It was an unusually quiet Monday morning at University of California, San Diego (UCSD) Medical Center as emergency department (ED) nurses were remarking how they had time to restock and to take breaks. By 2:00 pm, all had changed as the first of 30 walk-in patients and five ambulances began arriving for the afternoon. "It doesn't matter how well you are staffed at the beginning of the shift, because the patients just keep coming through the door," said Dr. Ted Chan, emergency physician and UCSD Medical Center Project Director for The Robert Wood Johnson Foundation's Urgent Matters program.

In an effort to help combat ED crowding problems, the California Department of Health Services created a new mandate regarding nurse-to-patient ratio, which took effect January 1, 2004.

Under the rules, nurses should not have to care for more than four patients at a time in the ED, and not more than eight patients at a time in med/surg. units. Additional phased-in rules apply to med/surg, specialty, telemetry, and step-down. Licensed vocational nurses cannot comprise more than 50 percent of the assigned nurses, and only registered nurses (RNs) can care for critical trauma patients (1:1). The rules also require at least one RN serve as a triage nurse in the ED. The same level of staffing must be provided for staff breaks, and the charge nurse may not be counted in the ratio except for breaks.

Hospitals are struggling throughout the state to meet the new requirements. At least two hospitals (Santa Theresa in Duarte, CA and Santa Paula Memorial in Century City, CA) have recently announced they are closing due in part due to these requirements. The challenge for the ED is the lack of control over patient volume. Under the Emergency Medical Treatment and Active Labor Act rules, all patients must receive a medical screening exam and only ambulances can be turned away prior to arriving. According to the Centers for Disease Control and Prevention, however, ambulances make up only 18 percent of ED visits nationwide.

There are other complicating rules that require the ratios be met at all times, no matter the patient volume, staff breaks, or other factors. Nurses must identify themselves and document their time for each patient contact - no matter how insignificant. This can add work and documentation time to an overburdened schedule as assisting another nurse with medications or relieving a nurse for a short break will trigger this documentation requirement.

But hospitals are taking definitive steps to meet the requirements. Kaiser's California hospitals began meeting these standards three years ago and during that period hired greater than 3,000 nurses to meet these standards. They have also conducted numerous patient volume studies that now allow their hospitals to approach these new requirements with some confidence. Other hospitals have begun to replace technicians and transporters in favor of RNs to provide staffing redundancy and protection against violating the rules.

And it's not just California hospitals that are likely to be affected long-term. Already at least six states are studying the issue or have pending legislation. The newly recommended ratios are also being studied at the national level by the Emergency Nursing Association. Nationwide, all eyes appear to be on California - eagerly awaiting the implications of this new mandate.

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Mike Williams
President, The Abaris Group
Walnut Creek, CA