08.02.05

Journal Medical Care: New Study Finds Lower RN-to-Patient Ratios A Cost Effective Measure for Saving Lives and Improving Safety in Hospitals

Cost of Ratios is Less than Other Common Lifesaving Measures in Hospitals Such as Clot-Busting Drugs for Heart Attacks and PAP Tests for Cancer

First of Kind Study Bolsters Case for Massachusetts Bill to Regulate RN-to-Patient Ratios

CANTON, Mass.—Implementing registered nurse-to-patient ratios similar to those proposed in pending legislation for Massachusetts hospitals is a safety measure that could save thousands of lives at a reasonable cost, according to a new study published the August issue of the Journal Medical Care, the official medial journal of the American Public Health Association. To receive a copy of the study, contact David Schildmeier at 781.249.0430.

The study, the first to look at the cost effectiveness of specific RN-to-patient ratios in hospitals, found the cost of reducing a nurse's patient load to just four patients, which is the recommended standard for medical/surgical floors in pending national and state legislation, is less costly than a number of other basic safety interventions currently common in hospitals, including the cost of conducting PAP tests for cervical cancer and clot-busting medications to treat heart attacks. If a patient-to-nurse ratio of 4:1 were implemented nationally, the researchers estimate as many as 72,000 lives could be saved annually.

The study was conducted in response to numerous studies that show a direct link between poor RN-to-patient ratios and poor outcomes for patients, as well as the ongoing debate regarding legislation—passed in California and pending in Massachusetts—to regulate specific RN-to-patient ratios in hospitals. The researchers conducted a study to evaluate the cost effectiveness of different RN-to-patient ratios.

According to lead researcher on the project, Michael B. Rothberg, MD, MPH, an assistant professor of medicine at Tufts University and a physician with the Division of General Medicine and Geriatrics at Baystate Medical Center in Springfield, Mass., "We wanted to test our hypothesis that improved patient outcomes from lower ratios would cost less than many other commonly accepted safety measures. Our study bore that out."

"Considered as a patient safety intervention, improved nurse staffing has a cost-effectiveness that falls comfortably within the range of other widely accepted interventions," the study's authors concluded. "If a hospital decided for economic reasons, not to provide thrombolytic therapy [blood thinning medications] in acute myocardial infarction, physicians would likely refuse to admit to that hospital, and patients would fear to go there. Physicians, hospital administrators and the public must now begin to see safe nurse staffing levels in the same light as other patient safety measure."

While the researchers found that improving ratios costs more money in labor costs, nearly half of those dollars would be recouped in savings from the reduced length of patients' hospital stays. More importantly, the lower the number of patients assigned to a nurse, the more lives that would be saved.

The study analyzed the cost-effectiveness of patient-to-nurse ratios ranging from 8:1 to 4:1, using a measurement of the costs per life saved in 2003 dollars. The cost estimates were drawn from medical literature and the Bureau of Labor Statistics. Patient mortality and length of stay data for different ratios were based on two large hospital-level studies, including a study in the Journal of the American Medical Association conducted by researchers at the University of Pennsylvania School of Nursing. The study, which evaluated the care of more than 232,000 surgical patients treated in Pennsylvania hospitals found every patient in addition to four assigned to a nurse resulted in a 7% increase in the risk of death for each patient.

"We found that improving ratios from 8:1 to 4:1 at a cost of $136,000 per life saved was more expensive than testing for HIV infection, which costs $22,000 per life saved, yet was significantly less costly than administering clot busting medications which costs $182,000 per life saved, or conducting routine PAP tests which costs $432,000 per life saved," Rothberg explained.

Rothberg, a physician himself, believes physicians are an important audience for his findings as his study clearly demonstrates the important value good RN staffing has on the safety of their patients.

"Physicians would go ballistic if a hospital attempted to remove a preferred medication from their formulary, yet they don't blink an eye when staffing levels are cut and have the same negative impact on the safety of their patients. They don't see staffing as their responsibility in the same way they view the drugs they prescribe or the equipment they use."

The new study appears at a time when the Massachusetts Legislature is debating competing versions of legislation to improve patient safety in Massachusetts hospitals. The Massachusetts Nurses Association, along with a coalition of 91 leading health care and consumer groups is promoting H. 2663, legislation that would establish safe, minimum RN-to-patient ratios in Massachusetts acute care hospitals. The Massachusetts Hospital Association is proposing a bill that allows hospitals to continue to set their own staffing levels and report those levels to the Department of Public Health.

A hearing on the two nursing bills was held in July before the Joint Committee on Public Health, which is considering both.

"This new study strongly validates our position in this debate and argues for passage of legislation to regulate a safe standard of care for all Massachusetts patients in the form of RN-to-patient ratios," said Karen Higgins, RN, President of the Massachusetts Nurses Association. "It clearly shows that an investment in improved ratios as we are proposing is consistent with other widely accepted safety measures, it costs less than those measures, and most important of all, it will save many, many lives."

While Rothberg and the study do not take a side on the issue of RN-to-patient ratio legislation, Rothberg believes hospital administrators should take a hard look at the cost effectiveness of better ratios. The study highlights the debate over ratios that came before the passage of a law to regulate ratios in California, where the nurses' association was recommending a medical surgical ratio of 3:1 and the hospital industry wanted it to be 10:1. The state eventually settled on a ratio of 5:1 to be phased in over two years. Kaiser Permanente, the largest hospital chain in the state, voluntarily chose a 4:1 ratio, the same as what is proposed in the Massachusetts ratio bill.

According to the Rothberg, "Based on our analysis, Kaiser's choice seems a cost effective one."

The study follows a number of Massachusetts-based studies that have been released this year that demonstrate that patients in Massachusetts hospitals are suffering greatly under current staffing conditions.

A survey of the state's nurses released on July 13 found that 90% of RNs believe the quality of patient care is suffering in hospitals due to poor ratios, with 77% reporting an increase in medication errors, 68% reporting an increase in complications and more than a third (34%) reporting patient deaths directly attributable to having too many patients to care for. A survey of past patients in the state's hospitals over the last two years released in March found that one-quarter reported their safety was compromised because their nurse had too many patients to take care of and one-third reported the quality of their care suffered. A survey of the state's physicians found that eight in 10 believe staffing levels in Massachusetts hospitals are too low and a greater percentage believe the quality of care in hospitals is suffering as a result. More than 60% report an increase in mediation errors, 54% report an increase in complications for patients, and 1-in-5 physicians report patient deaths directly attributable to poor ratios. Both surveys found strong support for the nurses' bill to establish minimum RN-to-patient ratios, with 82% of past patients and 75% of physicians supporting the bill.

The nurses' bill, H. 2663, An Act Ensuring Patient Safety, is sponsored by Rep. Christine Canavan, RN (D-Brockton) and Sen. Mark Pacheco (D-Taunton). It has 106 co-sponsors with a majority in both branches. The bill sets minimum standards for RN-to-patient ratios that would be adjusted to reflect the types of hospitals units and the severity of patient conditions. It would also ban the use of mandatory overtime for nurses, prohibit requirements for nurses to practice in areas of the hospital for which they are not appropriately prepared and prohibits the replacement of registered nurses with lesser qualified, unlicensed personnel—all of which are common practices in the hospital industry that contribute to the deterioration in patient care identified in recent years.