The Health Policy Commission has approved final regulations underpinning the ICU Safe Patient Limits Law, which was enacted last year to ensure patients in Mass. hospital ICUs receive one-on-one care from their registered nurse, while allowing a nurse to take a second patient if and when it is deemed safe to do so.
Click here to view the full text of the law.
Click here to view the final regulations for the new law.
While the law is now in effect, the regulations established a staggered process for hospitals to follow in developing a tool nurses can use, known as an acuity tool, to assist them in determining when patients are stable enough to allow a two-patient assignment. Under the regulations, each hospital that is an academic medical center shall complete its acuity tool for NICUs by January 31, 2017, and for all other types of ICUs by March 31, 2016. The six academic medical centers include: Beth Israel Deaconess Medical Center, Boston Medical Center, Brigham and Women’s Hospital, Massachusetts General Hospital, Tufts Medical Center and UMass Memorial Medical Center. All other hospitals must complete their acuity tools no later than January 31, 2017.
Unfortunately, the Massachusetts Hospital Association, in direct violation of the law and the explicit direction of the Health Policy Commission and the Department of Public Health, is claiming that the law is not in effect until the acuity tool process is complete, and many hospitals are adopting the MHA’s illegal position. To aide nurses in complying with the law and to protect their license which obligates nurses to follow the law regardless of the actions of their employer, we have provided the following guidelines for nurses to ensure the safety of their patients:
- No matter what your managers or administrators tell you, the law IS in effect, and has been since September 28, 2014. Your license to practice nursing in the Commonwealth obligates you to follow this law and you can be held personally accountable for anything untoward that happens to your patients while you are working outside the dictates of the law.
- The law and the regulations apply to ALL acute care hospitals in the state both public and private and to ALL manner of ICUs as defined by the Department of Public Health, including NICUs, PICUs, CCUs, SICUs, MICUs, Burn Units, etc.
- The law requires that a staff nurse be assigned one patient at a time, with the option of accepting a second patient only if the nurse has assessed that BOTH patients are stable enough, and the nurse has the skill and resources, to allow a two patient assignment.
- If and when a DPH-certified acuity tool is available, the staff nurse must use the acuity tool to aid them in making their assessments. However, until the tool for your facility is developed and certified by DPH, the law dictates that it is the assessment of the staff nurses on the unit who have the authority to determine both the stability of the patients on the unit and the appropriate patient assignments for the nurses on the unit. If you don’t feel safe taking a second patient, it is your right to refuse that assignment.
- The only time a nurse manager can be involved in decisions regarding patient assignments is when the staff nurses on the unit cannot agree on appropriate assignment. Then and only then can a nurse manager or supervisor be called in to assist the nurses in determining the assignment of patients on the unit.
- There are no exceptions to the law requiring that a nurse shall be assigned a 1:1 or 1:2 patient assignment. “Notwithstanding any general or special law to the contrary, in all intensive care units the patient assignment for the registered nurse shall be 1:1 or 1:2 depending on the stability of the patient as assessed by the acuity tool and by the staff nurses in the unit.” At no time does the law or the regulations allow a nurse to accept a third patient – never. This includes nurses’ who may be asked to assume the assignment for other nurses taking breaks and when nurses are transporting patients off the unit.
- At no time can hospitals board non ICU patients on the unit to allow a two or three patient assignment. Any patient on the ICU is subject to the law and the patient assignment is subject to assessment of the nurses on that unit.
- In documenting your assessment of the patient, we encourage nurses to include the patient assignment needs assessment (whether a 1:1 or 1:2 assignment is called for) in your nursing documentation. However, should management refuse to follow your assessment, you should immediately follow the steps below and if necessary, fill out and submit the Violation of the ICU Law form.
- If you and/or your colleagues assess your patients and believe a proposed patient assignment is in violation of the law, contact a manager or supervisor to inform them of the violation and request the staff and/or other resources necessary to comply with the law.
- If the manager or supervisor is unwilling/unable to provide adequate staffing and/or resources to prevent a violation, or if they persist in overruling your patient assessment and force you to accept more patients, you must under your license make a decision to refuse the assignment if you believe it is unsafe or if you choose to take the assignment (you are responsible for the outcomes) you should inform management that you will report the violation to the State’s Health Policy Commission, the Department of Public Health, and the office of the Attorney General.
- Fill out the Violation of the ICU Law form. Copies of the form should also be available on your unit or can be obtained from your union rep. The MNA will file this complaint with the Health Policy Commission, the Department of Public Health, and the office of the Attorney General or take other legal actions as appropriate.
ICU Staff Nurse Participation in the Development of an Acuity Tool
- Under the law and new regulations, each hospital is required to include front line ICU staff nurses on a committee to help develop the acuity tool or tools (i.e. if different tools are needed for adult, NICUs, PICUs) for each unit in each hospital. In fact, the regulations specify that each acuity tool committee at a hospital must be composed of “at least 50 percent staff nurses in the ICU in which the acuity tool will be deployed who are not managers.”
- The MNA has informed management at each hospital where the nurses are represented by MNA that the local union will be working with its members to identify and support ICU nurses who wish to participate on the committee creating the acuity tool for their hospital. The work of the committee does not negate any additional obligations the employer has including, but not limited to, bargaining and providing any and all information necessary to appropriately represent members of the bargaining unit. If you are interested in joining such a committee, contact your union rep.
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