Legal UpdateOctober 2020
I’m Capped! Should Staffing Ratios Apply To Docs As Well?Title 22 California Code of Regulations Division 5 (“Title 22”) was a novel 2004 California law that placed hospital wide limits on nurse/patient ratios.1 The restricted ratios of nurses to patients vary depending on the location in the hospital and the acuity level of the patient. For example, in the ED, a single nurse may not take on more than one trauma patient, two critical care patients, or four general medical patients.2 Violation of the established ratios subjects the hospital to civil and/or criminal penalties.3 Nine other states are now similarly considering restrictions on nurse staffing ratios.4 Proponents of the limitations cite improved patient outcomes and reduced nurse burnout, while opponents purport longer wait times, increased labor costs, and lack of flexibility to address surges in patient volumes.5 While there is no commensurate law applicable to physicians, there have been parallel statutes enacted to address physician fatigue resulting from long continuous hours of work. Many of you are sure to recall the story of Libby Zion. Ms. Zion was a troubled youth from a well-to-do New York family that overdosed on a cocktail of prescription medicines and cocaine.6 She presented to the ED with a fever and other flu-like symptoms.7 Her autopsy suggested the rare and unrecognized serotonin syndrome as the cause of her death. Instead of implicating an uncommon diagnosis resulting from an unrecognized overdose, the Zion family, and their attorneys, concluded that long resident physician hours were the cause-in-fact of their child’s death.8 Whereas the long resident hours may have been a substantial factor in her death, the theory of too many concurrently managed patients was never articulated as a contributing factor in the mismanagement of Ms. Zion. I believe though, that many in graduate medical education realized this issue was a potential problem as there was soon established a limit to thenumber of patients a resident could admit during the course of their call time. I know many of you recall during the course of your residency, the admitting IM resident stating that he/she was “capped” and could no longer take on any more admitted ED patients. Why was there a “cap” put in place for them? Every state has now enacted laws, and the ACGME has adopted resolutions limiting the working hours of physicians–in-training. The primary goal of these restrictions are to have non-fatigued and focused physicians caring for their patients. I believe the intent of the regulations though, overlook what California recognized in its Title 22 enactment. Surely we can all manage a single patient for days on end without much difficulty. When additional patients are thrown into the mix, the ability to juggle multiple patients competently becomes increasingly more difficult. As a Darwinian adaptation, we all attempt to minimize external stimuli when navigating complex tasks. For example, have you ever been on a driving trip with your family? The radio is blaring, the kids are fighting, and your wife’s trying to discuss dinner plans when you get to Disney. Then suddenly it begins to downpour. What do you do? The logical reaction is to eliminate at least one of the external stimuli to focus on your driving. Telling your spouse to stop talking is a poor choice! Yes, turning off the radio would be the most commonsensical choice to ensure a safe arrival at the mouse-house. We may subconsciously, to our personal and patient’s detriment, do this same action when our individual patient volumes increase beyond our capacity to safely manage. We might discharge a patient we ordinarily would have admitted, just to quickly get them off our overloaded radar. These poor decisions may be further exacerbated with the desire to clear your patient plate and get home right after shift change. I would logically posit that our individual care, customer satisfaction scores, and longevities in the profession would be improved by limiting the number of patients we are permitted to manage at any particular time. I realize this is a radical proposition, as it was for California hospitals in 2004. Understandably, limiting doctor to patient ratios would be difficult to impose, but it’s some food for thought, and an idea that probably deserves some further discussion. Kenneth Alan Totz, DO, JD, FACEP No information within this publication should be construed as medical or legal advice. Independent medical and/or legal advice should be sought based on each individual’s particular circumstances. 1 Did you know that California law sets nurse-to-patient ratio requirements for hospitals? |
