SEIU Hospital Staffing Proposal
January 9, 2000
Title 22, Division 5, Chapter 1
Proposed regulations are underlined, deletions have been stricken. Amendments made 7-11-01
are in italics.
§70053.2. Patient Classification System
(7) The administrator of nursing service shall respond in writing, within two weeks, to direct
patient care personnel or their representatives who have requested information or asked
questions about staffing.
A method for nursing administration to respond to staffing concerns.
Direct care nurses have a professional responsibility to be sure that the care is safely
provided.1 In order for nurses to fulfill that responsibility, there must be a prearranged
method of responding to direct care nurses requests for additional staff.
Many nurses report they frequently notify nursing administration of serious staffing
problems with no timely response or no response at all. The director of nursing
administration has, @authority, responsibility and accountability for the nursing service @2,
but there is no delineated plan for holding him/her accountable for solving problems in
the nursing service.
Two weeks is a reasonable time period, given the relationship of adequate staffing to
patient outcomes, for a written reply to direct care nurses concerns about staffing.
S.70053.2 (8) A method to ensure that administrative and fiscal constraints are not used as
a basis for the system.
Staffing based on patients needs, not finances.
Staffing on each shift, on each unit, should be adjusted to meet the individual needs of
patients, and not dictated by administrative financial decisions. Patient classification
systems are routinely adjusted to meet the needs of the budget, not the needs of the
patients.
Department of Health Services surveyors confirm that patient classification systems are
often cost based and even the requirement to validate the system in Section 70053.2.
(a)(2) is used as an excuse to go back into the system and reduce staffing numbers. 3 In
addition, administrators frequently speak openly of the fact that their staffing systems are
budget driven rather than based on patient needs.
SEIU Nurse Alliance proposes an addition to the regulations to require hospitals to
implement patient classification systems based on individual patients= needs, not on the
budget.
1
California Business and Professions Code, Div. 2, Ch. 6, Art. 2, Sect. 2725 (d)
Title 22, Division 5, Chapter 1, Article 3, Section 70211. (c)
3 Transcript, DHS Acute Care Training, Patient Classification System, March, 1999, p. 2,3
2
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(b) Direct care nurses responsible for implementing care on the basis of the patient classification
system and administrators responsible for assigning patient care based on the system shall
demonstrate knowledge and competency in the use of the particular system used by the specific
facility.
The patient classification system must be understood be direct caregivers and by
administrators responsible for assigning care.
In order to maximize the effective use of patient classification systems for staffing, their
purpose, function and mechanics must be well understood by nursing staff.
In addition, since each hospital may use its own unique patient classification system,
staff and administrators must be trained to understand the peculiarities of the system
used by the specific facility.
Direct care nurses utilizing the patient classification system must be thoroughly trained by
a knowledgeable instructor to be comfortable with its use.
Patient classification systems have become increasingly complex and sophisticated. The
systems are often lengthy and require many steps to complete. There can be mistrust,
misuse and lack of use of the systems due to a lack of understanding. Determining cost
effective staffing levels appropriate to the identified needs of patients is critical to
achieving positive patient outcomes. Lack of staffing leads to avoidable negative
outcomes. 4
'70101. Inspection of Hospitals
(c) All hospitals for which a license has been issued shall be inspected periodically by a
representative or representatives appointed by the Department. Inspections shall be conducted
as frequently as necessary, but not less than once every two years, to assure if that quality care
is being provided. During the inspection, the representative or representatives of the Department
shall offer such advice and assistance to the hospital as is appropriate. The inspection team
shall include surveyor staff with demonstrated knowledge and competency in patient
classification systems. For hospitals of 100 licensed bed capacity or more, the inspection team
shall include at least a physician, registered nurse and persons experienced in hospital
administration and sanitary inspections.
Importance of surveyor competency.
The patient classification system is critical to protecting patient safety even with adequate
staffing ratios. It should be used to determine adequate staffing based on the needs of
the patients. Adequate training is imperative for every surveyor of the system.
4
Christine Kovner, Peter J. Gergen, Nurse Staffing Levels and Adverse Events Following Surgery in U.S. Hospitals
Image: Journal of Nursing Scholarship, Vol. 30, Num. 4, Fourth Quarter 1998: 319
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A Department of Health Services, Licensing and Certification trainer recently stated that
DHS surveyors find the patient classification systems used in California hospitals,
@difficult to understand@5. In addition, representatives of the California Healthcare
Association, Kaiser Permanente and SEIU agree that there is a lack of understanding
about patient classification systems on the part of DHS surveyors.
SEIU requests patient classification system surveyors who are fully knowledgeable and
competent in the system. Surveyor competency is critical when attempting to determine a
systems compliance with regulations and the ability of the system to establish adequate
staffing.
'70102. Complaints
'70102. Complaints.
Department of Health Services shall investigate all complaints, written or verbal, and shall
protect the identity of the complainant.
Investigation of all complaints.
SEIU Nurse Alliance proposes additions to the regulations to require the Department of Health
Services to investigate all complaints received by the department and guard the identity of the
complainant. Failure to investigate complaints made verbally deters consumers and workers
from complaining. Further, failure to protect the identity of complaints puts at risk the jobs of
workers and the health and safety of patients.
The Department now operates a responsive complaint program that includes confidentiality. The
proposed language will place much of current practice into regulations.
S.70102 (b) DHS shall conduct an unannounced, on-site reinspection of a facility that has been
found to have a deficiency within six months after the plan of correction has been received
and approved by the Department. Such re-inspection may be consolidated with visits for
other purposes.
Mandatory re-inspections after a substantiated deficiency.
A hospital’s awareness of an impending unannounced reinspection will create a more effective
incentive to comply with the regulations.
We have received numerous complaints from direct care nurses that, after receiving written
deficiencies, hospitals fail to comply with the agreed upon plans of correction. There are no
standardized timelines for compliance, and we have no record of any California hospital having
received a penalty for failing to comply.
SEIU=s proposed amendment will allow DHS six months to repeat an inspection to verify
compliance, and may be carried out during a subsequent visit to hospital facilities due to a CALS
survey or for any other reason.
(f) Reports on the results of each inspection of a hospital shall be prepared by the inspector or
5
Transcript, DHS Acute Care Training, Patient Classification System, March, 1999, p.2
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inspection team and shall be kept on file in the Department along with the plan of correction and
hospital comments. The inspection report may include a recommendation for reinspection. All
inspection reports, lists of deficiencies and plans of correction, any documents relating to
certification for participation in the Medicare program or the Medicaid program, or both, and
documents demonstrating compliance with regulations regarding adequate staffing of health
facilities shall be open to public inspection without regard to which body performs the inspection.
Public disclosure of records relating to staffing.
Members of the public should be able to compare staffing from hospital to hospital as
California Advocates for Nursing Home Reform does for nursing homes and Consumers
Union does for HMOs.
Joint Commission on Accreditation of Healthcare Organizations in 1998 refused to reveal
to SEIU staff specific hospitals’ accreditation status. JCAHO refuses to provide detailed
information about hospital surveys. Hospitals are accredited year after year despite
negative patient outcomes and public interviews with JCAHO surveyors that reveal
serious problems.
According to a 1998 study done by National Research Corporation, the public’s level of
trust in hospitals is 8 percent lower than it was one year ago. 37.5 percent of 170,000
survey respondents said, hospitals are more interested in making a profit than providing
quality care.@6 Public disclosure would help to restore public confidence.
Documents related to staffing plans and patient classification systems are routinely
copied or made available by hospital facilities for surveyor review. These same
documents need only be placed in files at respective DHS district offices to be available
for public requests.
(j)The Department shall perform periodic inspections of compliance with laws and regulations
regarding the provision of safe patient care and staffing, including compliance with requirements
regarding the patient classification system, that are not announced in advance of the date of the
inspection. Inspections may be conducted jointly with other inspections by other certifying
entities. However, if the Department conducts any inspection jointly with any certifying entity that
provides notice in advance, the Department shall conduct an additional inspection for the
purposes of this section that is unannounced and that is separate from the periodic inspection
required by Section 1279 of the Health and Safety Code. Periodic inspections pursuant to this
provision shall be conducted no less than once every three years and more frequently at the
discretion of the department.
Unannounced inspections are essential for guarding patient safety.
SEIU Nurse Alliance proposes an addition to the regulations to require DHS perform an
unannounced inspection to determine compliance with the patient classification system, staffing
and all laws and regulations relating to safe patient care. This may be the CALS survey if it is
not previously announced.
6
Phil Richmond, Who Trusts Who?, National Research Corporation, 1999, p.3
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JCAHO has continued to accredit acute care hospitals year after year where patients
have been subjected to serious harm, even death, with little or no impact on their
accreditation status. The 1999 Inspector General’s report on HCFA’s oversight of
JCAHO concurs that announced surveys are, AUnlikely to identify patterns of
substandard care.Y@.7
Direct care nurses presented impressive testimony to JCAHO Director, Dennis O=Leary at the
October 1998 SEIU Nurse Alliance Conference concerning hospitals’ elaborate preparations
before inspections, and subsequent lapses. The nurses cited multiple instances across the
country of such preparation and of intimidation of workers willing to speak up on behalf of
patients. This testimony has had no effect on JCAHO’s plans for altering their inspection
patterns. Currently, only about 5 percent of their inspections are conducted randomly and
unannounced. And, hospitals get 24-48 hours notice before JCAHO’s so-called unannounced
visits.
Many hospitals in California have been cited for multiple violations of state and federal
regulations found during CALS surveys which are conducted concurrently with JCAHO, and still
receive good accreditation reports from JCAHO.
Announced inspections are dress inspections, not reflections of real life and real care. To
evaluate the normal daily quality of a facility, Department of Health Services should
perform periodic unannounced inspections.
'70210. Patient Care Committee
Staffing needs not determined by the patient classification system shall be reviewed by a patient
care committee to assure sufficient staffing to meet patient care needs. Areas to be reviewed
include housekeeping, pharmacy, laboratory, engineering, and other units. This committee shall
include:
(1) Non-management hospital staff whose staffing is not directly determined by the patient
classification system. These staff will be selected by the collective bargaining agent or in the
absence of a collective agent by election by the other staff.
(2) Hospital management who shall be selected by the administrator.
(3) Representatives of the patient classification committee, including both direct patient care
staff and persons appointed by the nursing administrator.
Hospital Staffing In Every Unit Should be Reviewed by Hands-On Staff
The third most frequent complaint received by the SEIU enforcement program concerns dietary
services and most often involves vermin or other unsanitary conditions that result in
contaminated food for patients. Short staffing in engineering endangered patients in another
hospital in which the hospital had only one employee in the engineering department resulting in
interruption of oxygen for up to 20 minutes to the intensive care unit on multiple occasions.
Several instances have been reported in which supplies are so short that employees use their
own money to buy toilet paper and soap for patients: this lack of basic sanitary supplies creates
a risk of nosocomial infections.
7
Department of Human Services, Office of the Inspector General, the External Review of Hospital Quality, July
1999, p.1
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The hospital is an integral whole: shifting staffing in one area affects others. Reducing
housekeeping staff may require nurses to scrub operating rooms between surgeries, again
creating the risk of infection as well as stretching nursing staffing. Reducing dietary staff delays
meals or requires staff on the floors to deliver trays, putting other duties at risk. Eliminating
clerical staff disrupts scheduling, causing misuse of diagnostic and treatment resources.
Input from hands on staff can avert disruptions in care.
'70215. Planning and Implementing Patient Care
(e) Licensed vocational nurses and licensed psychiatric technicians may participate in the
nursing process by performing a basic assessment (data collection),
participating in planning, and contributing to the evaluation of individualized interventions related
to the care plan or treatment plan to the extent permitted by their individual scopes of practice as
defined in existing regulations.
(1)Licensed vocational nurses may perform a basic assessment that may include, but is not
limited to, observation, palpation, and auscultation.8
SEIU Nurse Alliance proposes an addition to Section 70215 in order to clarify the role of
licensed vocational nurses and licensed psychiatric technicians in the nursing process.
SEIU proposes NO change in the scope of practice of licensed vocation nurses or
licensed psychiatric technicians. We propose a clarification of existing scopes and
roles.
There is current confusion about the role of licensed vocational nurses and licensed
psychiatric technicians in the nursing process since the most recent Title 22 amendment
requiring a registered nurse to, Adirectly provide ongoing patient assessments@.9 Some
hospitals are not clear about the ability of LVNs and psychiatric technicians to perform
any type of patient assessment. This confusion has resulted in unnecessary loss of jobs
for licensed vocational nurses during a nursing shortage. 10
Existing regulations, California Code of Regulations, Title 16, Sections 2518.5 and
2576.5 respectively, clearly delineate the role of LVNs and psychiatric technicians in
assessment. The Board of Registered Nursing, Board of Vocational Nursing and
Psychiatric Technicians and DHS have been working since the fall of 1998 on a
document to clarify the roles of the licensed caregivers according to their scopes of
practice and the requirements of Title 22. Many attendees at the meetings of the Board
of Vocational Nursing and Psychiatric Technicians, including representatives of several
nursing schools, have asked for this clarification.
The addition of language to the regulations directly from the practice acts of licensed
vocational nurses and licensed psychiatric technicians into Section 70215 is a simple
method of making their roles in the nursing process clear.
' 70217. Nursing Service Staff
8
Ann Shuman, Board of Vocational Nursing and Psychiatric Technicians, Letter dated June, 1993
Title 22, Division 5, Article 3, Section 70215 (a)(1)
10 Ralph R. Cornejo, Service Employees International Union, Local 250, Letter dated Sept. 1999
9
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(b)(5) On request, direct care nurses shall be provided , in writing, the acuity of individual patients and staff
provided based on the patient classification system and shall be provided the formula or formulas used to
determine staffing based on the individual acuities. This shall be provided during the shift or, on request of
the direct care nurses, subsequent to the shift.
Nurses should know the acuity level and staffing requirements for patients under in their care.
Direct care nurses need to be able to identify the acuity level, usually determined by the previous
shift, of individual patients and the process for translating the acuity level into the staffing
provided.
Acuity for individual patients is required to be determined on a shift-by-shift basis as in Section
70217(b)(2). Generally each shift determines patient acuity for the next shift. Since acuity can
change rapidly, nurses should be able to readily review the acuity determined by the previous
shift, and decide if readjustments are necessary.
The formula for determining staffing based on acuity of individual patients is often either
incomprehensible or unavailable to direct care nurses. The system may involve many different
forms to complete, may require totaling large columns of numbers per patient, and/or need input
into a computer program in the staffing office. The enormity and complexity of the system
frequently removes it entirely from the patient care unit and does not allow oversight by direct care
nursing staff. Direct care nursing staff believe the numbers are adjusted according to the budget
and do not reflect patient needs.
DHS Training Preceptor, Catherine Fowler explained how staffing systems can be skewed with
the help of computer programs:
“I then I became a Director of Nurses at a 133 bed hospital a long time ago. We
implemented the ANSOS staffing system, which is a computerized system. You’ve
probably have seen similar systems out there. And this was supposed to be more
accurate. This was based on time and motion studies that we’ve done. We followed the
nurses around; used a stop-watch. Of course, we always chose certain nurses that knew
they were chosen because they were the good nurses that got their work done on time.
So then we put that data into the computer. You push a button and it is supposed to give
you your staffing requirements. But then I found out, administration gave me the finance
numbers to plug into that computer. So you did that and all of a sudden the other
numbers started to change. The point I’m making here is numbers can be manipulated
any way for whatever purpose your intent is. Be aware of that during the razzle dazzle.@11
SEIU Nurse Alliance requests the addition of language to the regulations to allow direct
care nurses to have immediately available to them for review, the acuity level of
patients as determined by the previous shift. In addition, direct care nurses should be
able to directly view the system and process used to determine staffing based on
the determined acuity.
(c)The reliability of the patient classification system for validating staffing requirements shall be
reviewed at least annually by a committee appointed by the nursing administrator to determine
whether or not the system accurately measures patient care needs.
(d)At least half of the members of the review committee shall be licensed staff, including
licensed nurses, who provide direct patient care and whose staffing is determined by the patient
classification system.
11
DHS Acute Care Training, Patient Classification System, Transcript, p.2
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(1)The direct patient care staff committee members, including registered nurses and licensed
vocational nurses, shall be appointed by a legally recognized bargaining agent, or agents, if any.
In cases where no legally recognized bargaining agent represents direct care members,
members of the committee shall be elected by licensed direct care hospital staff whose staffing
is determined by the patient classification system.
(2) The nursing administrator may appoint the other members of the review committee or may
allow them to be selected pursuant to (d) (1).
(3) The committee shall include representatives of the staffing committee.
(4) Nothing in this section shall be construed to alter the scope of practice or roles of health
professionals as determined by existing law or regulations.
Patient classification system members appointed by their bargaining agent or
elected.
SEIU Nurse Alliance requests changes and additions to the regulations to give authority
to legally recognized bargaining agent (agents) to appoint members to the patient
classification committee. Where a legally recognized bargaining agent does not exist,
the members will be elected by other direct care staff.
The purpose of having direct care givers on the committee, in addition to nurse
managers, is to give those who provide hands-on care a voice in patient care.
Nursing administration may appoint committee members who will echo management
opinions or might even stack the committee with administrative nurses. In two extreme
examples, two Catholic Healthcare West hospitals were recently cited because the
committee was only composed of administrative nursing staff@.12
When unions or co-workers have the authority to appoint committee members, it
balances the voice of management with the voices of workers who are actually on the
units giving the care to patients. It allows the members to be placed on the committee
through a democratic process, either through direct election or selection by
democratically elected representatives (the collective bargaining agent).
(2)The other members of the review committee may be appointed by nursing administration
or selected by the method in (d) (1).
Nursing administration appoints other members of the committee.
This is consistent with both the present language and the suggested amendments.
(k) A direct care licensed nurse may request, at his or her sole discretion, a re-examination of a
patient by an appropriately qualified physician to verify the appropriate unit placement for the
patient. The nurse shall be provided a verbal report of the examination during the shift.
Verification by a physician of appropriate unit placement for individual patients.
Unit placement often determines the amount and type of nursing care received by a
patient. It is decided by a physician’s order. Licensed nurses should be able to request
verification, by an appropriately qualified physician, of appropriate unit placement for
12
Department of Health Services, Statement of Deficiencies, #05-0011898,p.2,#05-0011896,p.3
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individual patients.
Inpatient hospital stays have been reduced in the last decade as the trend continues to shorter
stays. In turn, stays within individual units within the facilities have become shorter. Patients are
being moved more quickly out of units that require close monitoring to newly created units with
less monitoring by fewer staff. Patients having open heart surgery may stay only 12-18 hours in
critical care, then move to a step-down unit where their needs are not greatly decreased, but
there are more patients per nurse. With shorter stays in every unit, it is critical that patients
receive care appropriate to their individual needs and conditions. Over the last decade
standards have changed and verification of correct unit placement is a safeguard.
Asking whether a physician’s order is correct, both to verify it and to seek a re-evaluation
of that order, is at the heart of nursing practice. Registered nurses are required under
Title 16, Division 14, Article 1, Section 1443.4 to act as a patient’s advocate, Aas
circumstances require, by initiating action to improve health care or to change decisions@
which are against the interests of a patient. Licensed vocational nurses are required
under Title 16, Division 25. Chapter 1. Article 4. Section 2518.6 to, safeguard
patients’/clients’ health and safety@ .
These requirements certainly include the authority to verify, when necessary, correct unit
placement in a hospital. Requesting a physician to re-examine a patient is a critical part
of the process. Double checking physicians is an essential element of the role of the
nurse and is recognized as such in professional practice guidelines.
(k)(l) Unlicensed personnel maybe utilized as needed to assist with simple nursing procedures
subject to the requirements of competency validation. Hospital policies and procedures shall
describe the responsibilities of unlicensed personnel and limit their duties to tasks that do not
require licensure as a registered or vocational nurse.
(l)(m) Nursing personnel from temporary nursing agencies shall not be responsible for a patient
care unit without having demonstrated clinical and supervisory' competence as defined by the
hospital's standards of staff performance pursuant to the requirements of subsection 70213(c)
above.
(m)(n) Hospitals which utilize temporary nursing agencies shall have and adhere to a written
procedure to orient and evaluate personnel from these sources. Such procedures shall require
that personnel from temporary nursing agencies be evaluated as often, or more often, than staff
employed directly by the hospital.
(n)(o) All registered and licensed vocational nurses utilized in the hospital shall have current
licenses. A method to document current licensure shall be established.
(p) All hospitals with at least 100 beds shall have at least two respiratory therapists on duty at all
times.
Sufficient respiratory therapists to respond to emergencies
Respiratory therapists must be available for labor and delivery, the emergency room, recovery
rooms, and treatments throughout the hospital. Respiratory therapists are always required when
a patient codes. If only one respiratory therapist is available in a hospital, then patients who code
will be at risk of not having a respiratory therapist available. In addition, respiratory therapists are
often required at night if a baby goes bad after an emergency delivery and in critical care units
due to respiratory suppression deepening at night when other health professionals tend to be
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unavailable.
S. 70218 Nursing Service Clerical Staff
Sufficient clerical staff, whose primary responsibilities are nursing unit specific, shall be
provided to support nursing staff providing direct patient care only. Clerical staff shall
be provided in the following proportions:
1) One unit or ward clerk whenever a unit has four or more patients.
2) One unit or ward clerk to no more than 15 patients
3) One unit or ward clerk for each critical care unit
4) One unit or ward clerk for every ten patients in a telemetry unit
Unit or ward clerks who are assigned clerical responsibilities shall be assigned to
monitor no more than four monitors.
Sufficient clerical staff to support the work of nurses and other licensed
professionals.
Unit or ward clerks provide needed clerical support for direct care staff. These
staff answer telephones and questions continuously, transcribe physician orders,
often coordinate schedules of multiple staff and physicians, and provide
emergency support services.
Without sufficient clerical staff to perform these responsibilities, direct care staff,
including both physicians and nurses, are unable to perform their responsibilities
in a timely and effective manner.
' 70220.1. Medical and/or Surgical Unit Service
' 70220.1. Medical and/or Surgical Unit Service.
Medical and/or Surgical unit service means a unit in which there are nursing and supportive
personnel providing medical and nursing care to patients with medical and/or surgical
conditions.
A defined service for medical and/or surgical patients.
The medical surgical unit service should be defined and recognized in regulations in
order to provide organized minimal medical oversight, staffing, and other requirements.
Working nurses, nursing administration and state surveyors need clearly defined and
outlined regulations that directly apply to medical surgical patients. Patients placed on
these units deserve the same quality of oversight as all other units in the hospital. We
frequently receive inquiries and complaints from nurses and other hospital workers
indicating that the lack of specific regulation of medical-surgical units causes
considerable confusion.
The acuity level of patients in medical surgical units approaches, and in some cases
exceeds, the level of acuity of critical care patients twenty years ago. Patients no longer
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stay on medical surgical units for three days after a dilatation and currettage or stay three
months for low back pain: patients like this are cared for on an outpatient basis. Patients
on medical surgical units are now acutely ill and require intensive nursing care and
medical intervention.
To fail to acknowledge these patients in regulations is a disservice to patients and nurses
who need clear direction the oversight of their care.
SEIU Nurse Alliance proposes addition of regulations to recognize the existence of
hospital units that have existed for many years.
' 70220.2. Medical and/or Surgical Unit Service General Requirements.
(a)Written policies and procedures shall be developed and maintained by the person
responsible for the service in consultation with other appropriate health professionals and
administration. Policies shall be approved by the governing body. Procedures shall be
approved by the administration and medical staff where such is appropriate. The policies and
procedures shall include but not be limited to:
(10Admission, discharge, and transfer policies.
(20Staffing requirements.
(30Routine procedures.
(40Emergency procedures.
(b)The responsibility and accountability of the Medical and/or Surgical unit service to the medical
staff and administration shall be defined.
General requirements for medical surgical units.
Policies and procedures help ensure uniformity and a standard of practice based on current
nursing practice. Proposed language recognizes existing practices in hospitals and ensures
future revisions as necessary.
' 70220.3. Medical and/or Surgical Unit Service Staff.
' 70220.3. Medical and/or Surgical Unit Service Staff.
(a)A physician with training in and experience in the care of medical and/or surgical patients
shall have overall responsibility for the service. The physician shall be responsible for:
(10Implementation of established policies and procedures.
(20 Assuring there is continuing education for the medical staff and nursing personnel.
(30 Final decision regarding admissions to and discharges from the unit.
An appropriately trained physician with responsibility for the medical surgical unit
service.
The medical surgical unit service should have organized medical oversight, staffing, and
other requirements necessary for patient safety.
Medical surgical units already have policies and procedures governing activities such as
admission, discharge, procedures, etc. The proposed language will provide regulations
acknowledging current practices.
(b) A registered nurse with training and experience in the Medical and/or Surgical Unit service
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shall be respons ible for the nursing care and nursing management when a patient is present.
Nursing management for medical surgical units.
Medical surgical units already have nurse managers responsible for the nursing care on
the units. Proposed language will provide regulations consistent with current hospital
practice.
(c) All licensed nurses shall have had training and experience in care of medical and/or surgical
patients.
Training and experience in medical surgical nursing.
All direct care givers are required to maintain unit specific competency levels by Section
70213 (c). Additionally, studies show that the higher the qualifications of the nursing
staff, the better the quality of care.13
(d) The licensed nurse:patient ratio shall be 1:4 or fewer at all times.
Minimum staffing for medical and/or surgical units: One Licensed nurse to Four Patients
SEIU Nurse Alliance requests a ratio of one licensed nurse to four patients for the acutely ill
patients found on medical surgical units today. AB394(C.945 of 1999) requires specific staffing
ratios in general medical units. The proposed ratio is flexible enough for primary care nurse
staffing or team nursing. Nurses can be a combination of registered nurses and licensed
vocational nurses as long as there is at least one licensed nurse for every four patients. SEIU
does not propose a change in the scopes of practice of any licensed health professional.
13
Patricia A. Prescott, NURSING ECONOMICS, Nursing: An Important Component of Hospital Survival Under a
Reformed Health Care System, July-August 1993, Vol. 11, No. 4, p.193
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Over the past fifteen years, work redesign in hospitals, often called APatient Focused Care@,
has realigned staffing. And redesigns of staffing have led to lower staff hours per patient and
lower skilled, lower cost providers.14 Redesign has resulted in cuts in both licensed and
unlicensed personnel, including both those who provide direct hands on care and those who
support the work of direct care givers, including unit clerk, housekeepers, supply management,
engineering, pharmacy and other functions.
At the same time shorter more restricted hospital stays have resulted in inpatients with more
complex problems requiring more interventions than ever.15 Medical surgical patients today are
comparable to critical care patients twenty years ago. California regulations require a staffing
ratio of one licensed nurse to two patients in critical care units.
Patient classification systems are not providing adequate staffing for medical surgical units.
SEIU nurses report that they are often unable to meet patients= needs for adequate pain control,
patient teaching and monitoring and intervening in problems. Even simple tasks necessary to
maintain physical hygiene often go undone. This means that relying on patient classification
systems to remedy the inadequacies of too low ratios will not provide safe and adequate
careBmuch less the quality care called for by Governor Davis in his signing message.
Today every medical surgical nurse on every shift must do the following for every
patient:16
Make assessments of all patients on admission, and during the shift. Listen to heart,
lung and bowels sounds, check dressings, questions the patient, check skin color,
turgor and integrity, take vital signs, check oxygen saturation. Check and maintain
patency of all drains, intravenous and central lines. Admissions happen frequently
during the shift and it is not uncommon for patients to be admitted or transferred to
the unit and then discharged during the same shift.
Write and revise nursing care plans as necessary based on patient assessment,
physicians= orders and information supplied by other members of the healthcare
team. After making an assessment the nurse writes a care plan in detail that includes
the nursing diagnosis and doctor=s orders. The doctor may need to be notified of the
nursing diagnosis and order changed or added.
Initiate immediate interventions of identified problems based on protocols,
physicians= orders and/or current standards of nursing practice and notify
physicians of all problems requiring changes in intervention.
Supervise other licensed or unlicensed personnel as necessary and engage in
constant dialogue with other caregivers to ensure communication.
Constantly evaluate the effects of care to determine if changes in the care plan are
needed
14
15
Blegan, Goode, Reed, Nurse Staffing and Patient Outcomes, Nursing Research, Vol. 47, No.1, p. 43
Ibid.
16
All of these responsibilities are within the scope of practice of a registered nurse; most but not
all are also within the scope of practice of a licensed vocational nurse. Again, SEIU proposes
NO change in the scopes of practice of any licensed health professional.
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SEIU Hospital Staffing Proposal
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Assign and supervise or carry out ongoing patient and family teaching.
Chart all assessments and other patient care activities and record patient charges
according to the hospital’s system.
Record patient charges.
Answer telephones and patients’ call lights.
Today every medical surgical unit nurse will always do the following for at least
some patients during a shift:
Infuse blood and blood products, total parenteral nutrition, heparin drips, insulin, IV
antibiotics and other medications.
Ambulate patients and teach crutch walking.
Administer oral, subcutaneous, intramuscular, intraocular, rectal, intradermal,
intravenous and central line medications, including controlled substances, as ordered
and on time.
Infuse and titrate medications such as chemotherapeutic agents that require constant
monitoring.
Perform sterile, unsterile, or wet-to-dry dressing changes (wet-to-dry dressings are
applied to large open wounds).
Insert and care for multiple invasive lines such as foley catheters and nasogastric tubes.
Care for isolation patients with protective clothing and special handing of all trash and
linen.
Attend to patients= needs for hygiene and nutrition including bathing, shaving, linen
changes, feeding or serving food.
Track and record controlled substances.
Confer continuously with doctors and other caregivers, transport patients for treatments
and surgery.
Today every medical surgical unit nurse will often do some of the following for at
least some patients during a shift:
Spend an hour of the shift with just one patient starting an intravenous line if he or she
has difficult veins.
Change all peripheral lines every 72 hours, or more often.
Change and check dressings at least once per shift or more often if infection is involved.
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Assist physicians with minor surgeries such insertion and removal of chest tubes, bone
marrow biopsies, thoracenteses, paracenteses, lumbar punctures, liver biopsies, central
line insertions, needle aspirations, removal of drains, irrigation and drainage of wounds,
debridement of wounds, and monitor the patient during conscious sedation necessary for
many of these procedures. (An advisory by the Board of Registered Nursing states that
a registered nurse can have no responsibility for other patients during administration of
conscious sedation.17)
Adjust intravenous medications per protocol.
Administer inhalation therapy treatments and oxygen.
Respond appropriately to cardiac emergencies and still maintain adequate care level for
other patients.
Licensed nurses are expected to provide more sophisticated care to more patients of
higher acuity.
Until recently, some of the tasks listed above would have been performed only by a physician or
would have been performed in other, more specialized units of the hospital with additional
nursing staff.
Experienced nurses recommend no more than four medical surgical patients for one nurse.
Adequate ratios have worked well for critical care units for many years, and they are needed
now for today’s sicker patients in medical surgical units.
One nurse to four patients is the minimum safe staffing level for the acutely ill patients
found on medical surgical units today.
' 70220.4. Medical and/or Surgical Unit Service Equipment and Supplies.
'70220.4. Medical and/or Surgical Unit Service Equipment and Supplies.
Equipment and supplies shall include at least the following:
(10 Crash cart and DC defibrillator.
(20 Resuscitation equipment.
(30 Glucometer.
(40 Endotrachael suctioning equipment and supplies.
(50 An alarm system for summoning physicians or cardiac arrest teams.
(60 Oxygen administration equipment and supplies including intubation, tracheostomy and chest
tube insertion trays.
(70 Drainage and intermittent and continuous suction equipment.
(80 Urinary bladder catheterization supplies.
(90 Dressing supplies.
(100Irrigation and lavage suppies.
(110Restraints.
(120Adequate equipment for taking vital signs with separate equipment for isolation rooms.
(130Parenteral administration equipment and supplies including, but not limited to, syringes,
17
Board of Registered Nursing, Conscious Sedation, 9/95
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needles, intravenous tubing, intravenous fluids and plasma expanders, nasogastric tubes, and
equipment which regulates the administration of intravenous fluids and tube feedings.
(140 Portable datascope with oxygen monitor.
Supplies and equipment to meet the needs of medical surgical patients.
Adequate and appropriate supplies should be readily accessible at all times on the unit.
Delays in obtaining supplies put patients at risk of death, injury or permanent disability.
Down-sizing and cutbacks affect supplies as well as staffing. 18 Staffing cuts make
adequate and appropriate supplies more critical since caregivers do not have time to go
rummaging around to find what they need. Unfortunately, SEIU now routinely hears
complaints about lack of basic supplies such as soap and toilet paper for patients.
The proposed list of medical surgical unit supplies and equipment is similar to
requirements for other units recognized in regulation, but adapted for this specific unit.
70220.5. Medical and/or Surgical Unit Service Space.
(a) In addition to the construction requirements in Section T17-316, Title 24, California
Administrative Code, the following shall be met:
(1)Beds in the medical and/or surgical unit shall be included in the total licensed bed
capacity of the hospital.
Medical and /or Surgical unit beds counted as licensed beds.
The proposed language requires beds in medical and/or surgical units to be counted as
licensed beds and is consistent with existing language for other regulated hospital units. It
will prevent facilities from evading licensing requirements.
S. 70235 Anesthesia Service Staff
(e) There shall be sufficient licensed nurses to meet the needs of the patients.
(e) The licensed nurse to adult patient ratio shall be 1:2 or fewer at all times.
(f) The licensed nurse to pediatric patient ratio shall be one to one or fewer at all times.
(f)(g) Nurses......
Post Anesthesia Staff
Existing law (C. 945 of 1999) requires nurse to patient ratios in post anesthesia units.
Patients recovering from anesthesia are among the most acute and fragile in a hospital. Such
patients are at high risk because of suppression of respiration, risk of cardiac events, and danger of
post-operative complications, including bleeding, internal and external. Post anesthesia patients
require careful monitoring and rapid intervention. While anesthesia is one of the great inventions
that permitted modern medicine, it necessitates careful nursing care to assure the patient’s survival.
The acuity of post anesthesia patients in hospitals has increased because more than half of all
surgery is now done on an outpatient basis. The quick, simple procedures are done on an outpatient
18
Blegan, Goode, Reed, Nurse Staffing and Patient Outcomes, Nursing Research, Vol. 47, No. 1
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basis. Surgeries done on an inpatient basis are often lengthy and complicated. Length of surgery is
directly correlated with risk during recovery. Complicated procedures also increase risk of adverse
events during recovery.
Post anesthesia or recovery room nurses recommend a ratio of one nurse to two patients for adults
and one to one for pediatric patients who are more likely to crump with less warning. Pediatric
patients are also inclined to panic and to struggle uncontrollably as a result of fear and pain. Such a
reaction may require two to three nurses to manage a patient but one to one is the minimum safe
staffing.
' 70415. Basic Emergency Medical Service, Physician on Duty, Staff
(e)There shall be licensed nurses and additional skilled personnel as required to support the
services offered.
(e) The licensed nurse:patient ratio shall be 1:3 or fewer at all times in addition to the staffing in
70415,(f)(g)(h). Amended 7-11-01
(e) The number of licensed nurses and additional trained and skilled personnel shall be
determined on a yearly basis using the following system.
(1) One registered nurse to perform triage assessments.
(2) A second triage registered nurse shall be added when at least five patients are waiting
for an initial assessment or when the first triage registered nurse is unable to reassess
any patient within two hours.
(3) Core staffing shall be based on information that shall include, but not be limited to, the
previous yearly number of patient visits, time per visit, needs of the individual patient
population, season, day of the week, time of day and proximity to hospitals with
emergency department closures.
(4) An emergency department staffing committee composed of at least half emergency
department licensed personnel who provide direct care shall review the information in
order to determine staffing levels for the next year.
(5) The direct care emergency department licensed personnel members shall be appointed
by their legally recognized bargaining agent, or agents, if any. In cases where no legally
recognized bargaining agent represents direct care members, members of the committee
shall be elected by licensed direct care hospital staff whose staffing is determined by the
system.
(6) The director of nursing services shall appoint the non-direct care members of the
emergency department staffing committee who have experience in emergency room
nursing.
(7) (e) The staffing determined by the committee shall be a licensed nurse:patient ratio of
1:3 or fewer at all times in addition to the staffing in 70415,(e)(1)(f)(g)(h).
(f) A registered nurse shall be available to respond to trauma patients at all times.
(g) Staffing for a patient that a physician has determined to be ready for placement in a critical care
or step-down unit shall be in the same ratios as those required in critical care or step-down units.
(h) Additional skilled personnel shall be assigned as necessary to support the services. Amended 7-1101
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Minimum staffing for emergency room services.
SEIU Nurse Alliance supports adequate staffing ratios in emergency departments in
order to implement the intent of existing law (C.945 of 1999). A ratio of one licensed
nurse for every three patients is necessary to meet the needs of emergency room
patients.
A nurse manager=s concerns about ED staffing were reported in The Journal of
Emergency Nursing: AShe noted that many hospitals still look only to the number of
annual ED Avisits@ to determine staffing and that, while some semblance of acuity has
been factored in, it isn=t coming close to capturing the reality of how busy ED nurses
are.@ 19
First, fewer patients with health insurance and emergency room closures have turned
EDs into busy places, with a wide variety of patient problems. As ED nurses struggle to
meet the needs of an ever expanding uninsured population, current staffing patterns
have become inadequate.
Today=s ED nurses must be counselors, specialists in collection of evidence for police
labs, triage decision makers.
In one shift, an emergency room nurse may see:
Minor trauma cases such as broken bones, sprains , cuts, bruises,and domestic
violence.
Victims of child abuse, elder abuse, and sexual assault patients in need of counseling.
Patients with altered mental status due to substance abuse, intoxicated patients.who
can=t walk and are brought in to be sobered up and deloused
Diabetics with a recent seizure history who may have had a trauma that puts them at risk
of infection and loss of limb.
Patients getting surgeries such as dilation and currettage, irrigation and drainage of
abcesses or wound closures who need close monitoring while getting short-acting
anesthetics: surgeries and anesthesia that would have been done in the operating
room until recently.
Children with high fevers and inexplicable illnesses.
Patients with chest pain, for whom the ER must rule out myocardial infarction, and
patients with unstable myocardial infarctions who require close monitoring, extra lab
tests and multiple interventions, such as cardioversion.
In addition to nurses giving direct care, nurses are needed to support the services.
Discharge counseling may require a full time nurse to give out medications and make
19
Lenahan, Gail Pisarcik, Journal of Emergecy Nursing, ED short staffing: It is time to take a hard look at a growing
problem and strategies such as standard nurse-patient ratios, April 1999, vol. 25, No. 2
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follow-up appointments. Another nurse may do only medical screening exams (triage).
Emergency room visits are often no longer just Avisits@, they are Astays@. ED patients
may stay two hours to thirty-six hours waiting for treatments, labs, consultations and
authorizations for care. ED patients are also stacked waiting for beds in other units,
especially intensive care. During such stays, these patients require monitoring and
medications as well as assistance with activities of daily living such as visits to the
bathroom and telephone calls.
Short-staffing in at least one ED has resulted in a public complaint. Marsha Carter, a 52year old patient hospitalized with asthma the last week of March, 1999 took her story to
the Ventura County Star after being left for 12 hours in the emergency room of St.
John=s Regional Medical Center where she was told Aa bed might open up soon@, but in
the meantime, Ashe would have to continue to wait, wearing her wet hospital gown and
lying on a urine-damp sheet@. Marsha finally left against medical advice to care for
herself at home during a Alife-threatening situation@.20
In order to avoid this kind of care, experienced emergency room nurses recommend that
the patients in the emergency room require staffing in a ratio of not more than three per
nurse.
(f) A registered nurse shall be available to respond to trauma patients at all times.
A registered nurse available at all times for trauma patients.
At least one registered nurse should be available at all times for the care of trauma patients
in the ED.
20
Koehler, Tamara, Ventura County Star, Hospital cost-cutting, April 1999
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It may, at times, take one registered nurse to rapidly infuse fluids, one for assessments and
one for other interventions. The trauma team may include other health care members, but
the trauma nurse is often responsible for implementation and coordination of the care of the
trauma victim.21
SEIU Nurse Alliance requests additions to the regulations to ensure a registered nurse with
training and experience in the care of trauma patients is available when necessary.
(g) Staffing for a patient that a physician has determined to be ready for placement in a critical care
unit shall be in the same ratios as those required in critical care units. Amended 7-11-01
Staffing for critical care patients.
Critical care patients have special needs for monitoring and interventions and require
appropriately trained and experienced staff in the correct nurse to patient ratio to ensure
positive outcomes.
The existing staffing ratio of 1 licensed nurse for two patients in critical care units has proven
effective in assuring safe and adequate care. Holding critical care patients in an emergency
department for extended periods is a plain effort to evade the intent of this existing
regulation.
The Emergency Nurses Association reports that patients are now spending more and more
time in EDs. They may be held in the ED for up to 36 hours. 22 Some of these patients are
critically ill patients who are awaiting transfer to an appropriately staffed critical care unit. ED
staff must continue to receive and care for other patients while critically ill patients may not
receive care in the same nurse to patient ratio they would in a critical care unit. 23
The American Academy of Pediatrics recommends a ratio of 1.0/1.5 nurses per pediatric
patient requiring intensive care24. Sections 70465 & 70495 require ratios of not less than one
nurse for two adult patients in critical care units.
SEIU Nurse Alliance requests additions to the regulations to require the same level of
staffing for critical care patients in the same ratios as those required in critical care units.
(h) Additional skilled personnel shall be assigned as necessary to support the services.
Acuity of individual patients determines additional staffing needs.
Acuity of patients may warrant the assignment of additional licensed and unlicensed
staff.
21
Jacobs, Barbara Bennett, Emergency Nurses Association, Trauma Nursing Core Course, 1995, pp.1-9
ENA Position Statement, Hospital and Emergency Department Overcrowding, 1996
23 Department of Health Services, Statement of Deficiencies, #05-0011898,p. 5
23 Department of Health Services, Statement of Deficiencies, #05-0011898,p.2,#05-0011896,p.3
22
24
American Academy of Pediatrics, Hospital Care of Children & Youth, 1978, p.9
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'70455. Comprehensive Emergency Medical Service Staff.
(e)There shall be licensed nurses and additional skilled personnel as required to support the
services offered.
(e) The licensed nurse:patient ratio shall be 1:3 or fewer at all times in addition to the staffing in
70415,(f)(g)(h).
(f) A registered nurse shall be available to respond to trauma patients at all times.
(g) Staffing for a patient that a physician has determined to be ready for placement in a critical
care unit shall be in the same ratios as those required in critical care units.
(h)There shall be additional licensed and skilled personnel shall be assigned as necessary to
support the services.
* Justification for proposed amendments are same as under Section 70415.
'70440. Neurosurgery Radiological Intervention Unit Service
'70440. Neurosurgery Radiological Intervention Unit Service.
(a)Neurosurgery radiological intervention service means a service to perform procedures for
obtaining physiologic, pathologic, and angiographic data on patients with neurological disease or
to correct neurological disease or conditions.
A defined service for patients receiving radiological neurosurgical interventions.
The neurosurgery radiological intervention unit service should be defined and
recognized in regulations in order to provide organized minimal oversight,
staffing, and other requirements.
Invasive procedures occur on neurosurgery radiological intervention units that
were only performed in the operating room a few years ago. In many instances,
these procedures are more complicated than those previously performed in the
operating room because of the accuracy of the technology permits finer
interventions that requires more precise and careful work. For example,
corrective interventions are performed on arterio-venous malformations.
70440.1 Neurosurgery Radiological Intervention Unit Service Staff.
(a)A physician shall have overall responsibility for the service. This physician shall be certified or
eligible for certification by the American Board of Neurosurgery. The physician shall be
responsible for:
(1)Establishing and implementing policies and procedures.
(2)Supervision and training of all personnel, including in-service training and continuing
education.
(3) Assuring proper safety, function, maintenance and calibration of all equipment.
(4) Maintaining a record of all procedures performed.
(b)A physician who is certified or eligible for certification by the American Board of Radiology
with special training or experience in neurosurgery radiology shall be available to the
neurosurgery radiological intervention service staff.
(c) Two registered nurses, with training and experience in neurosurgery radiological
interventions and procedures shall be present during the performance of all neurosurgery
radiological interventions and procedures.
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A registered nurse should be present in order to assist as required during all neurosurgery
radiological intervention procedures. These procedures require handling complex sterile
supplies and instruments, administration of intravenous medications, set-up and preparation for
general anesthesia and post-operative care.
Similar procedures are performed in the operating room where current regulations require the
presence of a registered nurse.
One registered nurse per unit is the current minimum required by Section70217. (i).
SEIU Nurse Alliance requests an addition to the regulations to require at least one registered
nurse on a unit where neurosurgery is regularly performed under general anesthesia.
(e) Additional personnel with training and experience in neurosurgical radiological intervention
procedures shall be assigned as necessary.
Additional personnel may be required during procedures.
An additional licensed nurse or other supportive personnel may be required to
assist during the surgeon or anesthesiologist during procedures.
Many patients requiring these procedures are critically ill. The one required registered
nurse may be fully occupied assisting the anesthesiologist, assisting the surgeon, or
obtaining and setting up additional supplies. More qualified supportive personnel may be
needed.
(1)Anesthesia for neurosurgery radiological procedures shall be administered by a physician
who is certified or eligible for certification by the American Board of Anesthesiology.
Only an appropriately trained anesthesiologist to anesthetize patients for neurological
radiological intervention procedures.
Many physicians with no formal training in anesthesia are providing anesthesia services
to patients in California. They have had no preparation other than on-the-job training,
coaching and reading.
Neruosurgical radiological procedures are very delicate procedures often performed on
critically ill patients. Additionally, the acuity of neurosurgical patients warrants the use of
only appropriately trained anesthesiologists.
' 70470.1. Telemetry Unit Service
' 70470.1. Telemetry Unit Service Definition.
Telemetry unit service means a unit in which there are specially trained nursing and supportive
personnel with necessary diagnostic and monitoring equipment necessary to provide medical
and nursing care to patients in a stable condition suspected of or having coronary heart disease,
heart failure or dysrhythmia or multiple systems problems requiring cardiac monitoring.
A defined service for telemetry patients.
Telemetry units should be defined and recognized in regulations in order to provide organized
minimal medical oversight, staffing, and other requirements.
Working nurses, nursing administration and state surveyors need clearly defined and outlined
regulations that directly apply to telemetry unit patients. Patients placed on telemetry units
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deserve the same quality of oversight as all other units in the hospital.
The acuity level of patients in telemetry units equals the level of acuity of critical care patients
twenty years ago. To fail to acknowledge these patients in regulations is a disservice to
patients and nurses who need clear written direction for the oversight and planning of their
care.
SEIU Nurse Alliance proposes addition of the above regulations to recognize units that have
existed in hospitals for many years.
' 70470.2. Telemetry Unit Service General Requirements.
(a)Written policies and procedures shall be developed and maintained by the person
responsible for the service in consultation with other appropriate health professionals and
administration. Policies shall be approved by the governing body. Procedures shall be
approved by the administration and medical staff where such is appropriate. The policies and
procedures shall include but not be limited to:
(10 Admission, discharge, and transfer policies.
(20 Staffing requirements.
(30 Routine procedures.
(40 Emergency procedures.
(b) The responsibility and accountability of the telemetry unit service to the medical staff and
administration shall be defined.
Oversight for telemetry units.
Patients placed on telemetry units need the same quality of oversight and continuity of
care as all other units in the hospital.
Telemetry units already have policies and procedures governing activities such as
admission, discharge, procedures, etc. The proposed language will provide regulations
that recognize current practices.
' 70470.3. Telemetry Unit Service Staff.
A physician with training and experience in cardiovascular disease shall have overall
responsibility for the service. The physician shall be responsible for:
(1) Implementation of established policies and procedures.
(2) Assuring there is continuing education for the medical staff and nursing personnel.
Final decision regarding admissions to and discharges from the unit.
A physician to oversee the care of medical surgical patients.
A physician with training and experience in cardiovascular disease care should over see
the care of patients in telemetry units. Patients in telemetry units are receiving a variety
of interventions very similar to those in coronary care units. They may be receiving
vasopressors, multiple antibiotics, multiple treatments, and have multiple monitoring
devices. Their acuity is on a close level with patients placed in coronary care units.
Telemetry unit patients require a standard of oversight similar to the standards in
coronary care units, including an appropriately trained and experienced physician.
A registered nurse with training and experience in the telemetry unit service shall be responsible
for the nursing care and nursing management when a patient is present.
Nursing management for telemetry units.
Telemetry units now have nurse managers responsible for the nursing care on the units.
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Proposed language will provide regulations consistent with current hospital practice.
All licensed nurses shall have had training and experience in care of patients requiring telemetry
monitoring.
Nurses trained and experienced in the care of patients on telemetry units.
The proposed language is consistent with current requirements for competency before
receiving a patient care assignment in Section 70214.
(d)The nurse:patient ratio shall be 1:3 or fewer at all times. Licensed vocational nurses may
constitute up to 50 percent of the licensed nurses.
Minimum staffing for the telemetry unit service.
Existing law (c.945 of 1999) requires specific ratios for telemetry units. SEIU supports
adequate ratios.
Telemetry patients have the acuity of intensive care patients of the early 1970's and
require a comparable level of intervention. A ratio of 1:3 is barely sufficient to assure
safe careCand is a lower standard than California adopted in 1975 for patients requiring
as many medications, as many treatments, and as much monitoring.
Patricia Benner, Professor of Physiological Nursing at University of California at San
Francisco School of Nursing explains, AYthe acuity level of patients is far higher than it
used to be and that most of these patients have conditions where there is very little room
for error. They need instantaneous interventions and great skill@25
Telemetry unit patients are often one half step out of a critical care unit or have multiple
systems problems requiring close monitoring. It is critical they are cared for by adequate
numbers of skilled licensed nursing staff.
Telemetry patients have serious, but usually stable cardiac problems. They require close
monitoring. These patients often have multiple systems problems requiring many
medications: the more medications, the greater the danger of medication interactions,
the greater the need for monitoring and the greater the danger of medication errors due
to sheer complicatedness. Most telemetry patients have an intravenous line and are
elderly and thus require substantial assistance with activities of daily living. Such
assistance provides the registered nurse with an opportunity for assessment of the
patient.
Other states are looking at minimum staffing requirements for telemetry units. Senator
Joseph F. Vitale, New Jersey introduced SB 1755, on March 15, 1999; an act to direct
Department of Health and Senior Services to adopt regulations establishing minimum
nurse to patient ratios for telemetry units.
SEIU Nurse Alliance requests additions to the regulations to set standardized minimum
nurse to patient ratios for all California hospitals. One licensed nurse for every three
patients on a telemetry unit is the minimum safe level for the acutely ill patients found
on telemetry units.
' 70470.4.(e) Telemetry patients on hospital units other than a telemetry or critical care unit,
shall be cared for by nursing staff with training and experience in the care of patients requiring
25
Blau, Esther, The Coastal Post, The Disastrous Effects of Greed in Hospital Care, May, 1996.
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telemetry monitoring. The nurse:patient ratio shall be 1:3 or fewer at all times.
Telemetry patients receive the same level of care throughout the hospital.
Telemetry patients on medical surgical or other hospital units require the same quantity
and quality of nursing care as those in telemetry units. Staffing levels and staff
expertise for telemetry patients should be the same regardless of unit placement.
' 70470.4(f) A licensed nurse or other supportive staff with training and experience in
recognition of cardiac dysrhythmias shall continuously observe the electrocardiographic
oscilloscopic monitors.
Telemetry monitors observed at all times.
A licensed nurse or other supportive staff who are properly trained in recognition of
cardiac dysrhythmias should continuously observe the cardiac monitor at all times.
Some hospitals now assert that their telemetry equipment does not require continuous
observation by qualified staff. This trend has resulted in at least one death in a California
hospital. At Sutter Medical Center of Santa Rosa, nursing administration at the hospital
maintained that, AY after the placement of the Zymed Telemetry system in 1997, an
assigned 24 hour dedicated monitor watchers was no longer necessaryY:26 In March,
1998, the husband of a 79 year old telemetry patient Acame out of the room and stated,
>My wife needs help she=s having a seizure.= The patient is found unresponsive,
cyanotic, and without a pulse.@ She later expired after transfer to a critical care unit.
Nurses who have used electronic devices designed to permit distant monitoring of
telemetry report chronic error, including both inaccurate over-reporting of cardiac events
and failing to report cardiac events: in both instances, nurses are unable to react
appropriately. Physical observation of the monitors is necessary given even the finest
technology now available.
Patients can be placed at serious risk if cardiac monitors are not continuously observed
and dysrrhythmias are not responded to appropriately. Patients are placed on telemetry
units in order to receive cardiac monitoring and treat or prevent potential problems
resulting from cardiac events.
SEIU Nurse Alliance requests additions to the regulations to require California hospitals
to provide appropriately trained personnel to continuously observe cardiac monitors.
' 70470.4. Telemetry Unit Service Equipment and Supplies.
(a)Equipment and supplies shall include at least the following:
(10 Cardiac monitoring for each bed.
(20 Crash cart and DC defibrillator.
(30 Resuscitative equipment.
(40An intercommunication system connected to the nearest continuously staffed nurses=
station, which will enable the nurse or physician to contact the nearby unit without leaving the
telemetry unit.
(50An alarm system for summoning physicians or cardiac arrest teams.
(60Refrigerated storage for drugs and biologicals.
(70 Glucometer.
(80 Endodotrachael suctioning equipment and supplies.
(90 An alarm system for summoning physicians or cardiac arrest teams.
(100 Oxygen administration equipment and supplies including intubation, tracheostomy and
26
Department of Health Services, Doc. No. 01-0008523
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chest tube insertion trays.
(110 Drainage and intermittent and continuous suction equipment.
(120 Urinary bladder catheterization supplies.
(130 Dressing supplies.
(140 Irrigation and lavage suppies.
(150 Restraints.
(160 Adequate equipment for taking vital signs with separate equipment for isolation rooms.
(170 Parenteral administration equipment and supplies including, but not limited to, syringes,
needles, intravenous tubing, intravenous fluids and plasma expanders, nasogastric tubes, and
equipment which regulates the administration of intravenous fluids and tube feedings.
Supplies and equipment to meet the needs of telemetry patients.
Adequate and appropriate supplies should be easily accessible at all times on the unit.
Down-sizing and cutbacks can affect all levels of care in hospitals 27 Great cost savings
can be realized by reducing inventories of medical supplies, yet cost cutting must be
balanced with patients= care needs and be prioritized.
Nurses and other staff are frequently under time pressures to meet patients= need. The
above list of supplies, though by no means inclusive of all supplies needed, will meet the
basic needs of telemetry patients and is standard to most medical surgical units.
The proposed list of telemetry unit supplies and equipment is similar to requirements for
other units recognized in regulation, but adapted for this specific unit.
' 70470.5. Telemetry Unit Service Space.
In addition to the construction requirements in Section T17-316, Title 24, California
Administrative Code, the following shall be met:
(1)Beds in the telemetry unit shall be included in the total licensed bed capacity of the
hospital.
Telemetry unit beds counted as licensed beds.
The proposed language requires beds in telemetry units to be counted as licensed beds
and is consistent with existing language for other regulated hospital units.
' 70485. Intensive Care Newborn Nursery Service Staff
(g) A respiratory therapist trained in the respiratory care of the newborn shall be available to the
service present at all times in a ratio of one respiratory care practitoner: two or fewer intensive
care patients are receiving ventilator support.
Sufficient respiratory care practitioners for intensive care newborns.
In intensive care newborn nurseries, respiratory care practitioners (RCPs) have
responsibility for the control of life support equipment for critically ill newborns. Yet, cost
pressures in some hospitals have reduced the number of RCPs in the entire hospital on
the night shift to one RCP to care for patients in intensive care units, emergency rooms,
and all other units. Many of these units have ventilator dependent patients whose needs
do not decrease at night. This staffing stretches, and exceeds, the limits of an
acceptable standard of care. RCPs report they make it through many nights just
hoping one more patient doesn=t go sour or no more are admitted until help
27
Blegan, Goode, Reed, Nurse Staffing and Patient Outcomes, Nursing Research, Vol. 47, No. 1
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arrives in the morning.
This is not an acceptable standard of care.
Newborns in intensive care nurseries are sicker than ever. Twenty years ago, no one
could have expected the survival of newborn infants below 24 weeks, yet now because
of advanced techniques, infant survival below 24 weeks sometimes occurs.
Technology advances may improve the outlook for sick newborns, but will also require
more skilled caregivers. Respiratory care services must be provided by practitioners with
documented competency. RCPs are particularly qualified to assess patients with
respiratory problems and to deliver the various modalities of respiratory care. 28
RCPs undergo unique and rigorous formalized nationally accredited training. Other
practitioners who may be expected to delivery respiratory care services have had little or
no formal training.29
Sick newborns should get an acceptable standard of respiratory care twenty- four hours
a day in an intensive care nursery. American College of Obstetricians and Gynecologists
recommends that an RCP be immediately available to the unit.30
SEIU Nurse Alliance proposes regulations to ensure the presence of an RCP when at
least two newborns are receiving ventilator support in an intensive care nursery.
' 70495. Intensive Care Service Staff.
(f) An inhalation therapist, A physical therapist, and other supportive service staff shall be
available depending upon the requirements of the service.
(g) Respiratory care practitioners shall be present in the unit at all times in a ratio of one
respiratory care practitioner:four or fewer intensive care patients who are receiving ventilator
support.
Adequate respiratory care practitioners for intensive care patients on ventilators.
Respiratory Care Practitioners have responsibility for the control of life support
equipment for critically ill patients. Yet, efforts have been made in hospitals to reduce the
number of RCPs in the entire hospital. RCPs are required to maintain life-supporting
ventilators for numbers of patients in intensive care units, answer trauma calls in the
emergency room and perform inhalation therapy treatments in between.
Critically ill patients need the attendance of a properly trained licensed professional at all
times. The American College of Chest Physicians explains:
28
American College of Chest Physicians, Role of Respiratory Care Practitioners in the Delivery of
Respiratory Care Services, July, 1997, p.1
29 American Society of Anesthesiologists, Statement of Support for Respiratory Care Practitioners, Oct.
1996
30 American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, p. 22
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AAlthough other health-care providers may possess necessary training and experience
to deliver simple modalities of respiratory care, the RCP is uniquely qualified to assist the
physician in assessing the overall respiratory needs of patients, and in recommending
and delivering the necessary care.@31
SEIU Nurse Alliance recommends the addition of respiratory care practitioner staffing
ratios for critical care patients. RCPs in California recommend a ratio of one RCP for
four patients requiring ventilator support.
' 70500.1. Step-Down Unit Service
' 70500.1. Step-Down Unit Service.
A step-down unit service means a unit in which there are specially trained nursing and
supportive personnel with necessary diagnostic and monitoring equipment necessary to provide
medical and nursing care to stable patients transferred from a critical care area or stable
patients requiring close monitoring. Amended 7-11-01
A unit for the monitoring and care of patients with moderate physiologic instability, not requiring
aggressive hemodynamic/invasive monitoring, requiring technical support but not necessarily
artificial life support, a unit reserved for those patients requiring less care than standard intensive
care, but more than that which is available from medical-surgical care. Amended 7-11-01
A defined service for patients in step-down units.
Stepdown units should be defined and recognized in regulations in order to provide
organized minimal medical oversight, staffing, and other requirements.
Working nurses, nursing administration and state surveyors need clearly defined and
outlined regulations that directly apply to step-down unit patients. Patients placed on
step-down units deserve the same quality of oversight as all other units in the hospital.
The acuity level of patients in step-down units equals, or exceeds, the level of acuity of
critical care patients twenty years ago. To fail to acknowledge these patients in
regulations is a disservice to patients and nurses who need clear direction the oversight
of their care.
SEIU Nurse Alliance proposes addition of the above regulations to recognize the
existence of hospital units that have existed in hospitals for many years.
' 70500.2. Step-Down Unit Service General Requirements.
(a)Written policies and procedures shall be developed and maintained by the person
responsible for the service in consultation with other appropriate health professionals and
administration. Policies shall be approved by the governing body. Procedures shall be
approved by the administration and medical staff where such is appropriate. The policies and
procedures shall include but not be limited to:
(1)Admission, discharge, and transfer policies.
(2)Staffing requirements.
(3)Routine procedures.
(4)Emergency procedures.
(b)The responsibility and accountability of the close observation unit service to the medical staff
and administration shall be defined.
Oversight for step-down units.
31
American College of Chest Physicians, Role of Respiratory Care Practitioners in the Delivery of
Respiratory Care Services, July, 1997, p.1
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Patients placed on step-down should get the same quality of oversight and continuity of
care as all other units in the hospital.
Step-down units already have policies and procedures governing activities such as
admission, discharge, procedures, etc. The proposed language will provide regulations
that recognize current practices.
' 70500.3. Step-Down Unit Service Staff.
(a)A physician with training in and experience in critical care shall have overall responsibility for
the service. The physician shall be responsible for:
(1) Implementation of established policies and procedures.
(2) Assuring there is a continuing education for the medical staff and nursing personnel.
(3)Final decision regarding admissions to and discharges from the unit.
A physician to oversee the care of critically patients transferred to step-down units.
A physician with training and experience in critical care should over see the care of
patients in step-down units.
Patients in step-down units are receiving a variety of interventions very similar to those in
critical care units. They may be getting ventilator support, receiving vasopressors,
multiple antibiotics, multiple treatments, and have multiple monitoring devices. Their
acuity is as high or higher than patients now placed in critical care units.
Step-down unit patients require a standard of oversight similar to the standards in critical
care units, including an appropriately trained and experienced physician.
A registered nurse with training and experience in the critical care nursing shall be responsible
for the nursing care and nursing management when a patient is present.
Nursing management for step-down units.
Step-down units now have nurse managers responsible for the nursing care on the units.
Proposed language will provide regulations consistent with current hospital practice.
All licensed nurses shall have had training and experience in care of critical care patients.
Nurses trained and experienced in the care of patients on step-down units.
The proposed language is consistent with current requirements for competency before
receiving a patient care assignment in Section 70214. The high acuity of step-down
patients warrants a requirement for nurses to be competent in the care of critical care
patients.
(d)The nurse:patient ratio shall be 1:2 3 or fewer at all times. Licensed vocational nurses may
constitute up to 50 percent of the licensed nurses.
Minimum staffing for the step-down unit service.
Existing law (C.945 of 1999) requires specific staffing ratios in stepdown units. Hospitals
with higher nurse to patient ratios and richer skill mixes have been demonstrated to have
lower mortality rates.32
32
Patricia A.Prescott, NURSING ECONOMICS, Nursing: An Important Component of Hospital Survival Under a
Reformed Health Care System, July-August 1993, Vol. 11, No. 4, p.193
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Stepdown unit patients are most often patients recently transferred from an intensive
care unit who would have been considered ICU patients until recently.
Most have multiple system problems, including cardiac difficulties: this is evidenced by
the fact that stepdown patients automatically receive cardiac monitoring. Many are
recovering from serious procedures such as open heart surgery, major vascular
procedure or radical neck surgery.
Other patients, often younger, are post-trauma cases who are recovering from multiple
surgical procedures such as major orthopedic, vascular, plastic, neurological and/or
opthomalgic surgery. These patients require close monitoring and frequent adjustment of
treatment and medications during prolonged hospitalization.
Patients often need prolonged ventilator support. Their stability, blood pressure and body
systems are maintained by multiple drugs and treatments: they require monitoring as
intense as that of intensive care patients. Step-down patients often have chest tubes,
opening the chest cavity to the danger of infection and indicating serious lung condition.
These patients may breathing treatments at frequent intervals and monitoring for the
need for treatment.
Some require progressive ambulation which includes monitoring, taking vital signs,
physically walking with each patient, then monitoring after in a pattern.
Nurses on step down units assist with treatments, post operative teaching, planning for
discharge.
Nurses on these units also monitor and adjust dopamine or heparin drips according to
protocols. Patients may have multiple intravenous lines with medications infusing such as
dopamine or nipride. Heparin drips are adjusted in accordance with assessment of the
patients and physician=s orders: a minute error in heparin dosage can lead to death. The
protocols for care are the same as for critical care.
Ventilators patients may be chronic but very sick. They need lots of suctioning, turning,
and range of motion interventions as well as assistance with almost every activity of daily
living.
Post cardiac catheterization patients are equally ill.
In addition, patients that are there to rule out myocardial infarction need frequent EKGs
done by nurses.
Stepdown patients routinely are subjected to conscious sedation and cardioversion, both
of which require one registered nurse to one patient ratios during the performance of the
procedure. Staffing must be adequate to assure that other patients receive care while
such procedures are performed.
Nurses are required to Apush@ drugs that previously were only pushed in critical care.
SEIU Nurse Alliance requests additions to the regulations to set standardized minimum
nurse to patient ratios for all California hospitals. One licensed nurse for every two
three patients is the bottom line for the acutely ill patients found on step-down units.
' 70500.4. Step-Down Unit Service Equipment and Supplies.
(a)Equipment and supplies shall include at least the following:
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(1) Cardiac monitoring for each bed.
(2) Crash cart and DC defibrillator.
(3) Resuscitative equipment.
(4)An intercommunication system connected to the nearest continuously staffed nurses= station,
which will enable the nurse or physician to contact the nearby unit without leaving the telemetry
unit.
(5) An alarm system for summoning physicians or cardiac arrest teams.
(6) Refrigerated storage for drugs and biologicals.
(7) Glucometer.
(8) Endodotrachael suctioning equipment and supplies.
(9) An alarm system for summoning physicians or cardiac arrest teams.
(10) Oxygen administration equipment and supplies including intubation, tracheostomy and
chest tube insertion trays.
(11) Drainage and intermittent and continuous suction equipment.
(12) Urinary bladder catheterization supplies.
(13) Dressing supplies.
(14) Irrigation and lavage supplies.
(15) Restraints.
(16) Adequate equipment for taking vital signs with separate equipment for isolation rooms.
(17) Parenteral administration equipment and supplies including, but not limited to, syringes,
needles, intravenous tubing, intravenous fluids and plasma expanders, nasogastric tubes, and
equipment which regulates the administration of intravenous fluids and tube feedings.
Supplies and equipment to meet the needs of step-down unit patients.
Adequate and appropriate supplies should be easily accessible at all times on the unit.
Down-sizing and cutbacks can affect all levels of care in hospitals. 33 Great cost savings
can be realized by reducing inventories of medical supplies, yet cost cutting must be
balanced with patients= care needs and be prioritized.
Nurses and other staff are frequently under time pressures to meet patients= need. The
above list of supplies, though by no means inclusive of all supplies needed, will meet the
basic needs of step-down unit patients and is standard to most step-down units.
The proposed list of step-down unit supplies and equipment is similar to requirements for
critical care units recognized in regulation, but adapted for this specific unit.
' 70500.5. Step-Down Unit Service Space.
(a) In addition to the construction requirements in Section T17-316, Title 24, California
Administrative Code, the following shall be met:
(1)Beds in the close observation unit shall be included in the total licensed bed capacity of
the hospital.
Step-down unit beds counted as licensed beds.
The proposed language requires beds in step-down units to be counted as licensed beds
and is consistent with existing language for other regulated hospital units.
' 70539. Pediatric Service Staff
(d)The nurse:patient ratio shall be 1:3 or fewer at all times. Licensed vocational nurses may
33
Blegan, Goode, Reed, Nurse Staffing and Patient Outcomes, Nursing Research, Vol. 47, No. 1
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constitute up to 50 percent of the licensed nurses.
Minimum staffing for the pediatric unit service.
In 1978, the American Academy of Pediatrics recommended staffing ratios of between
two to five patients per nurse on intermediate and standard pediatric units.34 The
Academy has not published new recommendations since then and the acuity of all
hospitalized patients is higher in 1999.
SEIU Nurse Alliance requests additions to the regulations to set standardized minimum
nurse to patient ratios for all California hospitals. Our proposed ratio allows for flexibility
in staffing models for various California hospitals based on the acuity of patients. One
licensed nurse for every three patients is the minimum necessary to care for
acutely ill patients found on pediatric units.
(d) There shall be a registered nurse:patient ratio of 1:3 or fewer at all times for pediatric
oncology patients requiring chemotherapeutic treatments.
Registered nurses required for pediatric patients receiving chemotherapy.
Only registered nurses may infuse intravenous chemotherapeutic medications required
for oncology pediatric patients after receiving specialized training. 35 In addition, the
acuity of these patients is high. The care plans for these patients require frequent
changes and close monitoring.36
SEIU Nurse Alliance proposes regulations to require at least one registered nurse per
three pediatric oncology patients receiving chemotherapy.
(d)(e) There shall be sufficient other trained and experienced staff to provide adequate
care.
Additional staff based on acuity.
The acuity of individual patients may require additional licensed or unlicensed staff to
meet the specific needs of patients.
(e)(f) There shall be evidence of continuing education and training for the nursing staff in
pediatric nursing and pediatric resuscitation.
Training in pediatric resuscitation for pediatric staff.
It is critical to the safety of pediatric patients that all pediatric nursing staff receive
adequate training in pediatric resuscitation. The higher the qualifications of the nursing
staff, the better the quality of care.37
The requirement for all pediatric staff to receive training in life support for pediatric
patients is standard in hospitals. This proposed language recognizes current practices
by placing them in regulations.
34
American Academy of Pediatrics, Hospital Care of Children & Youth, 1978, p.9
Business and Professions Code. Chapter 6. Article 2. Section 2725(a-d)
36 California Code of Regulations.Title 16. Div.14. Article 4. Section 1443.5
37 Patricia A. Prescott, NURSING ECONOMICS, Nursing: An Important Component of Hospital Survival
Under a Reformed Health Care System, July-August 1993, Vol. 11, No. 4, p.193
35
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(g) Pediatric patients receiving care on a non-pediatric unit shall shall be cared for by nursing
staff with training and experience in the care of pediatric patients. The licensed nurse:patient
ratio shall be 1:3 or fewer at all times.
Pediatric patients receive the same standard of care regardless of unit placement.
Pediatric patients on other hospital units require the same quantity and quality of nursing
care as those in pediatric units. The standard of care for pediatric patients should be the
same regardless of unit placement.
' 70547. Perinatal Unit General Requirements.
(k) Rooming in should be permitted if requested in writing by the family. The family shall have
the right to refuse rooming in. All written information provided to the family describing perinatal
services will include information about access to the well-baby nursery.
Safety for baby while mother rests.
Hospitals should be required to document families= requests for rooming in and keep it
in the patient record. Families should have the right to refuse rooming-in for any reason
and be informed, in their own language, about access to the well-baby nursery.
Cost saving has placed babies at risk in the hospital environment. Hospitals all over
California have been cited repeatedly for failure to maintain well-baby nurseries.
Oftentimes, the nursery is a storage place for furniture and baby is carried around by the
nurse from room to room, placed at the nurse=s station, or in the hallway when mother
needs rest.38 Parents are never informed of these situations that place their newborns at
risk of abduction, infection, and other hazards.
Many hospitals provide beautiful literature to new parents about ACouplet Care@ and
rooming-in.39 They correlate the advantages of rooming-in with bonding and breastfeeding. For example, one brochure states AWe strongly encourage you to have
someone stay with you until you are discharged to help you with the baby.@40 However,
this literature does not inform the parents of their right to keep baby safely in the nursery
if no help from home is coming.41 It is unrealistic to expect that all new mothers will be
able to be accompanied 24 hours a day during their hospital stay.
Many new mothers want to have baby close by, but there are also times when they need
rest. Some new
mothers have just had
surgery such as a
Caesarian section or
sterilization procedure
and are not fully
recovered from
anesthesia. Others
just want to take a
shower or sleep after
the rigors of labor and
delivery.
38
Department of Health Services, Complaint #08-0013942 & # 6580
Sutter Medical Center of Santa Rosa, Perinatal Services brochure, Dec. 1997
40 Kaiser Santa Rosa, Prenatal Newsletter#7
41 My Baby Myself, Guide to Mother and Baby Care 1999
39
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Ana Gray tells her experience in a hospital without a nursery:
AThe worst part of my stay was after midnight with zero sleep since 4:30 am the morning
before when I asked my nurse if my son, who was fussy and not allowing me to get some
rest, could be watched for two hours. I was told they no longer had a nursery and
couldn=t take the babies anymore. I couldn=t believe it and all I could do was cry; sob
may be a better word from pure exhaustion.@42
There is no evidence that families are requesting rooming-in. Department of Health
Services has refused to enforce the current regulation as it is now written. Written
requests for rooming-in are necessary to ensure patients= knowledge of their rights to
nursery care. All literature presented to parents should present clear information about
nursery care.
' 70549. Perinatal Unit Staff.
(c) There shall be one registered nurse on duty on each shift assigned to the labor and delivery
suite. In addition, there shall be sufficient other trained personnel to assist the family, monitor
and evaluate labor and assist with the delivery.
There shall be additional staff assigned with the following system:
(1)Laboring patients shall have registered nurse to patient ratios of 1:2 or less at
all times.
A registered nurse to care for patients in labor.
The acuity of patients in labor requires the attendance of a registered nurse.
42
Ana Gray, Letter, July 1995
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SEIU Nurse Alliance recommendations for a minimum ratio of one registered nurse to
two laboring patients or less is are taken from the American College of Obstetricians and
Gynecologists, AGuidelines for Perinatal Care@.43
(2)Sufficient additional trained personnel to assist the family, monitor and evaluate labor
and assist with the delivery.
Trained personnel available as necessary for assistance.
Additional licensed or unlicensed staff are sometimes needed. Unlicensed personnel and
licensed vocational nurses may function as scrub assistants for Cesearean Sections,
which are often performed in the perinatal unit.
The requirement for trained personnel is consistent with requirements for competency in
Section 70214 and standards for safe patient care.
(d)There shall be one registered nurse on duty for each shift assigned to the antepartum and
postpartum areas. In addition, there shall be sufficient trained personnel to assess and provide
care, assist the family and provide family education.
There shall be additional staff assigned with the following system:
Antepartum/ postpartum patients in stable condition with complications shall have a licensed
nurse to patient ratio of1:3 or less at all times.
Staffing for antepartum and postpatum patients with complications.
Antepartum and postpartum patients with complications usually require close monitoring,
require various interventions and treatments and need to be cared for in a licensed nurse
to patient ratio of one to three. This ratio allows for team nursing, that is one RN and one
LVN at the hospital=s discretion and dependent on patient acuity.
SEIU Nurse Alliance recommendation for this staffing ratio is taken from the American
College of Obstetricians and Gynecologists, AGuidelines for Perinatal Care@.44
Antepartum/postpartum patients without complications shall have a licensed nurse to patient
ratio of 1:6 or less at all times.
Staffing for antepartum and postpatum patients without complications.
Antepartum and postpartum patients without complications are usually ambulatory,
largely self care and can be cared for in a licensed nurse to patient ratio of one to six.
This minimum ratio also allows for team nursing; that is one RN and one LVN at the
hospital=s discretion.
43
American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Fourth Edition,
1997, p.18
44 American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Fourth Edition,
1997, p.18
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SEIU Nurse Alliance recommendation for this staffing ratio is taken from the American
College of Obstetricians and Gynecologists, AGuidelines for Perinatal Care@.45
Mother-newborn couplet care shall have a licensed nurse to mother-newborn couplet
ratio of 1:3 or less at all times.
Staffing for mother-newborn couplet care.
Mother-newborn couplets are usually ambulatory, largely self care and can be cared for
in a licensed nurse to couplet ratio of one to three.
Currently hospitals assign nurses to couplets without regard for the newborn. It is
generally assumed that mother is caring for the newborn (many times without a nursery
for respite care). This recommended ratio will allow nurse to care for mother and baby.
Nurses will be able to spend time in patient teaching and doing adequate assessments of
newborns.
SEIU Nurse Alliance=s recommendation for this minimum staffing ratio is taken from the
American College of Obstetricians and Gynecologists, AGuidelines for Perinatal Care@.46
Antepartum testing shall have registered nurse to patient ratio of 1:3 or less at all times.
Staffing for patients having antepartum testing.
Nurse staffing for patients having antepartum testing should not exceed one registered nurse for
three patients.
Antepartum testing of pregnant patients includes infusing intravenous medications and invasive
procedures such as amniocentesis. Some tests may stimulate the onset of labor and may
require one registered nurse per patient. Assessment and interventions occur on a very fast
pace as patients move through the process of testing.
SEIU Nurse Alliance recommends addition of regulations to ensure a minimum ratio of one
registered nurse for three patients having antepartum testing.
Sufficient additional trained personnel to provide care, assist the family and provide family
education.
Additional trained personnel available as necessary.
Additional licensed or unlicensed staff are sometimes needed and may be assigned
based on patient acuity. Unlicensed personnel such as nurses= aides or medical unit
clerks often assist with direct or indirect patient care on the perinatal unit.
The requirement for training is consistent with requirements for competency in Section
70214 and safe patient care.
(d) A registered nurse who has had training and experience in neonatal nursing shall he
45
46
Ibid.
Ibid.
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responsible for the nursing care in the nursery.
A At least one registered nurse trained in infant resuscitation shall be on duty on each shift. in
the nursery at all times when three or more infants are rooming-in.
Staffing in the nursery when infants are rooming-in.
A registered nurse should be present in the nursery at all times when three in or more
newborns are rooming-in as part of a mother-baby couplet in the perinatal unit.
As a cost-saver, some hospitals will do everything they can do discourage mothers from
utilizing the nursery. Some hospitals keep furniture in the nursery. Some drag their feet
and make tired mothers wait for a nurse to be Aavailable@ to work in the nursery. [ Refer
to justification for proposed changes in Section70547.(k)]
Staffing for couplet care does not have enough flexibility to allow one nurse to leave
his/her patients and staff the nursery when a baby needs nursery care. As a result,
newborns are kept at the nurses= station, in the Intensive Care Nursery, carried from
room to room by nurses, etc. when mothers need respite.
A nurse must be pre-assigned to the nursery while ensuring safe care for other postpartum patients. SEIU Nurse Alliance recommends this addition to the regulations to
ensure safe care for all babies needing care in the well-baby nursery.
(2) A ratio of one licensed nurse to eight six or fewer infants shall be maintained for normal
infants.
Safe staffing in the nursery for newborns.
A ratio of one licensed nurse to six or fewer infants for the well-baby nursery is a safe
minimum nurse to patient ratio.
During a short hospital stay nursery nurses:
Care for newborns
Do teaching for breast feeding and normal newborn care
Make assessments of the mother=s interactions with baby for recognition of bonding
Make observations of the family unit for inappropriate behavior
SEIU Nurse Alliance recommended minimum staffing ratio of one licensed nurse for six
babies is taken from the American College of Obstetricians and Gynecologists,
AGuidelines for Perinatal Care@.47
(3)A ratio of one licensed nurse to four or fewer infants shall be maintained for infants needing
close observation in a continuing care nursery. Amendment 7-11-01
Staffing for newborns needing close observation.
A ratio of one licensed nurse to four or fewer infants is necessary when infants need
close observation in the well-baby nursery.
Transition from intrauterine life to newborn is traumatic. Newborns easily get cold stress
and must be assessed for increased oxygen requirements. Very small or very large
47
American College of Obstetricians and Gynecologists, Guidelines for Perinatal Care, Fourth Edition,
1997, p.18
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newborns have problems with blood sugar levels and require monitoring. Some have
aspirated meconium during birth. Others born to drug addicted mothers will require close
observation, yet not require admission to an intensive care unit. Most babies with the
problems we have listed can be cared for in a well-baby nursery if the nurse to newborn
ratio is adjusted to allow nurses the time they need to closely observe and care for the
newborns.
SEIU Nurse Alliance=s recommendation for this staffing ratio is taken from the American
College of Obstetricians and Gynecologists, AGuidelines for Perinatal Care@.48
In addition, there shall be a ratio of one licensed nurse assigned to the nursery for every five
mothers who are admitted to labor and delivery.
Staffing ready for new babies admitted to the nursery.
A licensed nurse should be assigned to the nursery for every five mothers who are admitted
to labor and delivery. Existing law (C.945 of 1999) requires staffing ratios for these units.
With five mothers in labor and delivery, babies can be admitted in rapid succession to the
nursery. Current nursing staff who already have full assignments of newborns can quickly
become short staffed and patients will fail to receive adequate care. It is often difficult to
add extra staff during a shift.
A licensed nurse may float to other parts of the perinatal unit while he/she is available for
the nursery.
SEIU Nurse Alliance proposes additions to the regulations that will ensure the availability of
a licensed nurse when there is an influx of newborns needing adequate care in the wellbaby nursery.
(f) There shall be evidence of continuing education and training programs for the nursing staff in
perinatal nursing, and infection control and infant resuscitation.
Training in infant resuscitation for perinatal nursing staff.
The requirement for training nursing staff in infant resuscitation is consistent with
requirements for competency in Section 70214 and current standards of safe patient care.
' 70594.1. Transitional Inpatient Care or Subacute Unit
' 70594.1. Transitional Inpatient Care or Subacute Unit Definition.
Transitional inpatient care or subacute unit service means a unit in which there are specially
trained nursing and supportive personnel with necessary diagnostic and monitoring equipment
necessary to provide medical and nursing care to patients in a stable condition who do not
require daily physician services and the immediate availability of technically complex diagnostic
and invasive procedures usually available only in an acute care hospital and for whom the
physician assuming responsibility for treatment management has developed a definitive and
time-limited course of treatment. The individual patient shall fall into one of the two following
patient groups:
(1) ATransitional medical patient@ which means a medically stable patient with short-term
transitional care needs whose primary barrier to discharge to a residential setting is medical
48
Ibid.
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status rather than functional status. These patients may require simple rehabilitation therapy,
but not a rehabilitation program appropriate for multiple inter-related areas of functional
disability.
(2) ATransitional rehabilitation patient@ which means a medically stable patient with short-term
transitional care needs, whose primary barrier to discharge to a residential setting is functional
status, rather than medical status, and who has the capacity to benefit from a rehabilitation
program as determined by a physiatrist or physician otherwise skilled in rehabilitation medicine.
These patients may have unresolved medical problems, but these problems must be sufficiently
controlled to allow participation in a rehabilitation program.
Patients who require both a rehabilitation program appropriate for multiple inter-related areas of
functional disability and complex treatment for multiple medical problems shall not be considered
transitional inpatient care patients.
A defined service for transitional inpatient care or subacute patients.
Transitional inpatient care or subacute units should be defined and recognized in
regulations in order to provide organized minimal medical oversight, staffing, and other
requirements.
Working nurses, nursing administration and state surveyors need clearly defined and
outlined regulations that directly apply to subacute and transitional inpatient care unit
patients. Patients placed on transitional inpatient care or subacute units deserve the
same quality of oversight as all other units in the hospital.
The acuity level of patients in transitional inpatient care or subacute units equals the level
of acuity of patients in medical surgical units or rehabilitation hospital units ten years ago.
These patients are often recovering from major surgery, illness or injury; have been
stabilized on intravenous medications; and have wounds that are healing but not healed.
Most require rehabilitation therapy. Most require respiratory therapy. However, these
patients are clinically stabilized so long as their therapy is managed correctly and
nosocomial infections averted. As provided in the definition, the course of treatment is
definitive and time limited. For example, an 86 year old recovering from a broken hip
with a heart condition but stabilized on intravenous and other medications and requiring
rehabilitation services might, if sufficiently stable, be an appropriate transitional inpatient
care patient.
In order to assure appropriate staffing and other support, SEIU proposes that such
patients be placed in discrete units.
To fail to acknowledge these patients in regulations is a disservice to patients and nurses
who need clear written direction the oversight and planning of their care.
SEIU Nurse Alliance proposes addition of the above regulations to recognize hospital
units that have existed in hospitals for many years.
' 70470.2. Transitional Inpatient Care or Subacute Unit Service General Requirements.
(a)Written policies and procedures shall be developed and maintained by the person
responsible for the service in consultation with other appropriate health professionals and
administration. Policies shall be approved by the governing body. Procedures shall be
approved by the administration and medical staff where such is appropriate. The policies and
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procedures shall include but not be limited to:
(1) Admission, discharge, and transfer policies.
(2) Staffing requirements.
(3) Routine procedures.
(4) Emergency procedures.
(b)The responsibility and accountability of the transitional inpatient care or subacute unit service
to the medical staff and administration shall be defined.
Oversight for transitional inpatient care or subacute units.
Patients placed on transitional inpatient care or subacute units need the same quality of
oversight and continuity of care as all other units in the hospital.
Transitional inpatient care or subacute units already have policies and procedures
governing activities such as admission, discharge, procedures, etc. The proposed
language will provide regulations that recognize current practices.
' 70470.3. Transitional Inpatient Care or Subacute Unit Service Staff.
A physician with training and experience in medical-surgical care, transitional inpatient care or
subacute care shall have overall responsibility for the service. The physician shall be
responsible for:
(1) Implementation of established policies and procedures.
(2) Assuring there is continuing education for the medical staff and nursing personnel.
(3) Final decision regarding admissions to and discharges from the unit.
A physician to oversee the care of transitional inpatient care or subacute patients.
A physician with training and experience in transitional inpatient care or subacute care
should over see the care of patients in these units. Their acuity is close to that of
medical surgical or rehabilitation patients.
Patients in transitional inpatient care or subacute units are receiving a variety of
interventions very similar to those in medical surgical or rehabilitation hospital units. The
primary difference is that their condition has stabilized while the course of treatment is
completed.
Transitional inpatient care or subacute unit patients require a standard of oversight
similar to the standards in medical surgical or rehabilitation units, including an
appropriately trained and experienced physician.
A registered nurse with training and experience in the transitional inpatient care or subacute unit
service shall be responsible for the nursing care and nursing management when a patient is
present.
Nursing management for transitional inpatient care or subacute units.
Transitional inpatient care or subacute units now have nurse managers responsible for
the nursing care on the units. Proposed language will provide regulations consistent with
current hospital practice.
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SEIU Hospital Staffing Proposal
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All licensed nurses shall have had training and experience in care of patients requiring medical
surgical, rehabilitative, transitional inpatient or subacute care. If half or more of the patients are
transitional inpatient rehabilitation patients, then a majority of the licensed nurses shall have had
experience in care of such patients.
Nurses trained and experienced in the care of patients on transitional inpatient or
subacute units.
The proposed language is consistent with current requirements for competency before
receiving a patient care assignment in Section 70214.
(d)The licensed nurse:patient ratio shall be 1:5 or fewer at all times.
Minimum staffing for the transitional inpatient care or subacute unit service.
Existing law (c.945 of 1999) requires staffing ratios for transitional inpatient care and subacute
care. Transitional inpatient care or subacute patients are acute care patients who are stabilized,
whose course of treatment is known and limited and whose primary barrier to return to home or
community is successful completion of the course of treatment.
SEIU Nurse Alliance requests a ratio of one licensed nurse to five patients for the acute
patients found on transitional inpatient care or subacute units today. The proposed ratio is
flexible enough for primary care nurse staffing or team nursing. Nurses can be a combination of
registered nurses and licensed vocational nurses as long as there is at least one licensed nurse
for every four patients. SEIU does not propose a change in the scopes of practice of any
licensed health professional.
Patient classification systems are not providing adequate staffing for medical surgical units or
transitional inpatient care or subacute units. SEIU nurses report that they are often unable to
meet patients= needs for adequate pain control, patient teaching and monitoring and intervening
in problems. Even simple tasks necessary to maintain physical hygiene often go undone. This
means that relying on patient classification systems to remedy the inadequacies of too low ratios
will not provide safe and adequate careBmuch less the quality care called for by Governor Davis
in his signing message.
Today every transitional inpatient care or subacute nurse on every shift must do
the following for every patient:49
Make assessments of all patients on admission, and during the shift. Listen to heart,
lung and bowels sounds, check dressings, questions the patient, check skin color,
turgor and integrity, take vital signs and check and maintain patency of all drains and
intravenous lines. Admissions happen frequently during the shift.
Write and revise nursing care plans as necessary based on patient assessment,
physicians= orders and information supplied by other members of the healthcare
49
All of these responsibilities are within the scope of practice of a registered nurse; most but not
all are also within the scope of practice of a licensed vocational nurse. Again, SEIU proposes
NO change in the scopes of practice of any licensed health professional.
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team. After making an assessment the nurse writes a care plan in detail that includes
the nursing diagnosis and doctor=s orders. The doctor may need to be notified of the
nursing diagnosis and orders changed or added.
Initiate immediate interventions of identified problems based on protocols,
physicians= orders and/or current standards of nursing practice and notify
physicians of all problems requiring changes in intervention.
Supervise other licensed or unlicensed personnel as necessary and engage in
constant dialogue with other caregivers to ensure communication.
Constantly evaluate the effects of care to determine if changes in the care plan are
needed
Assign and supervise or carry out ongoing patient and family teaching.
Chart all assessments and other patient care activities and record patient charges
according to the hospital=s system.
Record patient charges.
Answer telephones and patients= call lights.
Today every transitional inpatient care or subacute nurse will always do the
following for at least some patients during a shift:
Infuse blood and blood products, total parenteral nutrition, insulin, IV antibiotics and other
medications.
Ambulate patients and teach crutch walking.
Assist in rehabilitation by providing assistance with rehabilitation program as developed
and directed by rehabilitation specialists.
Administer oral, subcutaneous, intramuscular, intraocular, rectal, intradermal, and
intravenous medications, including controlled substances, as ordered and on time.
Perform sterile, unsterile, or wet-to-dry dressing changes (wet-to-dry dressings are
applied to large open wounds).
Insert and care for multiple invasive lines such as foley catheters and nasogastric tubes.
Care for isolation patients with protective clothing and special handing of all trash and
linen.
Attend to patients= needs for hygiene and nutrition including bathing, shaving, linen
changes, feeding or serving food.
Track and record controlled substances.
Confer continuously with doctors and other caregivers, transport patients for treatments
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and surgery.
Today every transitional inpatient care or subacute care nurse will often do some
of the following for at least some patients during a shift:
Spend an hour of the shift with just one patient starting an intravenous line if he or she
has difficult veins.
Change all peripheral lines every 72 hours, or more often.
Change and check dressings at least once per shift or more often if infection is involved.
Adjust intravenous medications per protocol.
Administer inhalation therapy treatments and oxygen.
Respond appropriately to cardiac emergencies and still maintain adequate care level for
other patients.
Licensed nurses are expected to provide more sophisticated care to more patients of
higher acuity.
Until recently, some of the tasks listed above would have been performed only by a physician or
would have been performed in other, more specialized units of the hospital with additional
Experienced nurses recommend no more than five subacute patients for one nurse.
One nurse to five patients is the bottom line for transitional inpatient or subacute patients,
patients who were medical surgical hospitals patients until the 1990's.
' 70220.4. Transitional Inpatient Care or Subacute Unit Service Equipment and Supplies.
'70220.4. Transitional Inpatient Care Equipment and Supplies.
Equipment and supplies shall include at least the following:
(1)Crash cart and DC defibrillator.
(2)Resuscitation equipment.
(3)Glucometer.
(4)Endotrachael suctioning equipment and supplies.
(5)An alarm system for summoning physicians or cardiac arrest teams.
(6)Oxygen administration equipment and supplies including intubation, tracheostomy and chest
tube insertion trays.
(7)Drainage and intermittent and continuous suction equipment.
(8)Urinary bladder catheterization supplies.
(9)Dressing supplies.
(10)Irrigation and lavage suppies.
(11)Restraints.
(12)Adequate equipment for taking vital signs with separate equipment for isolation rooms.
(13)Parenteral administration equipment and supplies including, but not limited to, syringes,
needles, intravenous tubing, intravenous fluids and plasma expanders, nasogastric tubes, and
equipment which regulates the administration of intravenous fluids and tube feedings.
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Supplies and equipment to meet the needs of transitional care unit patients.
Adequate and appropriate supplies should be readily accessible at all times on the unit.
Delays in obtaining supplies put patients at risk of death, injury or permanent disability.
Down-sizing and cutbacks affect supplies as well as staffing. 50 Staffing cuts make
adequate and appropriate supplies more critical since caregivers do not have time to go
rummaging around to find what they need. Unfortunately, SEIU now routinely hears
complaints about lack of basic supplies such as soap and toilet paper for patients.
The proposed list of transitional care unit supplies and equipment is similar to
requirements for other units recognized in regulation, but adapted for this specific unit.
50
Blegan, Goode, Reed, Nurse Staffing and Patient Outcomes, Nursing Research, Vol. 47, No. 1
2/12/2016