Entering a critical period: Valley Hospitals fight to meet nurse rules.

State mandates for improving nurse-patient ratios at all California hospitals set to take effect Jan. 1 are already causing many Valley facilities a great deal of pain as they struggle to find resources to hire the number of nurses needed to meet the new law without cutting programs or services.

"It's going to be a tremendous juggling act," said Robert Bills, president and CEO of Valley Presbyterian Hospital in Van Nuys.

Although the mandates were signed into law four years ago by former Gov. Gray Davis, industry wrangling over the details have delayed enactment.

As of the first of the year, however, every registered nurse working in an in-patient care facility would have no more than eight patients at a time, in some settings, the figure is between four and six.

Representatives for the California Nurses Association (CNA), which sponsored the measure, say four years is plenty of time for administrators to have hired enough nurses or implemented changes to accommodate the mandates.

Although the CNA calls them a myth, hospital officials say nursing shortages, about 15 percent statewide, are already driving up the cost of hiring and retaining nurses, as they leave one facility for another, chasing down bigger incentives and other sign-on bonuses.

But in addition, there is nearly unanimous agreement that the new law carries a surprise caveat that requires the ratios be implemented on a 24/7 basis, which means in addition to hiring nurses to meet the ratios, extra licensed nurses will be required to fill in.

"Our goal for meeting these requirements is to bring on about 175 licensed RV's and LVN's by Jan. 1," said Bills. "And we expect the impact to be somewhere between $1.2 million and $1.4 million annually on our bottom line. But the big challenge will be filling in for nurses who take breaks or need to leave for an hour or two for a personal matter."

Valley Presbyterian now has roughly 400 licensed nurses on staff.

Jim Sherman, president and CEO of West Hills Hospital in West Hills said while his facility has been actively preparing for the changes for the last two years, he, too, was not aware that the new mandates would require the ratios to be in effect at all times."

"The state asked us for input as to what the new mandates should be, so we were expecting the numbers," said Sherman. "But when the law finally came out in writing, there was something in there that we weren't expecting. And that's the rule that we have nurses to cover us on a 24/7 basis."

Outlining strategies

Sherman said one strategy in the planning stages is to open up a new patient discharge waiting area whine patients who are ready to go home can wait to be picked up instead of taking up beds that, trader the new laws, must be manned by registered nurses.

"We are going to have to start enforcing our 11 a.m. discharge time," said Sherman. "Although it's in place now, we often are flexible about it because patients' family members can't always come at 11 a.m. But we can't do that anymore."

In addition, West Hills is also planning to open a new recovery room for people coming out of outpatient surgery who, historically have been sent to inpatient beds to recover, even if for only a few hours.

Outpatient units do not have to be licensed for inpatient care, so are not subject to the new ratios mandates, however, Sherman said the new outpatient room would be manned by one RN.

Charge nurses at West Hills who now spend half their time with patients and the other half on administrative duties, will no longer have daily patient assignments, said Sherman, but will instead be used as relief nurses.

Sherman predicts the hospital will need to hire roughly 50 morn RNs to add to its current 600. But he, too, points to the nursing shortage as a critical barrier to accomplishing that goal.

"Just like everyone else, we're trying to recruit as many nurses as we can," said Sherman. "But the reality is, there are not 50 RNs out there to hire because of turnover rates. Everyone is competing and fighting for dollars, so the only real way we can address the laws is to implement these mitigation programs.

Sherman said if the hospital finds itself overloaded, as is expected, particularly in the emergency room, already operating at peak levels much of the time due to county closures and other gaps in the system, his staff would put patients before the law.

"We decided that if we can't comply, we will self report that to the state and just take care of the patients as we would today," Sherman said. "We'll take whoever walks in the doors."

Sherman said he's anticipating the new ratios will cost his facility an additional $3.5 million to $4 million a year.

Charles Idelson, communications director for the CNA, says hospital officials who say they didn't know the mandates would need to be in place around the clock, are simply not being truthful.

"The hospitals have had four years to prepare for this and those who are forward thinking have welcomed that opportunity and hired hundreds of registered nurses and are prepared to meet the letter and the intent of the law as of Jan. 1," Idelson said. "The law clearly stipulated in 1999 that they have to provide safe staffing levels in every unit around the clock, every day."

Idelson said nursing shortages were being used as a blanket excuse by many administrators across the state. He said the state Department of Health Services projected the number of nurses needed to meet the mandates across California would be around 4,900, but that in the four years since the law was signed by Davis, roughly 10,000 new nurses have moved into California from outside the stale or country and the nursing schools have graduated 5,100 RNs.

Longer waits

But it isn't just hospitals who are concerned about spreading their resources too thin. The Los Angeles County Department of Emergency Medical Services says the nursing shortages are real and ongoing. They add that the ratios are very likely going to mean fewer beds will be available in the hospital emergency rooms across the county, forcing emergency personnel, including the county's fire and rescue teams, to wait longer to find beds for so-called "9-11" patients."

"It's a public safety issue," said Carol Gunter, the agency's acting director. "I have 17 nurse positions open right now and I don't have people breaking down my door"

Kaiser Permanente has taken advantage of its wide network of hospitals and staff to address the mandates and, lot the most part, its two Valley facilities in Panorama City and Woodland Hills have been operating as if the law was already in place.

But that doesn't mean there won't be challenges.

"We're kind of leading the charge with nurse/patient ratios," said Matthew Gerlach, senior vice president and Valleys service area manager for Kaiser. "We've actually reached an agreement with labor to exceed those ratios, although we aren't quite there yet, but in most cases we are already at the new levels. But, from a business model, we have to look at other operations, and find ways for striking a balance there, which will include taking a look at administrative expenses."