Massachusetts Nurse :: September 2005

New study finds RN-to-patient ratios a cost effective measure for saving lives, improving safety

According to a new study published in the August issue of the Journal Medical Care, the official medical journal of the American Public Health Association, implementing RN-to-patient ratios could save thousands of lives at a reasonable cost.

The study, the first to look at the cost effectiveness of specific RN-to-patient ratios in hospitals, found the cost of reducing a nurse's patient load to just four patients, which is the recommended standard for medical/surgical floors in pending national and state legislation, is less costly than a number of other basic safety interventions now commonly used in hospitals, including the cost of conducting PAP tests for cervical cancer and clot-busting medications to treat heart attacks. If an RN-to-patient ratio of 4-to-1 was implemented nationally, the researchers estimate as many as 72,000 lives could be saved annually.

The study was conducted in response to numerous studies that show a direct link between poor RN-to-patient ratios and poor outcomes for patients, as well as the ongoing debate regarding legislation—passed in California and pending in Massachusetts—to regulate specific RN-to-patient ratios in hospitals. According to lead researcher on the project, Michael B. Rothberg, MD, MPH, an assistant professor of medicine at Tufts University and a physician with the Division of General Medicine and Geriatrics at Baystate Medical Center in Springfield, Mass., “We wanted to test our hypothesis that improved patient outcomes from lower ratios would cost less than many other commonly accepted safety measures. Our study bore that out.”

“Considered as a patient safety intervention, improved nurse staffing has a cost-effectiveness that falls comfortably within the range of other widely accepted interventions,” the study's authors concluded. “If a hospital decided for economic reasons not to provide thrombolytic therapy (blood thinning medications) in acute myocardial infarction, physicians would likely refuse to admit to that hospital and patients would fear to go there. Physicians, hospital administrators and the public must now begin to see safe nurse staffing levels in the same light as other patient safety measures.”

While the researchers found that improving ratios costs more money in labor costs, nearly half of those dollars would be recouped in savings from the reduced length of patients' hospital stays. More importantly, the lower the number of patients assigned to a nurse, the more lives that would be saved.

The study analyzed the cost-effectiveness of patient-to-nurse ratios ranging from 8-to-1 to 4-to-1, using a measurement of the costs per life saved in 2003 dollars. The cost estimates were drawn from medical literature and the Bureau of Labor Statistics. Patient mortality and length of stay data for different ratios were based on two large hospital-level studies, including a study in the Journal of the American Medical Association conducted by researchers at the University of Pennsylvania School of Nursing. The study, which evaluated the care of more than 232,000 surgical patients treated in Pennsylvania hospitals found every patient in addition to four assigned to a nurse resulted in a 7 percent increase in the risk of death for each patient.

“We found that improving ratios from 8-to- 1 to 4-to-1 at a cost of $136,000 per life saved was more expensive than testing for HIV infection, which costs $22,000 per life saved, yet was significantly less costly than administering clot busting medications which costs $182,000 per life saved, or conducting routine PAP tests which costs $432,000 per life saved,” Rothberg explained.

“This new study strongly validates our position in this debate and argues for passage of legislation to regulate a safe standard of care for all Massachusetts patients in the form of RN-to-patient ratios,” said Karen Higgins, RN and president of the Massachusetts Nurses Association. “It clearly shows that an investment in improved ratios as we are proposing is consistent with other widely accepted safety measures, it costs less than those measures, and most important of all, it will save many, many lives.”

Rothberg, a physician himself, believes physicians are an important audience for his findings as his study clearly demonstrates the important value good RN staffing has on the safety of their patients.

“Physicians would go ballistic if a hospital attempted to remove a preferred medication from their formulary, yet they don't blink an eye when staffing levels are cut and have the same negative impact on the safety of their patients. They don't see staffing as their responsibility in the same way they view the drugs they prescribe or the equipment they use.”

The new study appears at a time when the Massachusetts Legislature is debating competing versions of legislation to improve patient safety in Massachusetts hospitals. The Massachusetts Nurses Association, along with a coalition of 91 leading health care and consumer groups is promoting H.2663, legislation that would establish safe, minimum RN-to-patient ratios in Massachusetts’ acute care hospitals. The Massachusetts Hospital Association is proposing a bill that allows hospitals to continue to set their own staffing levels and report those levels to the Department of Public Health.

A hearing on the two nursing bills was held in July before the Joint Committee on Public Health, which is considering both. While Rothberg did not take a side on the issue of RN-to-patient ratio legislation, he believes hospital administrators should take a hard look at the cost effectiveness of better ratios. The study highlights the debate over ratios that came before the passage of a law to regulate ratios in California, where the nurses' association was recommending a medical surgical ratio of 3-to-1 and the hospital industry wanted it to be 10-to-1. The state eventually settled on a ratio of 5-to-1 to be phased in over two years. Kaiser Permanente, the largest hospital chain in the state, voluntarily chose a 4-to-1 ratio, the same as what is proposed in the Massachusetts ratio bill. According to the Rothberg, “Based on our analysis, Kaiser's choice seems a cost effective one.”