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Nurse-to-Patient Ratios
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State Rep. Barb Byrum Town Hall Meeting
Presented by Laurence Rosen, PhD
August 5, 2009
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Improving Hospital Quality of = Care and Patient Outcomes
nKey hospital issues
nHigher acuity patients
nPressure to discharge patients sooner
nSolutions: More bedside RNs
nLegislated nurse-to-patient staffing ratios
nVoluntary staffing p= lans
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Enac= ted Nurse Staffing Ratios
nCalifornia
nLegislation passed in 1999, enacted in 2004. <= /span>
nLegislation re= quires nurse staffing ratios formulated from patient and diagnostic data.
n= Ratios from 1:2 in ICU, NICU, Labor/Delivery <= /span>
nTo 1:5 Med/Surg., 1:6 Psych., Post-partum
nVictoria, Australia
nRegulations established in 2000.
nNurse staffing= ratio averages 1 nurse for 4 patients across all units.
n
------=_NextPart_01CA16AC.724E71D0 Content-Location: file:///C:/2398DA39/Rosen_Presentation_080509_files/slide0004.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Nurse to Patient Ratios in Michgian
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Outc= omes from Staffing Ratios
nCalifornia
nRN applications have increased by 60% since 1999.
= nUnfilled positions in Sacramento Hospitals have decreased by 69% since 2004.
= nMany hospital systems have seen vacancy and turnover rates fall below 5%.
nWages for CA nurses increased 12% over nurses in comparable areas outside of CA.
------=_NextPart_01CA16AC.724E71D0 Content-Location: file:///C:/2398DA39/Rosen_Presentation_080509_files/slide0053.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Nurse to Patient Ratios in Michgian
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Active RN Licensees in California
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Source: State of California, 2009 BRN survey
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3DPPAblue
Outc= omes from Staffing Ratios
nState of Victoria, Australia
nNurse staffing levels have increased with:
nMore personal care of patients.
nMore discretion in managing workloads. <= /div>
nMore time to complete paperwork.
= n2,300 nurses returned to the public hospital system in 2 years.
nPrior to 2000 returning nurses numbered 400 or fewer per year.
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3D"MAP
Source: California Nurses Association
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Michgian
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What does health care research= show?
nMore Patients per RN results in:
nReduced amount of time RNs can spend with individual patients.
nIncreased fatigue for nurses.
nDelays in receiving medication.
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-3.54%;top:.3em;font-family:Wingdings;font-size:75%'>nHigher likelihood of failing to intercept medical errors.
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-3.67%;top:.3em;font-family:Wingdings;font-size:75%'>nLess time to educate patients and family about courses of care.
n
n
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Nursing-Related Patient Outcomes
nFewer Patients per RN result in:
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nReduction in patient infections
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nLower ICU mortality
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nLower surgical unit mortality
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nReduced hospital-acquired pneumonia
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nReduced pulmonary failure
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nReduced complications
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>nReduced mortality after discharge
nOverall reduced mortality and length of stay
<= span style=3D'visibility:hidden'>n
<= span style=3D'visibility:hidden'>n
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Financial Implications of Staf= fing Ratios
n<= span style=3D'font-size:88%'>Adding RN staff adds to hospital costs
<= span style=3D'font-size:86%'>nRecruiting costs
<= span style=3D'font-size:86%'>nIncreased nurs= ing salaries
<= span style=3D'font-size:86%'>nTraining and continuous education
<= span style=3D'font-size:86%'>nManagement and supervision
n<= span style=3D'font-size:88%'>Adding RN staff reduces hospital costs
<= span style=3D'font-size:86%'>nReduced medical errors and associated costs
<= span style=3D'font-size:86%'>nReduces patient length of stay
<= span style=3D'font-size:86%'>nReduces turnov= er and recruiting costs
<= span style=3D'font-size:86%'>nImproves quali= ty of work life for nurses
<= span style=3D'font-size:86%;visibility:hidden'>n
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Costs & Savings Associated= With Care Outcomes
nNeedleman, 2005 --  Increase= the proportion of nurses providing care to the level seen in the top= 75th percentile of hospitals: <= /div>
n$810 million cost of additional RNs
n$980 million saved f= rom shorter lengths of stay
n$72 million from avoiding adverse outcomes
nNet savings of $242 million per year
n
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Costs & Savings Associated= With Care Outcomes
nEstimated annual savings from adding one RN providing 7.8 hours p= er patient day
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>n$7,400 from preventing adverse events
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>n$38,000 hospital-related savings
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>n$2,500 reduced professional services
n$10,300 in reduced productivity losses associated with patient mortality
<= span style=3D'mso-special-format:bullet;color:#666699;mso-color-index:2;positio= n: absolute;left:-4.23%;top:.3em;font-family:Wingdings;font-size:75%'>n$1,800 from faster recovery
nTotal savings =3D $60,100 = per year
n&= #13;
<= span style=3D'visibility:hidden'>n
<= span style=3D'visibility:hidden'>n
<= span style=3D'visibility:hidden'>n
<= span style=3D'visibility:hidden'>n
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Costs & Savings Associated= With Care Outcomes
nHospital-acquired pneumonia among surgical patients may add between $46,000 and $58,000 per patient to Michigan hospital costs.&#= 13;
nTotal costs for hospital-acquired pneumonia may be as high as $527 mill= ion per year in Michigan.
nReducing the nurse-to-patient ratio at Michigan hospitals may reduce Michig= an hospital costs by up to $100 million per year.
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High= er Nurse-to-Patient Ratios
Source:Needleman, 2001; Cho, 2003; additional computations by Public Policy Analysis, Inc.
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Potential Costs & Savings = Associated With Care Outcomes
Medicare ceased to pay for the following conditions if not present on admission starting on= October 1, 2008: 
<= span style=3D'font-size:86%'>nCatheter= -associated urinary tract infections
<= span style=3D'font-size:86%'>nDecubitus ulcers
<= span style=3D'font-size:86%'>nVascular catheter-associated infections
<= span style=3D'font-size:86%'>nMediastinitis = after coronary artery bypass graft surgery
nFracture, dislocations, or other hospital-ac= quired injuries= 3;
<= span style=3D'font-size:86%'>nObjects left in during surgery
<= span style=3D'font-size:86%'>nAir embolisms&= #13;
<= span style=3D'font-size:86%'>nBlood incompatibilities
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Adding Nursing Staff Does A= dd to Hospital Costs
nCost of RN salaries
nCost of RN benefits
nAdditional management and supervision
nTraining and continuing education
nFor every 1% increase in RN F= TEs there is an increase of approximately 0.25% in hospital operating costs.
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Financial Costs of Increasing = Nurse-to-Patient Ratios
n<= span style=3D'font-size:84%'>Ratios would add to the financial stress that most= Michigan hospitals have reported for the last decade
n<= span style=3D'font-size:84%'>But these additional costs only represent a very <= /span>small portion of Michigan acute-care hospital = operating costs. 
nMichigan hospi= tal operating costs in 2006 were $20.1 billion.
= nThe cost of increasing nurse-to-patient ratios in 2006 would raise statewide hospital operating cost= s = in Michigan to $20.44 billion.
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Financial Costs of Increasi= ng Nurse-to-Patient Ratios
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Financial Costs of Increasing = Nurse-to-Patient Ratios
<= span style=3D'font-size:81%'>n<= span style=3D'font-size:81%'>As demand for nurses increases, wages will go up.&= #13;
nCalifornia wag= es increased 12.0% over comparable areas.
nTotal wages of hospital nurses providing direct ca= re in Michigan could increase by $420 to $480 million.&#= 13;
<= span style=3D'font-size:81%'>n<= span style=3D'font-size:81%'>But with more nurses RN turnover tends to decline.=
nAt 10% annual turnover, costs related to turnover in Michigan (for roughly 150 acute-care and community= hospitals) would be $450 million at the 10.0% turn= over rate.
nIf turnover is decreased to 5% a savings of $250 m= illion will be realized for Michigan’s acute-care and community hospitals.
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Ratios and Quality of Work Lif= e for Nurses
n<= span style=3D'font-size:88%'>Fewer RNs per patient:
<= span style=3D'font-size:86%'>nDecrease in job satisfaction
<= span style=3D'font-size:86%'>nGreater nurse burnout
<= span style=3D'font-size:86%'>nIncreased turnover
<= span style=3D'font-size:86%'>nNew RNs more l= ikely to quit
<= span style=3D'font-size:86%'>nGreater recrui= tment costs
n<= span style=3D'font-size:88%'>More RNs per patient:
<= span style=3D'font-size:86%'>nReduced RN turnover
<= span style=3D'font-size:86%'>nReduced vacancies
<= span style=3D'font-size:86%'>nReduced overti= me costs
<= span style=3D'font-size:86%'>nReduced need f= or sign-on bonuses
<= span style=3D'font-size:86%'>nReduced worker compensation costs
<= span style=3D'font-size:86%;visibility:hidden'>n
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C= osts Associated With Staffing
<= span style=3D'mso-special-format:bullet;position:absolute;left:-4.9%;top:.3em; font-family:Wingdings;font-size:75%'>nPricewaterhouseCoopers found = that
n
n   “each percentage point increase in nurse turnover costs an average hospital about $300,000 annually.  Hospitals that perform poorly in nurse retention spend, on average, $3.6 million more than those with high retention rates.”
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Example: Kaiser Permanente’= s Sunset Hospital (California)<= /div>
n<= span style=3D'font-size:88%'>Impact of ratios on nursing costs:
nThe RN vacancy= rate prior to implementation was 14%-16%; it now averages 2.5%.
nThe turnover r= ate prior to implementation was 12%; it is now between 2.0% and 2.5%.
nOvertime costs dropped by 50% over 18 months. =
nIt is not necessary to offer bonuses to attract RNs.
nThere has been= a decrease in worker’s compensation and a 50% reduction in back injury reports.
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Conclusions: Higher Nurse-to-<= /span>Patient Ratios Usually Means:
nHigher quality of patient car= e—as indicated by fewer hospital-acquired infections and other adverse events.
nHigher quality of work life a= mong nurses with direct patient-care responsibilities—as is typically indicated by reduced nursing turnover and lower nursing vacancy rates.
n
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Conclusions: Higher Nurse-to-<= /span>Patient Ratios Usually Means:
n<= span style=3D'font-size:88%'>More efficient hospital operations and significant= financial savings for hospitals despite the need t= o expand the nursing staff—as indicated by
nlower costs associated with adverse patient events=
nlower costs from shorter length-of-stay
nreduced turnover and recruitment costs =
nreduced overtime and agency nurse costs. 
nreduced medical liability costs may also be a factor, although no definitive research demonstrating this= has been found.
n
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