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As COVID-19 Infections Rise, California Pauses Its Nurse-Patient Ratios


California is the only state in the country with legislation that defines strict nurse-to-patient ratios, but now the state is putting these ratios on hold as the number of new coronavirus infections and hospitalizations continues to rise. With fewer providers to go around, CA says it has no choice but to waive these strict ratios, even though it can put patients and staff at risk.

Bypassing Strict Patient Care Rules

When California implemented the nation’s first nurse-patient ratios back in 2004, they were meant to keep nurses and patients safe on the floor. These laws have been shown to improve patient satisfaction, reduce the chances of errors and clinical mistakes, and decrease the rate of fatigue and burnout among staff members.

Under that law, there could be no more than two patients per nurse in the ICU, four patients per nurse in telemetry, and five patients per medical-surgical nurse. Facilities could be fined as much $30,000 for violating these ratios.

However, Gov. Gavin Newsom recently gave hospitals the option of forgoing these ratios. Many facilities have been short-staffed; ERs and ICUs are nearly full across the southern region of the state, and there aren’t enough providers to go around. The governor’s office has since been granting waivers to facilities looking to increase the number of patients per provider.

So far, 250 of the state’s 400 facilities have taken advantage of these waivers, requesting 60-day exemptions.The exemptions only apply to intensive care, observation units, cardiac monitoring, emergency, and surgical care units.

Under the new ratios, there can now be up to three patients per nurse in the ICU, six patients per nurse in telemetry, and seven patients per medical-surgical nurse.

Pushing Staff Members to the Limit

While these waivers are meant to help facilities keep pace with the growing number of patients seeking treatment for COVID-19, nurses say their jobs have gotten much harder since the ratios changed.

Nerissa Black, RN, a telemetry nurse at Henry Mayo Newhall Hospital in southern California says her workload has nearly doubled. “We are given 50 percent more patients and we’re expected to do 50 percent more things with the same amount of time. I go home and I feel like I could have done more. I don’t feel like I’m giving the care to my patients like a human being deserves,” she told NPR.

Black now has six patients to look after instead of four, which is pushing her to her breaking point; she can only spend 10 minutes at a time with each patient instead of her usual 15 minutes. During that time, she has to analyze their lab work and imaging reports, communicate any abnormalities to the doctor, document her interventions, coordinate with case workers, and in many cases, call the hospital’s chaplain if someone has passed away.

“It’s very busy, the nurses and not just the nurses but the assistants, we are all exhausted. Morale is pretty low,” Black told the Associated Press.

Is There Another Way?

Jan Emerson-Shea, a spokeswoman for the California Hospital Association, is defending these waivers, saying, “We are literally in the worst crisis of this pandemic so far and are seeing caseloads that we have not seen to date. No one wants to have our staff emotionally and physically exhausted. But we have no choice. People need care.”

However, Gov. Newsom has yet to cancel elective procedures during the recent surge, which could help existing providers treat more coronavirus patients without spreading themselves too thin on the floor. Elective procedures can sometimes be some of the most lucrative procedures in the industry, and cancelling them would likely mean losing revenue.

Marc Brown, a spokesman for Kaiser Permanente, which has 36 hospitals across the state, says the company has so far requested 15 waivers. Brown says the health giant limited the number of waivers by cancelling elective procedures, so there are more providers to go around.

Travel nurses and temporary health workers can help fill in the gaps, but the state has already exhausted this option. After 10 months of combating the pandemic, the state has repeatedly requested additional healthcare workers from the federal government and various travel nursing agencies, but many have since left as they move on to their next assignment.

As Carmela Coyle, president and CEO of the state’s hospital association, put it, “Because California surged during the summer and other parts of the U.S. then surged afterwards, those travel nurses are [now] taken.”

As for Black and her colleagues working under the new nurse-patient ratios, it’s been a challenge, to say the least. “A lot of people say we signed up for this and no, we didn’t. I signed up to help take care of people, not to throw myself into the fire,” Black said.


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