For-profit hospitals, non-teaching hospitals, and hospitals in urban or more competitive locations fared best at achieving the mandated ratios. However, hospitals with high Medicaid or uninsured populations were significantly more likely to fall below the minimum ratios than their more affluent counterparts and did not achieve the marked gains in staffing ratios achieved in other facilities.
All in all, more than 20% of safety net hospitals failed to achieve the 2004 mandate of 1:5, compared with about 12% of the other types of hospitals.
Of the safety net hospitals that did achieve the mandate, one wonders what types of tradeoffs they had to make, Dr. Conway adds: “Are they closing emergency rooms? Investing less in new equipment and facilities? Hiring less-trained staff? This study raises those questions, although it doesn’t answer them.”
More and more, hospitalists are being held responsible for quality improvement programs and outcomes measures within hospitals. The targets monitored often are those most strongly influenced by nurse presence, such as the number of central line infections, pressure ulcers, urinary tract infections, ventilator-acquired pneumonia, and similar conditions.
On the other hand, “no one has yet studied what happens when a hospital goes from a ratio of 1:5 to 1:4,” Dr. Conway says. It is possible that the [patient] gains realized may not be large enough to justify the compromises a hospital might have to make in other areas to meet that goal. “We must determine what the tradeoffs are and identify optimal nurse staffing ratios. Adequate nurse staffing is a significant key to achieving a successful team management approach in a hospital.” TH
Norra MacReady is a medical writer based in California.
Editor’s note: Dr. Conway was featured in the February 2008 issue (p. 28) as a member of the White House Fellows Program.