetts Nurses Association has filed legislation similar to that of the CNA, HB 1186, An Act Relative to Safe Nurse Staffing to Ensure Safe Care, which the MNA hopes to pass in the current legislative session. The ratios proposed by CNA serve as a guideline for future work to be done here in Massachusetts, once our bill is passed.

CNA's proposal is the first to be based on an exhaustive research study of publicly available data - 21.7 million discharge records of California hospital patients over the past six years and the Diagnosis Related Groups (DRG) designations for the severity of illness (acuity) for those patients.

"Adopting strong, effective and enforceable ratios is the best response to the nursing care crisis that is undermining the quality of care in California hospitals, and driving out frustrated and exhausted RNs," said CNA President Kay McVay, RN. "Our proposal meets the intent of Governor Davis and the California Legislature in enacting the nation's first law requiring ratios for hospital nurses. It would restore the tattered patient safety net, rebuild our nursing care infrastructure, and redress the nursing shortage."

CNA's proposed minimum ratios are as follows: Intensive Care, 1 nurse to 2 patients (current law). Medical/Surgical Units, Telemetry, or other Specialty care 1:3. Emergency Room, 1:3. Burn, 1:2. Step Down/Intermediate Care, Definite Observation, 1:3. Active Labor and Delivery, 1:1. Obstetrics, 1:3. Post-Partum/Normal Newborn Nursery, 1:5. Pediatrics, 1:3. Psychiatric, 1:4. Subacute and Transitional Inpatient care, 1:4.

CNA's proposals derive from a research study by the Institute for Health and Socio-Economic Policy (IHSP), a non-profit research and policy group. The study was commissioned by CNA and sponsored in part by the United Steelworkers of America. "It is the first study in the nation to present a scientific basis for specific ratios based on publicly available data reflecting the actual patient need and severity of illness of an enormous data group - the entire hospital patient discharge population, nearly 22 million people," said McVay.

The IHSP analyzed 21.7 million patient discharge acuity ratings collected by California Office of Statewide Health Planning and Development (OSHPD) from 1993-1998 (the most recent years available). OSHPD records a DRG designation for each discharge. DRGs, the grouping of hospital patients together based on diagnostic, therapeutic and demographic characteristics, are the long established mechanism on which Medicare reimbursement rates are determined.

OSHPD assigns a severity of illness indicator, a computer program it buys from the 3M Corporation, for each of the nearly 500 DRGs it records.

To determine ratios by hospital unit, as required by AB 394, the IHSP assembled a RN expert panel in December of 25 direct care RNs from 22 diverse California hospitals with over 500 cumulative years of experience in hospital nursing. The panel was directed to identify in what unit in their hospital, based on their professional expertise, a patient with each of the DRG designations would most likely be placed under current conditions.

With all the DRGs, and their 3M acuity (severity of illness) indicator now grouped by presumed units, the IHSP then calculated the average acuity of each unit, based on the illness of the patients presently housed in those units. The IHSP used the Intensive Care Unit nurse-to-patient ratio of 1:2, which has been the law in California for two decades, as a baseline for establishing the ratios in other units.

Among its findings, the IHSP recorded that 15 to 20 percent of hospital patients are inappropriately placed in units not sufficient for the care needed for their degree of illness.

To compensate for potential error, the IHSP offered a low, middle, and high range of acuity, and potential ratio for each unit. The CNA Board of Directors subsequently voted to endorse the middle range recommendation for its proposed ratios.

To supplement the IHSP study, CNA also conducted a series of 19 Town Hall meetings held across the state this year (two more are scheduled later this month) to gather additional information - the direct experience of front line RNs about patient care conditions today.

"It was the overwhelming sentiment of the hundreds of RNs who attended our town hall meetings that we are in a grave patient care crisis. They testified that patients are jeopardized daily by dangerous conditions and poor staffing, and frustrated nurses are leaving the profession because they believe they can no longer provide the care their patients need," said McVay.

"These ratios, based on the actual conditions in hospitals today, and the severity of illness of today's hospital patients, are what the public needs for safe care," said McVay. She said the CNA will now "encourage the DHS to adopt these standards, and urge nurses across the state to rally in support of these safe ratios for their patients."

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