Metro-East News

Hospitals say Illinois bill to require more nurses will just make care more expensive

Belleville nurses want voice in Illinois mandatory nurse ratio legislation

The Illinois General Assembly is considering a bill that will call for mandatory maximum nurse to patient ratios for different parts of hospitals. Nurses say this could increase costs, wait times, elective surgery scheduling, but won’t improve care.
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The Illinois General Assembly is considering a bill that will call for mandatory maximum nurse to patient ratios for different parts of hospitals. Nurses say this could increase costs, wait times, elective surgery scheduling, but won’t improve care.

During a visit from nurse manager Kristin Atchisson, patient Frank Austin lays in bed during the 10th day of his stay at Memorial Hospital in Belleville after the Shiloh resident suffered a fall and hit his head on the concrete as he was walking out of church.

“(There’s) definitely an adequate number to let me know they have my interest at heart,” the 75-year-old Austin said, referring to the number of nurses and other hospital personnel tending to his care.

Austin’s nurse on Tuesday had four other patients, according to a white board at the nurses station listing assignments for the day on the fourth floor unit. Telemetry nurses will have between four and five patients a piece at Memorial Hospital, administrators said.

But under proposed legislation in Illinois, there would be certain nursing ratios mandated in the state, including up to three patients per nurse in telemetry. Austin and other patients could conceivably see more attention.

“Wouldn’t we all. There would be more, quicker responses to my calls,” Austin said. “That’s like saying wouldn’t we like it if our care takers would have less of a workload, they could concentrate more on us? Sure, we all would.”

However having more nurses wouldn’t come cheap.

“I know it’s going to create an expense,” Austin said.

That expense is something hospitals in the state are worried about. They point out the mandatory ratios may lead to patients needing to wait for care when they go to a hospital as hospitals would need to make sure they have adequate staff amidst a nursing shortage.

The proposed Safe Patient Limits Act calls for mandatory nurse-to-patient ratios at hospitals. The legislation includes a 1-to-3 ratio in telemetry, and 1-to-4 for medical and surgical floors. Intensive care units would need to have a 1-to-2 ratio; operating rooms would need 1 to 1.

Telemetry nurses typically care for patients who are out of the ICU, but need their vital signs monitored closely, such as after surgery. These are considered “step-down” units.

The Illinois Economic Policy Institute has argued in favor of the legislation. It says the hospital industry could save $1.4 billion with the mandatory ratios through improved staff injury rates and patient care costs. The savings would offset 75 percent of the cost of hiring the additional nurses that hospital lobbyists say would be needed to implement the patient limits in the legislation.

“While prior research has highlighted the fact that staffing standards would improve patient care and mitigate the occupational hazards that are driving about one-third of all new nurses out of the profession within their first three years, this subsequent research shows that the policy would mostly pay for itself,” said study author and ILEPI Policy Director Frank Manzo IV.

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A Memorial Hospital nurse works at the nurse’s station on the fourth floor South Wing patient floor. Derik Holtmann

The economic policy institute argued Illinois hospitals could afford the costs. They had $40 billion in expenses in 2018, but brought in $3 billion more in revenue than they spent, according to the organization.

The ILEPI argues that one of the reasons for the existing nursing shortage is because insufficient staffing levels can exacerbate the occupational hazards of nursing and undermine the quality of patient care. There also is a rising demand for health-care services and the labor market competitiveness for Illinois nursing jobs.

The Illinois Health and Hospital Association (IHA) has said the state’s proposed nurse staffing legislation would require about 20,000 more nurses in the state at a cost of nearly $2 billion.

“IHA’s figures appear to include only the labor cost of hiring more nurses, but fail to account for the significant cost burdens that understaffing currently imposes on our hospitals,” Manzo said. “This includes hundreds of millions of dollars in staff turnover and injury costs, reduced Medicare reimbursements due to higher patient readmissions, and additional patient time in costly intensive care and surgical units. On these four metrics alone, safe patient limits could save Illinois hospitals over $1.4 billion.”

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Kristin Atchison RN, speaks with Memorial Hospital patient Frank Austin. New Illinois legislation could force hospitals to maintain a specific patient to nurse ratio not based on care needs, but only on populaiton. Derik Holtmann

California enacted mandatory ratios in 2004 and has seen a reduced nurse turnover rate, lower hospital readmission rate, lower hospital mortality rates, and reduced the average length of patient stays, the economic policy institute said.

“Safe patient limits have been a net positive for patients, nurses, and the bottom line of California’s hospital industry,” Manzo said. “In debating similar standards, Illinois legislators must not just consider the short-term cost of adding health-care professionals, but the long-term benefits of better nurse retention and higher-quality care.”

Hospitals: It’s an unfunded mandate

Sulbrena Day, the chief nursing officer at Touchette Regional Hospital in Centreville, said she meets with nurses and supervisors every day to determine how to staff every unit of the hospital to meet patients’ needs.

“We rely on the clinical and professional judgment of the nurse to make these types of decisions because not all patients are equal in their presentation or in their continued stay in a hospital,” Day said. “I can tell you that Touchette cannot absorb any new, additional costs of an unfunded mandate to staff up to meet arbitrary, one-size-fits-all staffing ratios.”

Terri Halloran, the chief nursing executive for Memorial hospitals in Shiloh and Belleville, said most of the nursing ratios outlined in the bill match what the two campuses already have in place. However, for patients who would be in the telemetry department, those patients whose vitals need to be monitored, the hospital’s ratio of 1 to 4 or 5, would need to be adjusted to 1 to 3 under the legislation.

Under the proposal, hospitals face a fine of $25,000 a day for not meeting the ratios.

The legislation has been proposed several times in the past, but it has been voted out of committee, and the intensity around the legislation is a lot higher, Halloran said.

In March, the state House Labor and Commerce Committee recommended the legislation be passed in a 17-8 vote. State Reps. Jay Hoffman, D-Swansea, and Katie Stuart, D-Edwardsville, were among those to vote yes in committee. State Reps. LaToya Greenwood, D-East St. Louis, and Blaine Wilhour, R-Beecher City, voted no. The bill has since been referred back to the Rules Committee.

The state Senate version of the legislation has been referred to the Assignments Committee.

Halloran said the Memorial hospitals prefer to base staffing levels on patient acuity, or how complicated a particular patient’s diagnosis and treatment would be, such as whether he needs surgery and what the patient’s recovery plan is.

For example, a patient who is recovering from open-heart surgery would need more attention than a patient with a sprained ankle.

“We see acuity as these are the immediate needs that need to be addressed, whether they’re the physiological needs of your body all the way to the discharge planning needs you would require,” Halloran said.

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Nurses and staff members work at one of the nurse stations at Memorial Hospital in Belleville. Derik Holtmann

She said a patient who just had open heart surgery would have a nurse whose sole responsibility is to care for that patient. However, as the patient recovers, that same nurse could then take care of other patients as well.

“We do that today, based on knowing that an open-heart patient needs ICU care initially, and then as they get better, we progress them to different areas of the hospital, until they’re discharged,” Halloran said. “We kind of already have that kind of system in place, where we assign a patient to the right place in the hospital.”

The Illinois Hospital Association estimates the nursing ratios would add $2 billion a year in health care costs in the state. Halloran estimated the two Memorial campuses would need to spend an additional $6 million to $8 million a year to have an additional 80 to 100 more nurses.

“That dollar amount is going to be absorbed by hospitals, by patients, it’s going to be absorbed by health insurance companies, there’s no extra funding or way in order to recoup that needed dollar amount to recruit enough nurses to meet this ratio,” Halloran said.

There’s already a nursing shortage

To further make staffing more difficult to fill, Halloran said there’s a nursing shortage. By 2020, it’s estimated Illinois would have a shortage of 21,000 nurses.

The Hospital Sisters Health System has nine hospitals in Illinois including St. Elizabeth’s in O’Fallon, St. Joseph’s in Highland and St. Joseph’s in Breese.

HSHS St. Elizabeth’s Hospital President and CEO Patti Fischer said the proposed legislation is not workable.

“Our first priority as a health-care provider is to make sure we provide the best care possible to anyone who comes to a Hospital Sisters Health System facility for care. However, this proposal to create a mandatory nurse-to-patient ratio is simply unattainable due to the nationwide nursing shortage that continues to challenge the health care field,” Fischer said.

“We are additionally concerned that it removes the bedside nurse’s ability to make staffing decisions based on the acuity of the patient that he or she is caring for at the time.”

At Memorial, there are 40 unfilled nursing positions and filling a position can take three to six months.

“It (comes) at a time when all Illinois hospitals are struggling to hire nurses,” Halloran said.

Staff members at Memorial said their first impressions of the legislation is it would be good for patients. However, it ultimately could bring problems with access to care if hospitals can’t meet the ratios, forcing patients to wait for care.

Halloran argued California hospitals had to rely on nursing agencies to help fill the gaps, and patient outcomes such as preventing infections, falls and pressure ulcers did not improve, all while losing flexibility on how to handle staffing.

Halloran said if nurses in an emergency department are at their maximum patient amounts, then other patients would have to wait until a patient is admitted to the hospital or is discharged.

“Having an overpacked E.R. is not the right solution for our community, because there’s no way they’re getting the type of care, that acuity care we talked about, that they would need if they were in the right room in the hospital,” Halloran said.

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A Memorial Hospital nurse works at her portable workstation on one of the patient floors in the Belleville Hospital. Derik Holtmann

The hospital makes nursing assignments based on the hospital’s daily census, how much attention each patient may need based on their diagnosis, and the nurse’s experience level.

Having the mandatory ratios could have an adverse ripple affect on patient waiting times.

“If we’re looking at a 1-to-3 ratio, and this change just happened, we’re not going to be able to move the patient from the emergency room because you’re not going to be able to move the patients up on the floor. Not only that, they’re going to be waiting in the waiting room in the emergency room because they’re not going to be able to have the staffing they have to abide by, too,” said Atchisson, the nurse manager. “It’s going to impact our community because they’re going to be waiting longer times to get health care.”

Cathy Fenton, an operating room nurse at Memorial, said when people have elective or pre-planned surgeries they have to prepare for the procedures, sometimes week ahead of time, such as halting certain medications, going through tests, and not eating anything after midnight before the surgery.

Fenton feared pre-planned surgeries could be delayed with the ratios because emergent cases would always take precedence.

“I think the families would be very dissatisfied,” Fenton said.

Fenton said she hoped legislators listen to the concerns of hospitals.

“I would really like them to talk to the nurses and see how we are functioning now and listen to our concerns, because I think everybody comes here to do a good job. When patients come through these doors we want them to know we care for them and we don’t want something like this having a negative impact on their experience here in the hospital,” Fenton said.

Joseph Bustos is the state affairs and politics reporter for the Belleville News-Democrat, where he strives to hold elected officials accountable and provide context to decisions they make. He has won multiple awards from the Illinois Press Association for coverage of sales tax referenda.