Rules that nurses in Denver-area hospitals say leave patients vulnerable to shoddy care could change next year, if medical stakeholders and the Colorado health department can reach an agreement to raise the state’s staffing minimum or give nurses a greater voice.
Colorado requires hospitals to staff one nurse per unit at all times. Units vary in size and scope, with some larger general units and others that are more specialized, like patients recovering from burns or organ transplants.
Hospitals still can be cited by federal inspectors for insufficient staffing even if they meet the state requirement, but that typically only happens when a patient dies or is seriously harmed — and there’s evidence that nurses and other staff were too overwhelmed to prevent that harm.
Relatively few hospitals in Colorado actually have only one staff member on each unit, but nurses are still being overworked and “burning out,” said state Rep. Kyle Mullica, an Adams County Democrat and emergency room nurse who is involved in the discussions.
The Colorado Nurses Association has been pushing to raise the state’s requirement to two people per unit. Colleen Casper, the association’s executive director, said one could be a certified nurse assistant or other support-staff member, if the tasks don’t require a higher level of training.
“Patients don’t go to the hospital unless they need nursing care,” she said. “I don’t see how we can still be arguing about what is safe staffing.”
Amber Burkhart, director of public policy for the Colorado Hospital Association, said she understood that the idea of a two-person rule was off the table, because it doesn’t address the different models in urban and rural hospitals, as well different staff skill levels. The hospital association, the nurses association, Mullica and others have been working together on ways to ensure there are enough staff on duty, while allowing for a more “nimble” response, she said.
A two-person rule “really is a stable number and doesn’t take into consideration the flexibility that is needed,” Burkhart said.
Some nurses reported staffing was shorter since the COVID-19 pandemic began, but inspection documents show concerns dating back several years.
The Colorado Department of Public Health and Environment reviews all its regulations on a routine basis. This year, the review of staffing regulations coincided with nurses at multiple hospitals owned by HealthOne reporting they were overwhelmed. Multiple nurses and a doctor at metro-area HealthOne hospitals told The Denver Post that understaffing in some cases led to an increase in preventable pressure sores and infections, and a failure to regularly provide basic hygiene care.
According to state inspection records, a COVID-19 patient died at HealthOne’s North Suburban Medical Center in Thornton in May when no one was available to change the batteries on a machine measuring blood oxygen levels, allowing the patient’s deterioration to go unnoticed. The records showed some employees had complained about short staffing, but the issue wasn’t addressed.
HealthOne has always been committed to providing “exceptional” care and supporting employees, and multiple hospitals have been recognized for their care quality, said Stephanie Sullivan, assistant vice president of media relations and video content for HCA Healthcare, which owns the Denver-area HealthOne hospitals.
Stakeholders, like associations representing hospitals and nurses, will continue to meet to work on writing possible regulations, although the Colorado Board of Health has the final vote. Any changes likely won’t take effect until some time next year.
Elevating their voices
One area of discussion that seems to have broad support is requiring input from frontline employees on each hospital’s required master staffing plan, Burkhart said. The group also is discussing a requirement that hospitals have an oversight process, so staff have someone to go to if they have safety concerns, she said.
“The goal is to ensure we’re elevating the voice of nurses,” she said.
Strengthening the staffing plan is an important first step, because it would give nurses and others grounds to file a complaint with the state health department if their employers aren’t using the safe ratios in the plan, Mullica said. The health department could then compare the plan and actual staffing, to determine whether a hospital violated the conditions of its license, he said. It’s extremely rare for a hospital to lose a license, but the process allows the health department to demand changes to get back into compliance.
“As soon as you attach something to licensure, it takes a whole new meaning,” he said.
Frontline staff already are involved with annual and as-needed staffing reviews at HealthOne hospitals, Sullivan said. The network is sufficiently staffed, she said, with the number of staff on each unit based on how sick patients are, and what skills different providers have.
“We believe it is important that our nurses have a voice in decisions about the high-quality patient care we provide,” she said.
UCHealth reported it already has at least two staff members on every hospital unit, and SCL Health said it is starting a “nursing workforce optimization” initiative to include more frontline input on staffing and other issues. Other large Denver hospitals didn’t respond or referred questions to the Colorado Hospital Association.
Nurse representation on staffing committees is a positive development, but it still doesn’t offer certainty they’ll have the support they need to keep patients safe, Casper said. When nurses feel strained, that contributes to turnover and makes for worse care, she said.
A unit “functions best when the team knows each other,” Casper said.
No easy solutions
There aren’t any easy solutions to staffing, said a nurse leader with a HealthOne hospital, who spoke to The Post on condition of anonymity to protect her job. Other hospitals have the same problem, she said.
It makes sense to only bring in the staff you need for a given shift, but the need can change quickly, the nurse leader said. One example is that if a patient at risk of suicide comes in, a certified nursing assistant has to stay with that patient at all times, meaning one less staff member is available to help with all of the other patients’ needs.
Any solution needs to look at support staff as well as nurses, the nurse leader said. Some units in HealthOne hospitals no longer have certified nursing assistants available, so nurses have to answer call lights and help with hygiene, as well as giving medications and documenting all the care patients receive, she said.
“That’s killing them, and that’s why so many of them are leaving,” she said.
Sullivan said HealthOne’s turnover is actually lower than in many hospitals.
“We are proud that nursing turnover across HealthOne hospitals is at an all-time low — lower, in fact, than national averages,” she said.
Another problem is that the number of nurses and assistants needed varies over the year, so those that work on a call-in basis move on when they aren’t getting many hours, and aren’t available when demand picks up again, the nurse leader said. That’s a problem that defies easy solutions, since hospitals aren’t going to pay to hold onto nurses they don’t need every day, she said.
“If anybody can figure it out, they’ve got their ticket to paradise,” she said.
This content was originally published here.