CommonHealth Analysis: Nursing Staff Levels At Tufts Medical Center Trail Competitors, Data Suggest

There’s a heated dispute currently underway between the Massachusetts Nurses Association — specifically the 1,200 RN’s at Tufts Medical Center — and management at the hospital. They are engaged in contract negotiations that haven’t been pretty. The nurses accuse the hospital of allowing staffing levels to fall so low over the past year that patient care has slipped and conditions have become dangerous; the nurses have complained to the hospital’s board citing numerous examples of egregious care. The hospital, in response, says its care has in no way faltered, and that the complaints are part of a national union strategy to boost the nurses’ bargaining power.

So what’s the truth?

We decided to look at the numbers, and came up with a simple analysis of nursing staff levels based on publicly available 2011 data from a statewide hospital-sponsored website called Patient Care Link. According to these numbers, it appears that registered nurses at Tufts Medical Center do spend less time caring for patients in key medical units such as the emergency department and adult critical care unit compared to nurses at the other Boston teaching hospitals. Tufts also has a more meager nurse-to-patient ratio in its combined medical-surgical unit compared to other hospitals with similar units, according to the data from Patient Care Link.

Nurses: Less Time With Patients

Our analysis basically calculated the number of hours nurses are scheduled to work, and divided that by the average number of patients seen in the particular unit. This measure is called “nurse hours per patient visit.” So, for instance, in its emergency department, Tufts provides 1.98 nurse hours per patient visit (again, the average number of hours a nurse cares for a patient during that patient’s visit to the ER), according to the website numbers. That’s fewer nurse hours compared to the other teaching hospitals: we calculated 3.2 nurse hours per patient visit at Massachusetts General Hospital; 2.36 hours at the Brigham & Women’s Hospital and 2.31 hours at Beth Israel Deaconess Medical Center.

Let me say here that Patient Care Link is far from a precise measurement of staffing levels. It’s a site sponsored by the Massachusetts Hospital Association. It’s voluntary and non-binding. And all it asks is that hospitals submit their staffing plans. Still, these are the numbers that are available. And short of sneaking into the hospital undercover and doing headcounts, this is all the public has to work with. If anyone out there has a better way to figure this out, please let us know.

A spokesperson for Tufts Medical Center doesn’t dispute our numbers, per se, but says such comparisons don’t offer the full picture and that patient care at the hospital remains top-notch. “The numbers don’t truly tell the whole story,” says Tufts’ Julie Jette.

Nevertheless, here are the numbers:

Boston Teaching Hospitals
Unit Type Tufts MGH BWH BIDMC
Emergency Department
RN Hours Per Patient Visit
1.98 3.2 2.36 2.31
Adult Critical Care-Surgical
RN Hours Per Patient Day (24 Hours)
15.2 20.49 19.79 17.54
Hospitals with ACC Med/Surg Combined
Tufts Newton-Wellesley Good Sam Winchester
Adult Critical Care- Medical / Surgical Combined
RN Hours Per Patient Day (24 Hours)
13.33 15.48 15.45 15.04

Longer Wait Times

Nurses say this dip in staffing — with fewer nurses available for more patients — has a detrimental effect on patient care. Barbara Tiller, an RN at Tufts for 21 years, says patients now wait a lot longer for a nurse. “These are patients in pain, ringing the bell, and waiting 20, 40 minutes,” she says, “or patients who can’t get out of the bed to toilet themselves, and then they end up waiting there in a wet, soiled bed.”

Tiller said patients often wait if they have problems with their IV, and some wait just to get the IV started. “Some patients have waited three to four hours to start an IV — and if they have an infection, and are waiting for antibiotics, they’re that much sicker when we get to them,” she says. “With less nurses, the delays just snowball.” And these delays cause “a failure to rescue,” Tiller says. “If you have a nurse at the bed you notice more subtle changes which are indicative of patients getting sicker. Now, the patients get worse and nobody notices — there’s nobody watching because we’re all running around.”

Tiller said in the past year or two, “nurses on every floor have taken an increase in the patients they care for in the shift.” For instance, she said, at night, each nurse is assigned six or seven patients, when previously she had only five to care for. “If one patient has a problem, the others don’t get seen,” she said. During the day each nurse was assigned “three or four patients, now it’s five,” Tiller said.

Because of these staffing changes, the nurses’ union is ramping up its efforts, with a flash mob calling for “Safe Staffing Now,” earlier this week, and an informational picket later this month.

The Hospital Responds

Tufts offered a lengthy response to our analysis, but I’ve broken it down to three key points:

1. Apples to Oranges
“Categories of units in different hospitals, even if they are described or named similarly, may have significantly different patient populations and employ different technology, have different types of support staff, etc,” Tufts says. “Comparing units in separate hospitals can be like comparing apples to oranges. For example, some EDs include a clinical observation unit, which would change the staffing figures. And some CCUs accept overflow patients from surgical units who are not as critical as other ICU patients, which would mean they might not need to staff as high. Some hospitals have “step down” units where less critical patients who need less nursing attention can go following time in the ICU; other hospitals have these patients and the associated nursing assignments in their ICU numbers.

2. The Team Approach
“It is important to note that an advancement Tufts Medical Center has made is to bring teams of other caregivers to the units on a regular basis to assist in delivering care and in performing duties that do not need to be assigned to nurses. (This is in addition to the clinical care technicians whose time is also counted on Patient Care Link hppd figures.) For example, our inpatient pharmacists round with our physicians to interact directly with our patients regarding medications. We also have additional RN help who aren’t counted in the PCL figures, including clinical resource nurses who are available around the clock to assist any unit that needs additional assistance. These nurses are among our most highly skilled. Clinical Nurse Educators are also available to all nursing staff.”

3. Quality Counts
“We also think it’s important to note that staffing ratios are not a substitute for true quality indicators. Independent, third-party organizations have examined our quality and we compare very well with our local competitors and other academic medical centers nationally. Some of our recent quality achievements include:

In 2010, The University Health System Consortium rated us 6th in the country for quality and patient safety. (Right behind the Mayo Clinic at the #5 spot). This study, released annually, incorporates six areas identified by the Institutes of Medicine as key quality measures that are important to patient care: safety, timeliness, effectiveness, efficiency, equity and patient centeredness. Tufts Medical Center was the only hospital in New England to achieve this ranking.

When reviewing heart failure, pneumonia and heart attack care as well as surgical infection prevention, the Joint Commission’s most recent Quality Report in January 2011 gave Tufts MC the highest marks of any Boston academic medical center.

The American Heart and American Stroke Associations recently awarded Tufts MC the Stroke Gold Plus Achievement Award.

Harvard Pilgrim Health Care has placed the physicians of Tufts Medical Center and NEQCA on its Honor Roll with Distinction for Adult and Pediatric care.

Again, if anyone has an alternative way to get to the truth of this dispute, please step forward.

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