AACN News—June 2004—Practice

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Vol. 22, No. 6, JUNE 2005

Public Policy Update

Court Decision Cites Inadequate Nurse Staffing
A recent AP story that appeared in the Los Angeles Times profiled a woman who won a $2.7 million malpractice settlement in the first court decision "specifically pinned on inadequate nurse staffing." Becky Hartman won a malpractice settlement from Wesley Hospital in Wichita, Kan., in 2000, after her mother's health deteriorated while she "lay in a hospital room, all but ignored." According to the report, her mother suffered from a common type of heart failure.

Hartman supports efforts by nurses'unions to require mandatory nurse-to-patient ratios, such as those enacted by California in January.

Various studies have found that a nurse shortage is a factor in about one-quarter of hospital patient injuries or deaths; that long hours and fatigue contribute to errors; that preventable deaths and patient complication rates were as much as nine times higher in hospitals that depended more on licensed practical nurses and aides than RNs; and that patients'risks of dying after surgery rose 7% for each additional patient higher than four per nurse.

Bill Would Set National Nurse-to-Patient Ratios
A bill introduced in the U.S. House of Representatives would mandate specific nurse-to-patient ratios by 2007 and require hospitals to develop staffing plans. The Nurse Staffing Standards for Patient Safety and Quality Care Act of 2004 (Hospital costs incurred because of the new ratios would be partly offset by increased Medicare reimbursement.

The proposal, introduced by Rep. Jan Schakowsky (D-Ill.) in conjunction with National Nurses Day on May 6, would require nurse-to-patient ratios of 1-to-2 in critical care units, 1-to-4 in medical-surgical units, and 1-to-3 in emergency departments and pediatrics and telemetry units. A summary of the bill is available online on Schakowsky's Web site, which can be accessed at www.house.gov.

Department of Labor Retreats on Overtime Rule Changes
Criticism by the nursing community and others of proposed changes to the federal overtime pay rules has prompted the Bush Administration to revise its proposal. The revised Fair Labor Standards Act rules, announced April 20 by the U.S. Department of Labor, would allow workers who earn up to $100,000 a year to be eligible for overtime pay, a significant increase from the $65,000 cutoff point announced when the changes were first proposed in March 2003.

The new rules also specify that police officers, fire fighters, emergency medical technicians and licensed practical nurses would be eligible for overtime pay. The DOL reportedly received more than 75,000 letters commenting on the proposed changes to the rules in the last year.

In a related development, the Senate voted 52-47 to guarantee overtime pay to all qualified blue-collar workers, including paramedics, emergency medical technicians and licensed practical nurses, regardless of income. The guarantee, an amendment to corporate tax legislation, is a potential blow to Bush administration regulations to limit overtime pay to blue-collar workers earning up to $23,660 annually. The House and Senate must vote on the corporate tax bill before the amendment, sponsored by Sen. Tom Harkin (D-Iowa), can advance.

The Labor Department said its new regulations would strengthen overtime protection for the lowest wage workers. A department official told a Senate panel that Harkin's proposal would create confusion and potentially jeopardize overtime protection for millions of workers.

AACN opposed the initial overtime rule changes and supports the Harkin amendment. We will continue to follow and examine this issue for potential impact on protections for nurses. For more information, visit AACN's Legislative Action Center.

JCAHO proposes 2005 National Patient Safety Goals
The Joint Commission on Accreditation of Healthcare Organizations has released its proposed 2005 National Patient Safety Goals and Requirements for public review and comment. Among the changes for hospitals, JCAHO is proposing new goals for reducing the risk of harm from patient falls and the risk of surgical fires.

In addition, hospitals would have to develop a plan for implementing bar code technology at the bedside by January 2007. Under a "potential" expansion of the JCAHO goals, which hospitals must meet as part of the accreditation process, adopting bar code readers would become part of an overall goal of improving patient identification. The Food and Drug Administration published regulations in February requiring drug manufacturers to add bar codes to single units of medication by April 2006, but the rules do not require hospital participation.

JCAHO's board is expected to adopt the goals, pending the results of the field review, sometime this summer.

To view the potential goals and complete an online field review, go to www.jcaho.org > Accredited Organizations.

HHS Awards Additional $9 Million for Aging and Disability Centers
HHS Secretary Tommy G. Thompson has announced 12 grants totaling nearly $9 million to support state efforts to create "one-stop" centers to help consumers learn about and access long-term supports ranging from in-home services to nursing facility care. These new grants represent the second round of funding of Aging and Disability Resource Center Programs. A total of 24 states have now received HHS grants to develop streamlined access to long-term support services under this program.

Nurses Call for End to Active Cigarettes Promotions
Nurses from across America attended the annual shareholders meeting of Philip Morris (now under the parentage of Altria) in May in East Hanover, N.J., to call on the company to voluntarily end active promotion of cigarettes. Following the meeting, the nurses held a reading and shared a display of letters from previously secret tobacco industry documents sent to the company by its dying customers.

Link to the Tobacco Free Nurses Initiative
An organization called Tobacco Free Nurses is focused on providing support for nurses who smoke and establishing a framework for engaging nurses in tobacco use prevention and cessation. Funded by The Robert Wood Johnson Foundation, this national, collaborative initiative includes Web-based interventions, a media campaign, grassroots programs and training for nurse leaders to become strong advocates for tobacco control. The TFN Web site (www.tobaccofreenurses.org) provides information on smoking cessation, smoking research, international links, and strategies for quitting. AACN encourages members to use this important resource.

FY 2005 Budget and Appropriations Update
The FY 2005 budget and appropriations processes continue to move slowly. Congress must still negotiate a final budget resolution that will allocate spending limits for the 13 appropriations subcommittees. The House and Senate Budget Resolution bills are less costly than the president's budget for discretionary spending by $2 billion in the Senate and $1.6 billion in the House.

Sen. Ted Stevens (R-Ark.), chairman of the Senate Appropriations Committee, has said the Senate is unlikely to finish all 13 must-pass appropriations bills prior to the November elections. Stevens and Rep. C.W. Bill Young (R-Fla.), chairman of the House Appropriations Committee, have both commented that the shortened congressional schedule, combined with campaign efforts and political conventions, makes passage of these bills extremely difficult. They agree that the only appropriations bills likely to pass as "stand alone" measures prior to the November elections are Defense, Homeland Security and Military Construction. Young suggested that a large omnibus appropriations bill would be the preferred way to finish the appropriations process. However, Stevens said the Senate may instead pass several smaller omnibus bills.

What's Happening in Your State? Nevada and New York Move to Address Nursing Issues

Nevada Denies Mandatory Ratios
A Nevada legislative subcommittee has unanimously rejected a proposal to require nurse-to-patient ratios.

The Legislative Committee on Health Care Subcommittee to Study Staffing of the System for Delivery of Health Care in Nevada rejected mandatory ratios after several health professionals testified that ratios tied only to the number of patients and nurses do not necessarily improve the quality of care and would cost both hospitals and patients. Currently, Nevada hospitals say they set staffing based on patients'conditions.

In the last subcommittee meeting held in February, staff nurses, some of whom were members of the Service Employees International Union Local 1107, and contract nurses who work for several hospitals testified that ratios would alleviate some of their high-patient loads and long shifts.

The Legislature's Health Subcommittee did recommend the following other proposals that will be referred to the Legislature's full Health Committee:
� Requiring hospitals to report data such as lengths of stay, readmission rates, complications and hospital prices for patients admitted for common medical treatments.
� Prohibiting employers of traveling nurses from authorizing nurses to be responsible for staffing assignments at Nevada hospitals.
� Strengthening whistleblower laws to cover nurses.
� Prohibiting hospitals from "loading" patients onto staff nurses.
� Mandating residency programs for nurses to allow them more mentoring and orientation, which is required in some states.

New York Eyes 4-Year Degree Requirement
New York is considering requiring RNs to earn a bachelor's degree to keep their RN, a move that critics worry could serve as a blow to a profession already facing a severe shortage. Under the New York Board of Nursing proposal, RNs with associate's degrees would have to earn bachelor's degrees within 10 years or their RN certifications would be downgraded to that of licensed practical nurse. It would also add years and thousands of dollars to the difficulty of becoming an RN. Under the proposal, the certification change would affect only future graduates, not nurses already working.

The New York Board of Nursing has argued that the changing healthcare field requires nurses have more specialized knowledge than would come with an associate's degree education from a community college. It has pointed to a 2003 study in the Journal of the American Medical Association that indicated hospitals with more bachelor's degree nurses had better patient survival rates after surgery.

The notion of boosting the educational requirements of RNs has been debated for many years. North Dakota was the only state to require a bachelor's degree to practice as an RN, but the state overturned the requirement last year.

Public Policy Snapshot

Studies Show Lower Nurse Staffing Levels Contribute to Poor Patient Outcomes

The Agency for Healthcare Research and Quality has issued the latest in a series of Research in Action syntheses titled "Hospital Nurse Staffing and Quality of Care." It is intended to provide decision makers with the information they need to make knowledgeable choices about nurse staffing levels.

The reports indicate that hospitals with lower nurse staffing levels, nurses who spent less time with patients or fewer registered nurses compared with licensed practical nurses or nurses'aides tend to have higher rates of poor patient outcomes, including pneumonia, shock, cardiac arrest and urinary tract infections. Following is a summary of the findings:
� The six studies reviewed for the synthesis found different rates of adverse events, depending on the reason for the hospitalization, as well as other factors. Three of the studies found that pneumonia rates are particularly sensitive to nurse staffing levels, which were measured as the ratio of nurses to patients or nursing hours per patient per day.
� Several studies indicated that nurse staffing levels may also be associated with mortality rates. Two studies showed that the 30-day mortality rate and the likelihood of failure to rescue are higher when nurse staffing levels are lower. Another showed that a higher proportion of more highly educated nurses can reduce the 30-day mortality rate and the odds of failure to rescue. Closely related to the issue of nurse staffing level is patient acuity-the level of care and services needed by the patient. One study adjusted the total number of patient days of in-hospital care by the severity of illnesses and showed that, when nurse staffing levels remained the same as patient acuity rose, the ratio of nurses to patient days declined.
� Another important finding was that increasing nurse staffing levels does not significantly decrease a hospital's profits, in contrast to increases in nonnurse staffing. In addition, the costs associated with adverse events that might otherwise be avoided are considerable.
� Six states-Florida, Kentucky, Nevada, Oregon, Texas and Virginia-have staffing regulations but not ratios, and 18 other states introduced staffing bills last year.

The full report is available online www.ahrq.gov > Research Findings > Syntheses > Quality of Care or by contacting the AHRQ Publications Clearinghouse at (800) 358-9295; e-mail, ahrqpubs@ahrq.gov.

For more information about these and other issues, visit the AACN Web site.


Grants

July 1 is the deadline to submit applications for funding by the AACN Small Grant Program. Following is information about the grants that are available:

Medtronic-Physio-Control Small Projects Grant
One award of $1,500 is available. Funds will be awarded for projects involving patient education, competency-based education, staff development, CQI, outcomes evaluation or small clinical research studies. Topics should focus on aspects of acute myocardial infarction, cardiac resuscitation, sudden cardiac death, use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretive 12-lead electrocardiogram. Collaborative projects involving interdisciplinary teams, multiple nursing units, home health, subacute and transitional care or other institutions and community agencies are encouraged.

AACN Clinical Inquiry Grant
Five $500 awards are available to qualified individuals carrying out clinical research projects that directly benefit patients or families. Interdisciplinary projects are especially invited.

End-of-Life/Palliative Care Small Projects Grant
One award of $500 is available. Eligible projects may focus on any age group, patient education, staff development, CQI projects, outcomes evaluation projects or small clinical research studies. A broad range of topics may be addressed, including bereavement, communication issues, caregiver needs, symptom management, advance directives and life support withdrawal.

To find out about AACN's research priorities and grant opportunities, visit the AACN Web site or e-mail research@aacn.org.


Practice Resource Network

Q: We have a new cardiac surgeon who is asking the nurses to pull the epicardial pacing wires. Is this within our scope of practice?

A: Unless definitively stated otherwise in their state scope of practice, registered nurses can perform a procedure once they have been educated, trained and had their competency validated, and as long as they follow the prescribed policy, procedure or protocol of their hospital or organization. Because the scope of practice for RNs can vary from state to state, you should check with your state's board of nursing to determine if a procedure such as this falls within the scope of practice before implementing.

There is limited documentation in the literature addressing this issue. In 1995, an article published in Progressive Cardiovascular Nursing described a designated team of five telemetry nurses who were educated to discontinue epicardial pacing wires.1 In 1998, a study examined the risks associated with removal of epicardial pacing wires.2 However, in this study cardiac surgeons or cardiac surgical residents removed the wires.

Although uncommon, potential complications from removal of epicardial pacing wires include injury to grafts, bleeding, tamponade and ventricular dysrhythmias.

References
1. Wollan DL. Removal of epicardial pacing wires: an expanded role for nurses. Prog Cardiovasc Nurs. 1995;10(4):21-26.
2. Carroll KC, Reeves LM, Andersen G, et al. Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery. Am J Crit Care. 1998:444-449.