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Safe Patient Limits Initiative Inches Forward in MA

 |  By Alexandra Wilson Pecci  
   September 17, 2013

The Massachusetts Nurses Association is waging a battle against unsafe patient loads. Now it is behind a petition drive to get a Patient Safety Act on the 2014 statewide ballot.

When I worked in an after-school program in Massachusetts we were always being reminded about the state's mandated child-to-staff ratios. If we were ever fell out of ratio—meaning there were too many kids per each adult—the daycare center could get into serious trouble with the state.

In Massachusetts, the staff-to-child ratio for infants is 1:3; it's slightly higher for older toddlers. And these children are healthy. But do nurses in Massachusetts have the same such limits for sick patients? No.

"I have heard from nurses on medical/surgical unit taking up to eight or nine patients" at a time, says Donna Kelly-Williams, RN, president of the Massachusetts Nurses Association. Research, however, shows these nurses should have no more than four patients at a time, she says. That's a big difference.

Loading up nurses with too many patients jeopardizes patient care incrementally. For instance, Kelly-Williams says that medical/surgical nurses should have no more than four patients at a time, and each additional patient after four compounds the chance of patient injury by 7%. That means that the fifth patient compounds injury risk for the other four patients by 7%; the sixth patient compounds the risk by 14%, and so on.

"It's not just that one patient that's put in harm's way," she says. "It's all of the patients at that point."

Nurses in Massachusetts are waging a battle to establish safe maximum patient limits, and they've achieved the first step in that fight: The Massachusetts Attorney General's office has certified a safe patient limit ballot initiative, which means the initiative's language has passed constitutional standards. Now, nurses are getting ready to gather the nearly 70,000 petition signatures they'll need to put patient limits on the ballot in 2014.

"I don't think we're going to have any difficulty getting the signatures," Kelly-Williams says. What might be more challenging is convincing Massachusetts voters, i.e., potential patients, why they should ultimately vote for this change.

"That's what so critical about this… just having the voters understand how critical this is," she says. And she also wants voters to understand that for all the arguments they'll hear for supporting maximum patient limits, they will also hear opposition that's as loud—if not louder—than what nurses are advocating for.

In fact, it's this opposition—mostly from hospital associations—that has prevented previous attempts at mandated safe patient limits from making it through the Massachusetts legislature, Kelly-Williams says.

Hospital groups argue that such a mandate would be expensive and would take resources away from innovation. But Kelly-Williams says just the opposite is true: Hospitals would actually save money by reducing readmissions and complications by making sure that patients are properly cared for in the first place. And she points to California, where such mandates have been in practice for nearly a decade, as a success story.

"No hospital ever closed as a result of having this law in place in California," she says.

The ballot initiative is something of a backup plan. The Massachusetts Nurses Association has filed a companion bill in the legislature while also pursuing the ballot initiative; this allows nurses to take the issue directly to voters should the legislation fail to pass.

The Patient Safety Act would establish specific safe patient limits in Massachusetts for nurses in different units/departments of a hospital. For instance, the proposed law calls for a maximum of four patients for each nurse on a medical/surgical unit; between one and three patients depending on the severity of the patient conditions for nurses in the ED; and between one and two patients for nurses in critical care units. The legislation also calls for hospitals to be fined $25,000 for each day of noncompliance with the law.

The bill also attempts to work flexibility into the legislation by reducing maximum safe patient assignments if patients require more intensive care.

According to the Massachusetts Nurses Association, Massachusetts is one of 10 states and the District of Columbia, to have filed this kind of legislation in the past two years. But right now, the Bay State has no maximum patient limits and no requirements for hospitals to adjust their staffing based on what patients really need, the Association says.

"It's a load 'em up mentality right now," Kelly-Williams says. "I hear from nurses all over the state… they're seeing this ramping-up of additional patients being assigned to a nurse at one time."

Kelly-Williams says not only has she heard of nurses who've been loaded up with nine patients at a time, but she's heard cases of nurses putting up a fight against unsafe patient loads, too.

Pushback does not come without ramifications. "I've heard from nurses who have told me that they have been told that they must take that patient, that they will be disciplined for not accepting that patient."

And she's also has heard of people saying a point-blank "No" to taking more patients.

"But not all nurses are empowered to do that," she says, "And nurses shouldn't be put into a position to have to do that, either."

Alexandra Wilson Pecci is an editor for HealthLeaders.

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