ANA\C recommends Section 70271- Nursing Service Staff (paragraph 2) be amended to
eliminate the statement “Licensed vocational nurses may constitute up to 50 percent of the
licensed nurses…” The staffing for many of the units discussed in these regulations should be
primarily RNs. The issue of Licensed Vocational Nurses (LVN) versus RNs should be discussed
in each section. The case loads for RNs increases when she/he has to supervise and assess LVNs
and their patients.
Number 1 Critical Care Unit.
ANA/C believes the Post Anesthesia Care Unit (PACU, Section 7) is a Critical Care Unit and
should be included under this section. As we interviewed different hospitals and nurses about this
issue, we learned that many PACUs are staffed only by RNs and the ratio is 1:1.
Rationale: Critically Ill patients are those thought to be at high risk for actual or potential life
threatening health problems. After surgery, this risk is at its highest because of the invasive
procedure the patient has undergone, the need to stabilize all vital functions and the use of high
technical and complex equipment. We believe these types of patients are found in those units
designated as CCUs or PACUs.1
Number 2 Surgical Services Operating Room
We believe there is likely to be misunderstanding regarding the language used, we are suggesting
the following language: “additional hospital staff person who has met the competencies to be a
scrub assistant …..” substitute for “additional person”.
Rationale: ANA\C is concerned that using the term “additional person” could imply that a doctor
or medical student could be considered the “additional person”. It needs to be clear there exist
specific definitions and standardized procedures for the person designated as a scrub assistant or
scrub nurse.2
Number 4 Postpartum area
ANA\C believes that an assignment of four mothers and four babies is unsafe especially when
this means that there could be one RN to 16 patients, when including LVNs as providers. As
noted above the RNs case load increases when she has to supervise the LVN and the patients she
cares for. Because of the high ratio of patients for the RN, we believe the patient is placed at
increased risk. Many hospitals have private rooms for the mother and the baby with the baby
being in the room at all times. ANA/C supports the Recommendations for RN/Patient Ratios set
by the American College of Obstetricians and Gynecologists (ACOG) for all areas of pregnant
patient care. 3
Rationale: There are numerous studies that demonstrate the importance of the “first few minutes,
hours and days” for both mother and baby. Early interventions, continuous support during labor
and delivery and the likelihood of the mother attempting and being successful at breast feeding all
point to the importance of having a ratio that allows the RN to provide emotional support and the
necessary education that needs to occur during this critical period in the life of the mother and
newborn.4
Number 5 Combined Labor/Delivery/Postpartum
ANA\C believes that a Registered Nurse should not be assigned a woman in labor and a
postpartum mother and infant. It is impossible to predict the amount of attention and time the RN
will have to spend with either patient. If the postpartum mother has problems with her recovery
the mother in labor will be ignored and vice versa. If it is believed that a safe minimum staffing
ratio in labor and delivery is 1:1 or 1: 2 then why is it safe for a 1:3 with postpartum women, a
baby and a woman in labor? Additionally, because this ratio allows 50% Licensed Vocational
Nurses, the Registered Nurse could be supervising 2 women in labor, 4 babies and four mothers.
This is an unsafe ratio.
Rationale: Again recent research demonstrates the likelihood of better patient (mother and infant)
if the RN has the time to provide “continuous support” to the mother before, during and after
labor.3 Research reported earlier this year, September, 2002, called into question the effect the
hospital environment has on the provider and recipient of nursing care as well as the need to
evaluate “evidence-based, hospital-wide strategies to alter the hospital birth environment to allow
effective nursing care”.5
Number 6 Pediatric Services
ANA\C believes “pediatric services” is too broad a term. Children’s Hospitals, just as adult care
hospitals have as many units and specialties. The ratios should reflect the diversity of care given.
These ratios need to be refined to reflect the unique units in pediatric hospitals.
Rationale: According to the National Association of Children’s Hospitals and Related
Institutions, “children under the age of 2 years require 40% more nursing care and that all
children need hospitals focused solely on their unique needs 6.” Evaluating the nursing
requirements to meet the needs of sick and dying children should be addressed as critically as
ratios for adults.
Number 8 Emergency Room
Emergency rooms are “critical care units” and the staffing should be reflective of the type of care
that is given in the emergency room. Since the proposed regulations recognize that a patient
transferred to the ICU should be staffed 1:1 then the staffing in the emergency room should be
reflective of the patients that come through the emergency room.
Rationale: Because the types of patients that enter the emergency room cannot be predicted, the
Emergency Room should have a predominance of Registered Nurses. We know the high rate of
uninsured and underinsured in California results in later access to care. Patients use the ERs for
“routine and episodic care’ – out of an inability to see their regular health care provider or
ignorance of the system, couple this with true emergencies, diversions because of closed ERs and
the patients require a higher level of assessment and evaluation that can only be rendered by the
RN.
Number 9 Step Down Unit
Artificial life support includes mechanical ventilation. If a patient cannot breath on their own
they are requiring support for vital bodily function. A 1:4 ratio is too high for patients with
invasive monitoring and ventilators. If invasive monitoring is used measuring more than one
parameter, i.e. carotid line versus a swan ganz, then the ratio should be a minimum of 1:2. Again,
with the ability to use LVNs, this ratio requires a Registered Nurse to be supervising eight
patients in a step down unit. There are many types of step down units. The term is used
differently from hospital to hospital. The Department of Health Services needs to review the
different types of step down and refine the ratios for step down reflecting this difference. Absence
a more comprehensive look at the varying definitions and types of care provided in “Step Down
Units”, we suggest a RN ratio only.
Rationale: Research documents the affect of RNs providing care to the more critically ill patient,
i.e. “higher hours of care provided by RNs were associated with shorter length of stay, lower rates
of pneumonia, shock or cardiac arrest, etc. Surgical patients have lower rates of “failure to rescue
and urinary tract infections”, all conditions that can severely impact morbidity and mortality.7
Number 10 Telemetry Unit
These ratios are problematic. They are the same as a medical unit. If a patient needs to be
segregated for monitoring from the general population, and they are charged more for this,
shouldn’t the staffing reflect the difference in the care required? We suggest a minimum ratio of
4:1. The definition of telemetry is also not clear. The Department of Health Services should
review the different telemetry units and refine this definition. The staffing ratios should reflect
this refinement.
Rationale:
Number 13 Psychiatric technicians
AB 394 was very clear that it only addressed staffing of RN’s and LVNs. The title nurse is
protected in law. It is not appropriate to define the staffing ratio of psychiatric technicians in
these regulations and we do not agree to the statement that they are included as licensed nurses.
This was not the intent of AB 394.
1- Policy Statements from the Association of Perioperative Registered Nurses (AORN) and
the American Association of Critical Care Nurses (AACN)
2- BRN Policy Statements: The RN as First Assistant to the Surgeon and Scrub Nursing
Functions by Non-RNs – Title 22: 70225
3- ACOG Recommendations:
a. 1:1-2 Antepartum
b. 1:2 Laboring patients
c. 1:1 Patients in second stage of labor
d. 1:1 All patients with complications
e. 1:2 Oxytocin induction or augmentation of labor
f. 1:1 Coverage for initiating epidural anesthesia
g. 1:1 Circulation for cesarean delivery
h. 1:6 Antepartum/postpartum patients without complications
i. 1:2 Postoperative recovery
j. 1:3 Patients with complications but in stable condition
k. 1:4 Recently born infants and those needing close observation
l. 1:6-8 Newborns needing only routine care
m. 1:2-4 Normal mother-newborn couplet
n. 1:2-4 Newborns requiring continuing care
o. 1:2-3 Newborns requiring intermediate care
p. 1:1-2 Newborns needing intensive care
q. 1:1 Newborns requiring multisystem support
r. >1:1 Unstable newborns requiring complex critical care
4- Perinatal Care in the 21st Century: Evidence that Supports Changing the Management
for Both Mother and Infant – Marshall Klaus, MD.
5- The Effectivenss of Nurses as Providers of Labor Support in North American Hospitals:
Results of the Nursing SCIL(Supportive Care in Labor) Trail: Ellen Hodnett, RN, PhD;
Nancy Lowe, RN, CNM, PhD et al: JAMA, Vol 28, #11, September 18, 2002:1373-1381.
6- All Children Need Children’s Hospitals Report – National Association of Children’s
Hospitals and Related Institutions.
7- Nurse Staffing Levels and the Quality of Care in Hospitals – Jack Needleman, PhD,
Peter Buerhaus, PhD, RN, et al – NEJM 346:1715-1722, May 30, 2002.