Hospitals target elements of nurse-patient ratio rules.

HOSPITAL officials across the entire San Fernando Valley spent the last few weeks of 2003 working at varying degrees to come into compliance with new nurse-patient ratio mandates as the clock for the Jan. 1 implementation of the changes wound down.

Although they held out hope for it, there was no action by Gov. Arnold Schwarzenegger to suspend the start date for the new ratios, despite letters and personal requests from both the Los Angeles County Board of Supervisors, State Assemblyman Keith Richman, who represents the Valley, and other elected officials.

There was movement, however, from the California Healthcare Association (CHA), which filed a lawsuit in Sacramento Superior Court Dec. 30 asking for a heating to force a re-interpretation of the component of the new mandates that requires the ratios to remain in effect 24 hours a day, seven days a week.

As of Jan. 1, every registered nurse working in an in-patient care facility is allowed to care for no more than eight patients at any one time, and in some instances, between four and six.

In addition, if those RNs need a break for even a few minutes, they must be replaced by an RN, not a licensed vocational nurse, or LVN, which effectively means hospitals in compliance one day could find themselves out of compliance the next if a nurse calls in sick or needs a vacation day, or has to leave unexpectedly.

For the most part, the new ratios are being met at many Valley facilities. But the 24/7 rule is forcing many to reconligure departments, shut down beds and strategize for future changes.

In addition, nursing shortages triggered a bidding war in 2003, forcing hospitals to hike up wages for staff nurses and, in many cases, pay out more than double those rates to cover salaries for temporary RNs from nurse registries, which are in very high demand these days due to the shortages.

"We have had to increase staffing by between 20 and 25 percent here," said Rick Miller, spokesman for West Hills Hospital. "And that includes paying higher salaries for temporary workers because there is such a huge shortage."

"Right now the big winners are the temporary agencies who are hiring nurses," said Jim Lott, president of the Hospital Association of Southern California. "Hospitals are in a bidding war to try to get enough nurses on staff and there is some serious price gouging going on out there with these registries. It was expected, and they are all getting rich."

Although hospital officials have been preparing for the changes for some time, many were not expecting the ratio law to include covering nurses who take breaks or have to leave for personal reasons, even for only short periods of time.

Normally, LVNs would be considered perfectly acceptable choices to serve as relief nurses. What's more, who hasn't been in the hospital and witnessed one RN filling in for another?

But the new ratios ban both systems, and, as a result, many anticipate that it will be next to impossible for any hospital to remain in compliance on a 24/7 basis. As a result, many are already planning on having to turn themselves in.

"What we anticipate will happen is there won't be enough nurses to continually fill the holes, so we will likely self-report to the state whenever we are out of compliance and let the county and the state decide what they want us to do," said Miller.

Recognizing that the 24/7 rules present the toughest challenges for hospitals, the CHA filed its suit requesting a hearing to address the policy and possibly rescind it.

There was no word on the status of the suit as of press time.

"What we are asking for is an expedited hearing to order the DHS to reinterpret its own regulatious on the 24/7 rule so that we don't have to have an RN standing in the wings at all times," said Jan Emerson, vice president of external affairs for the CHA.

According to Emerson, her agency simply wants the DHS to allow hospitals and their nurses to operate as they always have when nurses need a break.

"When a nurse needs to take a short break they use their common sense and good judgment and the other nurses cover for each other, Emerson said.

The new ratios are supposed to induce better care, and few hospital administrators dispute the need for it. But for some RNs the ratios will also bring new responsibilities.

According to Jill Furillo, an RN and director of national affairs for the California Nurses Association, as of Jan. 20, RNs who've been appointed to act as "compliance monitors" will begin filling out rate sheets plotting their units' compliance levels, shift by shift, day by day.

She said the first departments statewide to begin submitting the reports, which will be monitored by "professional performance committees," will be maternity wards. Why?

"Because that's the department we've found that seems to be the place that hospitals are most often against staffing with registered nurses," said Furillo. "Most hospitals do see the need to meet these ratios, but there will be some problems that we expect nurses to document."

Furillo said the union would likely set up meetings with hospital officials at facilities where there is "a pattern of noncompliance."

Unionized nurses will also be wearing "safe watch" ribbons on their shifts to indicate to patients that the hospital is operating under the new laws, but also to send a message to administrators that the situation is being monitored.

The Los Angeles County Department of Emergency Medical Services (DEMS) meanwhile is already preparing for serious problems at the county's emergency rooms where ratios are expected to mean fewer beds.

Hospitals often revert to diversion status when their beds are full, forcing emergency crews to go to the next closest facility, and diversion rates are expected to climb under the new ratios.

Staff Reporter Jacqueline Fox can be reached at [phone] or at [e-mail].