California regulators are running out of time to implement their state's landmark nurse-staffing law. On Dec. 14, Modern Healthcare's Daily Dose reported that the California Department of Health Services said it might implement "emergency ratios" that hospitals would be required to follow while regulators continue grappling with how many patients the law ultimately will allow for each nurse.
The emergency ratios would be a temporary way to carry out the law that is scheduled to take effect in January but has been the subject of ongoing controversy and delay, a DHS spokeswoman said. In 1999, California became the first state to pass legislation requiring that nurses monitor only a certain number of patients.
In accordance with the January timetable, California's 470 hospitals had expected the DHS to propose specific ratios before year-end so there would be time for a 45-day comment period, including public hearings. Regulators then would take time to consider the comments and make any necessary adjustments to the ratios.
That didn't happen. The DHS has yet to release its proposed ratios despite recommendations from nurses, hospitals, unions and others about which ratios would make the most sense. The California Nurses Association has proposed that each nurse care for no more than three patients in medical/surgical units, a huge distance away from the 10-to-1 ratio supported by the California Healthcare Association, which represents the state's hospitals.
As the window of time before the law takes effect rapidly closes, the DHS declined to project when it will issue proposed ratios.
"Our department has made a commitment to hold meetings across the state in recognition of the high level of interest in this issue," said Lea Brooks, a DHS spokeswoman. However, she said, "if you look at the calendar, we don't have 45 days left."
Brooks declined to say if the DHS would propose specific ratios before the end of the year. But on Dec. 12 she said the state would not meet its own Jan. 1 deadline, according to local media reports.
Instead, the DHS is considering emergency regulations that would require hospitals to operate under undetermined ratios until the final ones can be evaluated and codified next year, Brooks said. It is unclear when such regulations would come out or how quickly hospitals would be expected to comply with them.
The DHS' guiding question as it decides whether to exercise the emergency option: "Is there an emergency out there in California that requires the regulations to be implemented on an emergency basis?" Brooks said.
"There is no emergency in this state that demands the implementation of ratios on any particular date," said CHA spokeswoman Jan Emerson. "I would think we face a serious emergency if in fact the ratios are issued and they're too restrictive. That emergency would be access to care being jeopardized."
The CHA argues that California suffers from one of the nation's most severe nursing shortages, with a statewide vacancy rate as high as 20%. That will make it difficult, according to the CHA, if the forthcoming ratios demand the hiring of nurses who, the CHA claims, simply aren't there.
Proponents of the ratio law see things differently.
"We can't improve (nurses') working conditions without safe staffing levels," said Charles Idelson, a spokesman for the CNA, which represents 40,000 nurses in the state. "Australia implemented ratios last year, and they've had a 13% increase in the nursing workforce."
Emerson disagreed. "There is no evidence that the ratios will solve a shortage that's very acute. There are just not enough bodies."
If hospitals are required to staff at the levels the CNA advocates-one nurse to every three patients in medical/surgical units-95% of California hospitals would not be in compliance, according to a July analysis by San Francisco-based Public Policy Institute of California, a not-for-profit research group.
As hospitals scramble to find nurses, it could be a while before they know how many are really needed.
"Assuming the DHS stays on track and issues proposed ratios on an emergency basis for implementation, they still have a fairly lengthy regulatory process," said Lisa Hubbard, a spokeswoman for the Service Employees International Union, which represents 35,000 California nurses. "2002 will be a very busy year for nurses."