Dying for a nurse
Chicago Tribune, November 13, 2002

Here's a ratio to keep in mind next time you check into the hospital: 1 to 4.
That's one registered nurse to every four patients. When nurses try to care
for more than four surgical patients, the chances of those patients dying
rise - by 7 per cent for each patient added. That translates into as many as
20,000 deaths a year, according to the authors of a study released last month
in the Journal of the American Medical Association. It may seem obvious that an overburdened nurse could be dangerous for patient care. But medical
experts and hospitals have argued for years about where the line is. It's
time to stop arguing and start figuring how to fix the problem. Nursing has
been in a crisis for several years. In 2000, the Tribune's Michael Berens
documented that nursing errors caused thousands of deaths and injuries in a
five-year period, mostly because nurses were overburdened, undertrained or
both. Many nurses have fled the profession, complaining of burnout. Many
nursing schools report record low admissions. Nurses are the primary
sentinels of quality care in hospitals. They can be the difference in a
patient's survival. Over the last decade, however, some cash-strapped
hospitals have replaced nurses with lesser-trained and lower-salaried aides
and licensed practical nurses. That has only increased the frustrations and
burden of the remaining RNs. The hospitals have argued that they alone
should control staffing levels, since staffing needs change daily if not hourly,
and should be dictated by a number of factors, including how sick patients are.
That is undoubtedly true, but some hospitals have also shown the willingness
to scrimp on nurse staffing to save money. Hospital officials have argued
that there are no optimal levels, that whether a nurse has five patients or
six makes no significant difference in patient mortality. But the JAMA study
offers some compelling evidence that that's not true. Some hospitals have
wisely started to beef up their nursing corps. But hospitals face a
financial squeeze between rising health-care costs and insurers trying to rein in
payments. Some hospitals on the cusp of financial failure will no doubt
continue to staff at levels that put some patients at risk. Some experts
support California's solution-mandatory nursing ratios. But that is a blunt
instrument when something far more surgical is needed. Nursing staff ratios
are one of many criteria by which an informed patient can make a choice
between competing hospitals. Other key areas include success rates in
specialty areas such as heart bypass surgery, and infection rates. Right
now, hospitals are not required to disclose much of that information, including
nursing ratios. They should be. This page has urged the hospital industry to
develop uniform, clearly comprehensible standards for compiling such
statistics--a hospital report card, in other words. Only with that kind of
information can a prospective patient make an informed decision when
choosing a hospital. Many hospital officials realize that the "re-engineering" of the
1990s has failed, says Rick Wade of the American Hospital Association. He
says many hospitals are looking to new technology--mainly sophisticated, new
information systems--to help hospitals cut down on the time nurses spend
doing paperwork and increase their time with patients. That's a good idea.
Here's another: Listen to the nurses. One major frustration, many nurses
say, is that hospitals have disregarded their recommendations on staffing levels.
A bill to give nurses a bigger voice in staffing failed in the Illinois
legislature last year. But it shouldn't take a state law to give nurses a
seat at the table where staffing decisions are made. It's common sense.
After Berens' 2000 series, the Tribune called for a "total reappraisal, in
hospital boardrooms and administrative offices, of the importance of quality
nursing." That is still urgent. We'd add one more thing: When they're doing this
reappraisal, hospital officials should ask the nurses for their opinions -
and listen carefully.