It's a scene that plays out in hospitals every day around the country--a few overworked nurses struggle to keep up with a floor crowded with more patients than they can really handle.
After a while, the nurses are unable to check on patients as often as they should, or they make a mistake, and that puts their patients' lives in danger.
In a 2002 study, researchers from the University of Pennsylvania found that a patient's overall risk of death rose roughly 7 percent for each additional patient above four on a nurse's workload.
The increased risk of medical errors, in turn, puts hospitals at greater risk for malpractice claims at a time when they are under increasing pressure to reduce preventable errors.
As of October 1, for instance, the Centers for Medicare and Medicaid will no longer reimburse hospitals for a total of 11 conditions it says are reasonably preventable.
"The vast majority of the problems in hospitals are occurring with respect to nursing because nurses are with patients 24/7," says Thomas Sharon, an internationally known nursing and patient safety expert.
"As I see it, nursing is the most important area to focus on when it comes to preventing hospital mishaps," says Sharon, who has worked for two decades as a consultant to attorneys in cases where hospitals have been accused of preventable errors and runs the Web site Legal Nurse Consultant.
To manage their risk, hospitals need to pay close attention to their staffing levels, consider ways to attract and retain nurses, and transform the status quo to reduce errors and improve patient safety. That could include, for instance, trying novel ideas, such as the use of people doing community service as volunteers for small jobs that can help keep patients safe.
NURSE SUPPLY AND DEMAND
U.S. hospitals are already struggling to hire and keep nurses on staff. A 2007 survey by the American Hospital Association found that hospitals across the nation needed 116,000 RNs to fill immediate vacancies.
But over the next decade, as baby boomers get older and their health begins to deteriorate, the so-called census of patients will expand rapidly and demand for nurses is expected to rise. Yet, the supply of nurses is projected to fall sharply, says Holly Meidl, head of the healthcare practice at brokerage firm Marsh.
The average age of the registered nurse population is estimated to be 47, and many of today's nurses will begin approaching retirement age themselves in the coming years.
Absent aggressive intervention, the supply of nurses will fall 36 percent, or more than 1 million nurses, below requirements for the year 2020, according to a report by the Health Resource and Service Administration, "What is Behind HRSA's Projected Supply, Demand, and Shortages of Registered Nurses?"
"Nurses are not only becoming scarce and will be more so, but the median age of a nurse is aging, and so where it used to be that the average age of a nurse might have been 35 or 38, now its 45 to 48, and in less than 10 years we're moving into the 50s," Meidl says.
There are, however, not enough new nurses entering the profession to keep up with the growing demand.
"Although you've got a younger generation and a smaller populace and you've still got people going into nursing, you don't have the numbers going into nursing to care for the aging group that everyone is anticipating showing up at the hospitals," Meidl says. "That's where the shortage comes from."
What's worse is that even a sudden surge in interest in nursing won't solve the problem because the country's nursing schools couldn't handle the additional students.
Survey data for the academic year 2006-2007 from the American Association of Colleges of Nursing showed that nursing colleges and universities denied admission to 42,866 qualified applicants. The top reasons for not accepting applications to entry-level baccalaureate programs included insufficient faculty (71 percent), and admission seats filled (74 percent).
But in some cases, the nursing shortage goes beyond the simple demographics. Some hospitals create their own shortages because poor working conditions lead to a high turnover rate.
"There is a management style that will attract people and retain people and a management style that will cause people to want to quit," Sharon says.
Many nurses, he says, simply don't want to work in a hospital environment--sometimes because of poor management and other times because of the hours and demands of working in a hospital.
In other cases, the nursing shortage can come down to dollars and cents. A financially struggling hospital may look to cut costs by reducing nurse staffing.
But at some point, adding more nurses can yield diminishing returns, and hospitals that are pressured to hire more nurses may have to cut corners elsewhere.
HOSPITAL LIABILITY RISK
Even so, inadequate nurse staffing is an issue that could become a bigger factor in malpractice liability claims and could even lead to lawsuits against the board of directors if the inadequate staffing was part of management policy, Sharon says.
"Risk managers should count on lawyers more and more to make an issue of staffing levels," Sharon says.
Hospitals have already had to defend themselves against malpractice lawsuits that blamed the malpractice on inadequate nurse staffing.
Consider the well-publicized case of Shirley Keck. When 61-year-old Keck began to have trouble breathing, her daughter Becky Hartman rushed her to a Wichita, Kan., hospital where the emergency room doctor decided she was suffering from pneumonia.
But Keck did not have pneumonia. Instead, she was suffering from a heart attack that caused fluid to fill her lungs. Over the following several hours as Keck's condition deteriorated, her daughter repeatedly begged for help.
There were only two nurses working that shift, and they were overwhelmed with other patients. Help finally came, but by the time her ordeal was over, Keck had suffered a paralyzing stroke. She died four years later.
Her family sued Wesley Medical Center and won a $2.7 million malpractice settlement in July 2000.
It is believed to be the first malpractice decision specifically claiming that the problem was the result of inadequate nurse staffing. But it won't be the last.
Hospital Corp of America, the parent company of Wesley, is now facing a class-action lawsuit claiming that the company engaged in systematic understaffing of RNs throughout all of its hospitals.
The lawsuit notes that this practice places patients at increased risk for various health ailments, including infections, bedsores and death.
The U.S. Court of Appeals reinstated the lawsuit in May after U.S. District Judge J. Thomas Marten dismissed it two years ago.
An HCA spokesman has reportedly said that the company continues to deny the allegations and would defend them vigorously in court.
In that case, the lead plaintiff, Mildred Spires, claims her husband died after a surgical procedure and that his death went unnoticed for an hour because the nursing staff was stretched too thin.
With staffing shortages expected to get even worse in coming years, this could put hospitals at even greater liability risk, especially given that hospitals will no longer be reimbursed by CMS for preventable errors.
That could prompt patients to pursue a liability claim and use the CMS denial of payment as evidence of negligence, Sharon says. Risk managers, therefore, will be under pressure to challenge the denial of payment.
Hospitals are also at risk because plaintiffs' attorneys have figured out that nurse staffing is an issue, and they know to ask for information about nurse-patient ratios and staffing decisions when there's a malpractice claim.
Because schedules are often made up two months in advance, that gives hospital managers enough time to foresee a shortage and to find ways to avert the problem, Sharon says.
Many times, however, hospitals wait until the last minute to try to fix staffing problems that they could foresee weeks in advance. By that time, the nurses on the preceding shift are forced to scramble to find people to stay and work overtime or to find agency nurses, who may not be able to come at the last minute.
Sometimes agency nurses are requested in advance but then told at the last minute that they are not needed. After that happens a few too many times, agency nurses will decline to work at those facilities, he says.
Hospitals will not be able to successfully defend themselves against a malpractice lawsuit by claiming that they were unable to hire enough nurses because of the nursing shortage.
Most of the time, however, the malpractice claims will settle out of court before a trial, Sharon says. But the best way to protect the financial integrity of the facility, he says, is to avoid having the lawsuits in the first place.
RISK MANAGEMENT STRATEGIES
With the CMS reimbursement on the line, risk managers need to take action to reduce preventable errors, and one area for review is nurse staffing and retention, Sharon says.
"Most of the errors happen by nurses at the staff level at the bedside or while the patient is going through a process," Sharon says. "Underlying all of this is not having enough nurses."
Sharon says the nursing operation at many hospitals needs an overhaul. He recommends a clinical transformation process that avoids imposing a system of reward and punishment, which has been found to be unsuccessful.
He speaks of hospitals creating a movement to motivate people, to change attitudes and thinking, and to help empower nurses so as to change behavior and improve patient safety.
Hospitals are also trying to help nurses manage more patients by providing them with more technology to help monitor patients. That can sometimes backfire, too, because patients can perceive a lack of nursing care even though they were monitored remotely by nursing staff.
Other regulatory efforts are also in the works, but it's not clear how successful they will be.
To address the staffing problem, federal legislation was introduced in November 2007 aimed at implementing staffing systems that ensure appropriate registered nurse staffing levels at health care facilities.
The Registered Nurse Safe Staffing Act would require each hospital, in consultation with the nursing staff, to develop and implement a staffing system that ensures an appropriate number of registered nurses on each shift and in each unit of the hospital.
Other ideas include enlisting help from volunteers to help with certain very basic tasks that could help nurses and improve patient safety.
One idea, for instance, might be to get people who are required to do community service to sit in hospital rooms with patients and just watch them to make sure that they don't fall out of bed.
"There's no skill to that," Sharon says. "Just be there and watch to prevent falls," he says.
The shortage of nurses is real and expected to get worse over the next decade as the number of people needing care increases. But by planning ahead, making efforts to recruit new nurses, improving management and work conditions, and exploring new ways to keep patients safe, hospitals can go a long way to maintaining acceptable nurse staffing levels and reducing medical errors.
"Having a positive atmosphere and good labor relations are all keys to alleviating nursing shortages," Sharon says.
October 1, 2008
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