The byline on the City Room report is Nina Bernstein, the multiple-prize-winning reporter known for doing some of the country’s best work on immigrants, the poor and the social services system (See her latest feature, on an illegal immigrant who can’t get a kidney transplant.) The headline: “Nurses accuse equity firm of cutting patient care.” Nina has some fun with the Cerberus thing, writing:

Instead of the inflatable rat that has become ho-hum at union protests in New York, a giant three-headed dog with fangs was the effigy on display as about 250 unionized nurses rallied outside the Midtown headquarters of the private equity firm Cerberus Capital Management.

Last year the firm added 10 mostly Catholic community hospitals in the Boston area to its portfolio, promising to keep the same level of services or to provide even better services. But carrying signs that proclaimed “Cerberus Is a Lying Dog,” and that urged “Get Wall Street Out of Health Care,” members of the nurses’ union, National Nurses United, accused the firm of proving to be more like its namesake, the canine monster in Greek mythology that guarded the gates of hell.

Among the nurses’ accusations: A firing for trying to unionize, and corporate cuts in patients’ nighttime juice and bread. The story includes a response from Steward:

Christopher Murphy, a spokesman for Steward, called the allegations “totally fabricated” as part of a dispute over pensions, which is now in arbitration. The union’s campaign “has nothing to do with improving health care or even the conditions of their own nurses,” who are highly paid and working at award-winning hospitals, he said. “It is an attempt to pressure our hospitals to provide richer benefits.”

A press release from the Massachusetts Nurses Association says that boarding buses for a Park Avenue protest tomorrow will be MNA nurses from Steward-owned Carney Hospital, Good Samaritan Medical Center, Holy Family Hospital, Merrimack Valley Hospital, Morton Hospital, Norwood Hospital, Quincy Medical Center and St. Elizabeth’s Medical Center. From the release:

New York City – Hundreds of nurses and their supporters from across the U.S. will converge outside the offices of Cerberus Capital Management, 299 Park Avenue, on Tuesday, Dec. 20, at 12:30 p.m., to protest the practices of the multi-billion dollar private equity firm’s health care unit, Steward Health Care System…

The nurses — from Massachusetts, and joined by RNs from NY, DC, CA, Il, PA and NV — are members of National Nurses United, the largest union and professional association of registered nurses in the U.S., with 170,000 members. Nurses, allies and Occupy Wall Street protesters will speak at the rally, which will also feature theater and a 10-foot, three-headed dog, “Cerberus,” the mythical canine at the Gates of Hell.

QUINCY — A public hearing on the proposed sale of Quincy Medical Center became a battleground in a labor fight between the prospective owner and nurses from other hospitals it has bought.
Dozens of members of the Massachusetts Nurses Association walked out of Tuesday night’s hearing at Quincy High School as a lawyer for Steward Health Care accused the union of distorting facts about the dispute over a pension plan.
“They are willing to let these important community hospitals potentially close, taking with them thousands of jobs and creating economic chaos, all because they want more than ever and don’t care who is hurt in the process,” Joseph Maher, Steward’s general counsel, said of the union.
The Massachusetts Nurses Association asked the state attorney general to delay approvals of Steward’s purchase of Quincy Medical Center and Morton Hospital in Taunton until the issue is resolved. The nurses submitted signed petitions Tuesday to Steward CEO Ralph de la Torre calling for a resolution to the dispute.

Will the nurses’ complaints slow the sale of Quincy Medical Center to Steward? Not judging by how Jack’s story ends:

While some speakers at Tuesday’s hearing expressed concern about the labor dispute, all stated support for Steward’s $34 million purchase of the financially ailing Quincy Medical Center.
“Quincy needs a hospital,” said state Rep. Ronald Mariano of Quincy. “I’m more concerned about what happens if we don’t make this deal.”

The Tufts hospital administration didn’t dispute our numbers, but said that other medical providers are filling the RN gap. The administration maintains that patient care remains top-notch. Nurses, however, assert that patient care is deteriorating to dangerous levels. Here is a sampling of the thoughtful, and often painful, comments we’ve received:

From a Tufts RN:

I’ve been a pediatric nurse at Tufts through many turbulent times. There have been highs and lows as in any hospital. Never have the patients experienced any of the lows in the past because we were always able to work longer, forgo lunches and breaks to meet the needs of out patients. We can’t work that fast anymore. We come up short every single shift and the patients are feeling it. We can see it in the frustrated looks and angry comments from family members advocating for their children. We can hear the babies crying as we run down the halls to assist another child. Are they crying due to pain, due to hunger, are their diapers wet? All assessments that we have to make on the fly and hope that they are the right assessments. When these situations were brought up at an advisory meeting, we were basically told by the CNO that medicine has changed since we started over 30 years ago and we no longer have time to comfort the babies. Part of Tufts welcome page states “At our children’s hospital we treat each child as if they are our own”. I can tell you this is not how I treat my children and it kills me that I have to treat other people’s children this way.

From onefootoutthedoor, another Tufts RN:

Most of these patients don’t even realize how pushed to the brink the staff is. I witness unsafe situations almost daily, and it is getting worse. It appears that the Tufts Administration is perfectly happy to drive the most experienced nurses out of the hospital, we cost too much.

And this from Returning customer:

We have had repeated experience with hospitalization at New England Med Center and we noted a marked deterioration in the attentiveness of the nursing staff during a recent hospitalization. There may have been additional staff shortages this winter because of weather and difficulty getting to work, but the nurses on the floor were overworked, tired, and inattentive. We felt that one of our family had to be at our patient’s bedside all the time to make sure basic care needs were addressed, such as toileting and providing drinks of water. We don’t want to imagine what might have happened had our patient been alone in that hospital room. At one point we pressed the call button and no one came for almost 40 minutes. Finally, we pressed it repeatedly so the ring sounded like an emergency and a nurse was there in an instant.

And from a satisfied patient, Soxgrrl4evah:

The care at Tufts Medical Center is of the highest quality, and it’s delivered in the most professional manner by top notch staff. I was an in-patient twice following surgery and at every moment during my stay I felt my needs as a patient were always met quickly and professionally. The medical center’s nursing staff is highly trained and my nurses – as well as other helpful staff – were always attentive and available. It was a great comfort, too, that the nursing staff was very good at explaining exactly what medications I would be getting and why, as well as what to expect during a certain procedure or examination. I know based on reputation Tufts MC is one of the top academic medical centers in the nation. My own patient experience certainly confirms that.

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:

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.