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Big, Bad Medicine

Inpatient health care is deteriorating in Santa Cruz and across the country as hospitals increasingly put profits before patient

By Michael Mechanic

SEVERAL MONTHS AGO at a hospital in Washington state, an aide did a routine check of a patient's blood sugar levels. It was one of her duties that, in the past, would have been performed by a registered nurse. But with restructuring of the hospital's clinical facilities--a trend that has swept the country over the past year or two--many traditional nursing tasks have fallen to relatively untrained, and often unlicensed, support staff.

In this case, the blood test showed elevated glucose, but the patient appeared to be sleeping soundly, so the aide didn't bother reporting the result to her supervising nurse for several hours.

Luckily, the RN was able to get to the patient in time. What the aide mistook for a peaceful snooze was in fact a diabetic coma that could easily have resulted in death.

It is precisely this sort of situation that caregivers fear from hospital restructuring, incidents that are becoming more commonplace. An unlicensed person unplugs a respirator while washing a patient. Someone brings a blanket, failing to recognize that the patient's coldness is a warning sign that he is going into shock, or that the patient's shivering is not due to cold, but is instead an adverse reaction to pharmaceuticals.

In October 1994, the California Nurses Association set up a program called Patient Watch to collect complaints and concerns about patient care and safety resulting from hospital restructuring. It has received hundreds of calls. On more than one recent occasion, patients have called 911 from their hospital beds after overworked nurses failed to respond to their requests for assistance. Relatives have complained that they've had to stay around the clock because no one else was looking after their loved ones.

Hospitals have increasingly been putting business concerns first, causing changes in the clinical environment that are affecting the quality of care. Under pressure from insurers and HMOs to move patients quickly through the system, hospitals are admitting new patients less readily and discharging them more rapidly, meaning that the average patient is far sicker than in the past. Many hospitals are assigning nurses more patients and giving them new clinical responsibilities that in the past were handled by specialized technicians. Then, to ease the burden, hospitals hire relatively unskilled people to take over some of the nurses' responsibilities.

In critical care units, where high nurse-to-patient ratios are mandated by law, patients are being moved quickly to transitional care units, where the law requires far fewer licensed clinical staff members per patient. "We're getting more critically ill patients in TCU that normally would have been in ICU [intensive care] longer," says Kathy Welch, who has been an RN at Dominican Hospital for the past six years. "Open heart patients come to us after 24 hours now. They used to be in ICU for at least two days. Minimum."

Administrators attribute the changes seen around hospitals these days to cost-containment measures made necessary by lower patient counts and limited insurance reimbursements. While they often feign to be at the mercy of a changing system of health-care delivery, the numbers show that hospitals are as profitable as ever.

In 1994, the most recent year for which numbers are available, 529 California hospitals reported pre-tax profits totaling more than $1.9 billion, according to the Office of Statewide Health Planning and Development. Even Dominican Hospital, a non-profit, has been racking up some pretty impressive "non-profits." Dominican reported net income of nearly $4 million in 1994, more than $8 million in 1993 and nearly $7 million in 1992. Watsonville Community Hospital topped $2 million in profits in 1993 and 1994.

Many health experts and primary caregivers agree that, by focusing on the bottom line, hospitals have opened the doors for accidents and deterioration in the quality of patient care. "When you are giving care, you shouldn't let bean counters make decisions about levels of care, you look at acuity," notes Beth Shafran, a local labor representative for the California Nurses Association. "If you look at a nurse's licensure, you won't find anything about insurance reimbursements. It talks about being a patient advocate and caring for their patients."

Can't Do Everything

UNFORTUNATELY FOR patients, administrators don't adhere to a similar oath. Through layoffs, attrition and changes in hiring policies, hospitals nationwide have been cutting licensed clinical staff to what some caregivers believe are dangerously low levels. Shafran says patient-to-nurse ratios at Dominican have definitely increased, though she did not offer any numbers.

Mel Herman, an ICU nurse at Summit Medical Center in Oakland, says Summit RNs who used to handle six patients are now juggling nine patients each. "Two RNs have one aide and 18 patients and the aide is supposed to free the nurse for more technical duties, but the nurses are left with all the paperwork and all the responsibility," Herman says. "The real danger is not only in the number of patients. These patients are much sicker than 10 years ago. And then you add the rate at which patients are being driven through the system and you have a workload that's pretty unsafe."

Hard numbers support these observations. Between 1981 and 1992, clinical staffing in hospitals nationwide increased 5 percent, compared with a 21 percent jump in non-clinical personnel. During the same time, according to Medicare figures, the average "acuity," or illness level, of patients admitted to hospitals also rose by 21 percent.

"If you adjust the increased number of nurses for the case mix, there's been an absolute decline of 7 percent in terms of nurses, whereas if you look at levels of all employees, adjusted for case mix, that has gone up by 11 percent, and administrators have increased by 45 percent," says Linda Aiken, a professor in the School of Nursing at the University of Pennsylvania.

Citing an article by two John Hopkins professors, Aiken says clinical staffing in California hospitals, adjusted for the increasing sickness of the patients, declined 11 percent between 1981 and 1993.

"This is the explanation I give to hospitals who say nurses [who voice concerns] are just worried about their jobs," Aiken says. "There's evidence, with increased acuity levels, that patient care is being adversely affected because the nurses simply can't do everything the patients require."

Following the second of two sets of layoffs at Dominican in 1994, hospital president Sister Julie Hyer told local press that "cost-cutting actions" had prevented further layoffs. Last month, the hospital reorganized its Mental Health Unit--laying off three full-time RNs and eliminating several benefited part-time positions. While the staff had been expecting layoffs, nurses say the unexpected reorganization caused disruptions that have affected patient care. "It changed around teams that had spent quite a long time working together, and the team approach is quite important on the Mental Health Unit," says Barbara Williams, an RN at Dominican for 15 years.

Dominican Communications Director Penny Jacobi says nobody from the hospital administration was available to comment on how hospital restructuring has affected Dominican. She offers, however, that Dominican has a relatively lean administration and that any layoffs have been absolutely necessary. "If patient volume drops, we have to adjust the staffing accordingly," she says. "We use attrition, and we revise job descriptions so people can cover two jobs. We try to avoid straight layoffs, but there will be more. One of the factors is that a new hospital is coming in down the street."

In its efforts to reduce staff by attrition, Dominican has stopped hiring per-diem nurses, who comprise an in-house labor pool to be called upon when needed. Dominican is offering far fewer full-time RN positions and very few--and usually without benefits--part-time nursing jobs. In addition, the hospital no longer uses nurse registries--the temp agencies of the nursing world.

"The hospital is requiring more out of us and doesn't seem to want to pick up the slack by hiring benefited employees that will stay with the hospital," says Dave Escobar, an oncology nurse and chief nurse representative for the CNA's Collective Bargaining Unit. "They are trying to hire seasonal nurses--who get a flat rate, with no benefits, no mobility or seniority--just to fill in, but people out there are looking for good jobs."

Bare-Bones Staffing

NURSES AND THEIR labor representatives say many hospitals, including Dominican, are now operating on a "bare-bones" clinical staff. With the exception of emergency and critical care units, Dominican staffs its units solely based on number of patients, not acuity, and the increasingly sicker patients are placing a greater burden on the nurses.

Nurses also have more patients and staffing is often short, compelling nurses to work overtime. Welch says one nurse in her unit had done six double shifts during a recent two-week pay period. "That's working from 3pm to 7:30am," she says. "Sometimes, if nobody is found for the next shift, the charge nurse has to be two places at once or the nurses will take a bigger load. We definitely need more nurses."

Hospitals are required by the state accrediting agency to base staffing on acuity, as well as number of patients, but cost-conscious bureaucrats have been slow to implement such systems. At Dominican, Williams says, the hospital's Professional Practice Committee, a group that works with administrators on patient care issues important to nurses, has been working to set up acuity-based staffing in some units, but progress has been slow.

About 18 months ago, administrators at Dominican adopted a new clinical position. These patient care technicians--unlicensed, unregulated personnel--are trained by hospital staff to take blood sugar levels, draw blood, conduct EKG tests, bathe and move patients, empty bedpans, and do other tasks traditionally performed by RNs or licensed technicians.

Jacobi says such changes in staff mix at Dominican and other hospitals have freed up nurses for the clinical tasks they were trained for and have relieved RNs of some of the more mundane nursing duties.

Nurses welcome the assistance, but many are concerned about allowing unlicensed staffers to perform clinical tasks. "The hospital maintains that is okay for somebody without the medical background to take blood sugar levels. We say it's not okay, that it opens up patients to a lot of risks," says Williams, who chairs Dominican's Professional Practice Committee.

Williams says the main problem with hiring unlicensed personnel to carry out nursing tasks is that nurses end up spending less time assessing the health of their patients. "The RN is not always getting all the information and doesn't have the time to check on all the information she is receiving," Williams says. "Patient assessment itself is being fragmented, and that's a concern with critically ill patients."

Professor Aiken agrees: "If you replace nurses with untrained people, you are taking the only professional eyes and ears you have away from the bedside. These people can't recognize the beginnings of a problem, because they have no training. They can be trained to start IVs or do specific tasks, but they can't recognize when someone is getting into trouble."

Aiken, a former ICU nurse, says the main reason people are admitted to hospitals nowadays is that they require nursing care, and she adds that patients are not getting their money's worth. "Consumers should be outraged," she says. "The non-professional care you receive in hospitals is not even as good as staying home and being cared for by a spouse or a friend. Why would you want to pay $1,500 a day to have a high school grad take care of you?"

Administrators at Dominican Hospital are taking steps to blur the distinctions between licensed and unlicensed clinical staff. The hospital is changing all job titles to eliminate credentials and replace them with the generic term "associate." All hospital employees will get one of six new titles: Hospitality Associate, Diagnostic Associate, Therapy Associate, Nursing Associate, Patient/Family Support Associate or Business and Administrative Associate. All others will be called "Management Associates."

"The term 'associate' provides a stronger bond of similarity and doesn't emphasize separateness," according to the Jan. 11 issue of The Scanner, the administration's newsletter.

Beth Shafran says the CNA is opposed to the title changes. "I think the patient should know the credentials of anyone providing patient care," she says. "This is one of the classic early moves when a hospital wants to do restructuring."

Shafran adds that administrators recently presented a draft of a new job description for RNs that included a section forbidding nurses from criticizing the hospital in conversations with patients. As a result, she says, a patient's questions and gripes about treatment might have to be referred to hospital bureaucrats.

"Nurses are going to continue to speak out against proposals that would compromise health care," Shafran says. "And we will continue, by all legal means, to stop hospital restructuring. It's a dangerous model and we don't want it here in Santa Cruz County."

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