SAFE Staffing SAVES Lives
The Case for Minimum Safe RN-to-Patient Ratios

Why are Minimum RN-to-Patient Ratios Important?

Having more care by a Registered Nurse at the bedside has been proven to improve patient care, reduce hospital stays, and save lives.

Care standards in our hospitals have deteriorated as hospitals cut nursing staff to reduce costs. Nurses are caring for more patients at the same time that hospitalized patients are requiring increasing levels of care. 

Unsafe staffing levels in hospitals effect patients and nurses across our state, putting patients at risk of preventable errors, and driving nurses out of their profession.

We all expect specific safety standards for clean air and water, limits on classroom sizes, and staffing ratios for air travel and day care. Patients in hospitals are also entitled to minimum safety standards and public protection.

How Will HB 147 Improve Patient Care?

HB147 sets forth RN-to-patient ratios (the number of patients under a registered nurses’ assignment) in acute care hospitals in Pennsylvania for the various types of units in an acute care hospital.  The ratios are maximum ratios that would prohibit an RN from having more patients in their assignment.

Unit Type	RN-to-Patient Ratio
OR	1:1
Trauma Emergency Unit	1:1
Critical Care - ER Critical Care - All ICU	1:2
Labor and Delivery	1:2
PACU	1:2
Antepartum	1:3
ER	1:3
Pediatrics	1:3
Stepdown from ICUs	1:3
Telemetry	1:3
Intermediate Care Nursery	1:4
Medical/Surgical	1:4
Acute Care Psychiatric Units	1:4
Rehabilitation	1:5
Postpartum (3 couplets)	1:6
Well Baby Nursery	1:6

The bill directs the Department of Health to set RN-to-patient ratios for other units not listed above, including psychiatric units, of acute care hospitals.

HB 147 Only Applies to Direct-Care RNs
The bill states that the ratios above shall constitute the maximum number of patients that may be assigned to a direct-care RN.  A nurse, including a nurse administrator or supervisor, who does not have responsibility as a direct-care nurse for a specific patient shall not be included in the calculation of the nurse-to-patient ratio.

Lower Ratios are Permitted and Required Based on Acuity
Hospitals can develop a staffing plan that has RN-to-patient ratios that are lower (fewer patients per nurse) than the ratios above. The ratios above are maximum ratios—not a minimum threshold. 

The bill requires hospitals to develop an approved system for tracking patient acuity (complexity of care, or how sick a patient is)  and patient activity that is directly related to the staffing plan of the hospital and the RN-to-patient ratios.  An RN may need to take have fewer patients on a given shift due to patient acuity or activity on the unit.

RN-to-Patient Ratios Must Not Reduce Non-RN Staff
HB 147 explicitly recognizes the importance of all health care workers, including licensed practical nurses, social workers, nurse aides, monitor techs, etc, in ensuring quality patient care outcomes.  The bill spells out that the setting of staffing ratios for RNs is not to be interpreted as justifying understaffing of non-RN staff.

Hospitals Must Publicly Disclose Their Staffing Plan
The bill requires that hospitals post in a public space their documented staffing plan and that they keep daily records regarding adherence to the nurse to patient ratios, patient acuity, and patient outcomes.

Non-Compliance Risks Licensure and Penalties
Overall, HB 147 bill ties hospital licensure to both the adherence to the RN to patient ratios and the recordkeeping to show compliance to ratios and patient acuity.  The bill also imposes penalties and sanctions on hospitals for non-compliance.

Whistleblowers are Protected
HB 147 provides for whistleblower protections to ensure that an RN cannot be retaliated against for reporting incidents of non-compliance to the ratios.

Nurse Recruitment is a Priority
The bill includes directives to increase grants and loans for nurse recruitment to help ensure hospitals have the resources to hire RNs to meet the RN to patient ratios.

Where will More RNs Come From?

Registered nurses do not want to remain in understaffed, over-stressed positions where their ability to provide quality care is compromised.

When California passed minimum RN-to-Patient ratios for hospitals, hospital vacancy rates plummeted and the number of actively licensed RNs grew by over 10,000 each year – compared to 3,200 per year before the law passed. (California Board of Nursing)

Victoria, Australia, adopted RN-to-patient ratios in 2000 and has seen the number of employed nurses increase by over 24 percent.

What Does the Academic Research Say?

For each additional patient over four in a registered nurse’s care, the risk of death increases by 7 percent for surgical patients. In hospitals with eight patients per nurse, patients have a 31 percent greater risk of dying than those in hospitals with four patients per nurse.  Linda Aiken, et. al., “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction,” Journal of the American Medical Association, October 23/30, 2002.

Patricia Stone, Sean Clarke, et. al., “Nurses’ Working Conditions: Implications for Infectious Disease,” Emerging Infectious Diseases, November 2004. Demonstrates that in much of the research on infection outbreaks, the RN staffing mix and number of RNs were major factors.

Low nurse staffing levels are a key cause of 98,000 preventable deaths each year.  Institute of Medicine Report, Keeping Patients Safe: Transforming the Work Environment of Nurses, 2004.

Inadequate staffing precipitated 25% of all sentinel events.  The Joint Commission on the Accredidation of Healthcare Organizations.  2002.

“Until very recently, policymakers and health care leaders have not associated hospital nurse understaffing and burnout with medical errors and adverse patient outcomes . . . . This chapter explicates the link between nursing and quality and discusses the implications for the nation’s quality improvement agenda.” Linda Aiken, “Improving Quality through Nursing,” Policy Challenges in Modern Health Care, May 2005, Chapter 12.

“Considered as a patient safety intervention, improved nurse staffing has a cost-effectiveness that falls comfortably within the range of other widely accepted interventions. . . . Physicians, hospital administrators and the public must now begin to see safe nurse staffing levels in the same light as other patient safety measures.” Michael Rothberg, Ivo Abraham, et. al., “Improving Nurse-to-Patient Staffing Ratios as a Cost-Effective Safety Intervention,” Medical Care, August 2005.