Implications to Patient Care

1 January 2017

There are constant changes to laws and legislation regarding patient care and safety. The purpose of this report is to inform the reader of recent and upcoming changes to legislation that may affect nursing care of patients. Research by L. Aiken, et al. and A. Tourangeau, support the need for higher education of registered nurses. Their research proves that patient outcomes are improved when registered nurses carry a bachelor’s degree in nursing. Research conducted by J. Needleman, et al. concluded that reducing the nurse-patient ratio resulted in the patient being at less risk for developing hospital-acquired illnesses as well as a reduced risk of inpatient mortality. The reader will also be informed about the Joint Commission’s protocol for reducing the occurrence of wrong-patient, wrong-site, and wrong-procedure during surgical procedures. Politics, Legislation, and Implications to Patient Care As the American population ages, healthcare and its resources are in greater demand. As the demand for healthcare increases, the topic of patient safety has become increasingly important.

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Laws and legislation regarding patient care are changing almost constantly to maintain patient safety while still providing comprehensive patient care. This report will focus on informing the reader of recent and upcoming legislation regarding patient care, what has brought those changes about, and the effects it can have on the healthcare industry and patient care. It is important to stay informed of these changes because it may affect the registered nurses education requirements and scope of practice in the future. The Joint Commission has maintained reports of sentinel events since January 1995.

They define sentinel events as “…an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. ” (The Joint Commission, 2011). The top ten list of sentinel events includes wrong-site surgery, suicide, operative/post-operative complication, delay in treatment, medication errors, and patient falls, unintended retention of foreign body, assault, rape or homicide, perinatal death or loss of function, patient death or injury in restraints.

It is important to note that a sentinel event is not always a medical error. The Joint Commission states that: Since the sentinel event database was implemented in January 1995, The Joint Commission has reviewed 7,147 reports of sentinel events as of September 30, 2010. A total of 7,288 patients were affected by these events, with 4,844 or 66 percent, resulting in patient death. Because most of these events are voluntarily reported, and represent only a small proportion of actual events, no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

With reports such as those, it becomes increasingly obvious that changes need to be made to protect patients from medical errors. Especially when it is noted that from those events, all were voluntarily reported; this allows room for speculation that there are many more events taking place without being reported. A report by Jack Needleman, et al (2002), showed there is a significant relationship regarding registered nurse staffing ratios and patient outcomes while hospitalized.

The report found that the more hours dedicated to the patient by registered nurses resulted in lower incidences of urinary tract infections, gastrointestinal bleeding, pneumonia, shock, cardiac arrest, and failure to rescue. This report indicated the importance of reduced nurse-patient ratios because lower nurse-patient ratios result in less hospital-acquired illnesses and reduction in patient mortality. Additionally, according to Jack Needleman, et al (2007), another report indicated that there is a direct correlation between inadequate staffing ratios and a higher risk of patient mortality.

In the study performed by Needleman, et al, regarding the relationship of staffing and the risk of patient mortality, they state: The risk of death increased 2% each time a patient was exposed to shifts with below target RN staffing. The average patient in the study was exposed to three nursing shifts with below target staffing resulting in a 6% higher risk of mortality than patients with no exposure to below target staffing. ” The report further explained that the risk of death did not decrease when the ratio of certified nursing assistants and licensed vocational/practical nurses increased.

This further indicates that assessment information that is collected and analyzed by registered nurses is essential to improved patient outcomes. This evidence only further supports the notion that nurse-patient ratios result in better patient outcomes and is essential to helping to reduce hospital-acquired illnesses and patient mortality. According to the American Nurses Association (ANA. 2011), there are only 15 states that currently have regulations regarding nurse-patient ratios. California is the only state with legislation mandating a nurse-patient ratio.

California’s nurse-patient ratio is 1:5 and was signed into law in 1999 and was in full effect as of 2005. With mounting evidence supporting the need for regulated nurse-patient rations, in 2011 the ANA reintroduced the Nurse Safe Staffing Act for federal legislation. If put into effect, the ratios would take into consideration not only the acuity level of the patients but also the education and skills of the nurse who is to care for them, allowing ratios to be adjustable. To further improve patient care and to reduce patient mortality, the topic of increased and improved education of registered nurses has also become important.

According to Aiken, et al. (2003), in their article regarding patient outcomes associated with the education level of the registered nurse, when registered nurses with a bachelor’s degree or higher, care for postoperative patients, patient outcomes improve. In their report, they state that, “In hospitals, a 10% increase in the proportion of nurses holding a bachelor’s degree was associated with a 5% decrease in both the likelihood of patients dying within 30 days of admission and odds of failure of rescue” (pg. 617). These findings have led to a general notion that entry level registered nurses should have a minimum of a bachelor’s degree to practice. The article sites that registered nurses with higher levels of education, are more apt to identify trends of decline in a patient quickly and are more capable of applying nursing interventions to halt that decline. In a separate study by Ann Tourangeau, et al (2007), their research supported the research by Aiken.

Tourangeau, et al, performed a study of 46,993 patients and their article arrived at nearly the same conclusion as Aiken. They found that: Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients. From this statement, we can further conclude that higher levels of education result in better patient outcomes and a reduction in patient deaths.

The reason for improved patient outcomes is that the registered nurse with a bachelor’s degree in nursing has better critical thinking skills than that of a registered nurse with an associate’s degree in nursing. The bachelor’s degree programs have a higher degree of focus on critical thinking, evidence-based practice, and pathophysiology. Those areas of focus allow the nurse to more readily assess patients for trends to prevent decline. This study along with the study by Aiken, et al, has lead to a high degree of support for the “BSN in 10” legislation.

The “BSN in 10” legislation is a law enforcing that newly licensed registered nurses that have obtained their associate degree in nursing, will have ten years after their initial licensure, to obtain their bachelor’s degree in nursing. According to author Susan Trossman in her article in American Nurse Today (2008), only two states currently have state bills in process for this legislation, New York and New Jersey. Trossman explains that the legislation is not meant to affect registered nurses who are already practicing.

It specifies that newly licensed registered nurses would follow this legislation and that registered nurses who are already practicing will be grandfathered in. Additionally the legislation won’t affect students who are already enrolled in a nursing program. While this legislation has garnered a lot of support from several state nursing associations, as well as the American Nurses Association and the American Association of Colleges of Nursing, there are also a lot of critics. Some critics have speculated that requiring advanced education will only make the current nursing shortage worse.

In Trossman’s article, she explains that not only is there proof that the “BSN in 10” improves patient outcomes, there’s already evidence that the legislation would not worsen the current nursing shortage. She states: Improved patient outcomes has been the case at Rochester General Hospital in New York, where nurses have been offered incentives to earn their BSN. In 2002, 33% of staff nurses at the facility had their BSN degrees, compared with the current percentage of 47, says Deb Zimmermann, MS, RN, NEA BC, senior vice president and chief nurse officer at Rochester.

When comparing quality-targeted data in 2002 and 2007, the rate of patient falls decreased from 4. 9 to 3. 25 per 1,000 patient days. The medication error rate decreased from 1. 66 to 0. 82 per 10,000 doses administered. The length of stay declined from 5. 6 to 4. 6 days. Nurses also are more satisfied with their jobs; the RN vacancy rate at Rochester has plummeted from 22% to 3%. (This counters arguments that this potential education requirement could fuel the nursing shortage. ) While the “BSN in 10” has not been made into law in New York yet, Rochester General Hospital has made it a requirement to work there.

This is not an isolated case. While there are not currently any statistics that this author could find regarding this trend, many hospitals are now requiring a BSN as an entry level requirement or have a program similar to “BSN in 10” as hospital policy. Another protective requirement is commonly known as the “Time out procedure” during surgical procedures. Established by the Joint Commission in 2003, the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery, lays out the procedure to follow for verifying that the surgical team has the correct patient, correct operating site, and correct procedure.

According to the Joint Commission and an update out of the American Academy of Orthopedic Surgeons periodical, AAOS Now (Alander & Carmack 2009), the protocol is mandatory for all surgical procedures with the exception of: •Single organ cases (e. g. , Cesarean section, cardiac surgery) •Interventional cases for which the catheter/instrument insertion site is not predetermined (e. g. , cardiac catheterization) •Teeth-BUT, indicate operative tooth name(s) on documentation OR mark the operative tooth (teeth) on the dental radiographs or dental diagram. •Premature infants, for whom the mark may cause a permanent tattoo.

The protocol is important to protect patients from wrong site and wrong surgery mistakes in the operating room. As previously mentioned, the Joint Commission considers incidence like these as Sentinel events. According to the Joint Commission, from January 2010 through September 2010, there were 66 instances of wrong-site surgery reported. What we should take from this information is that mistakes can still be made. It is our responsibility as nurses and patient advocates to speak up if the surgeon or other surgical team member refuses to follow the protocol for time out verification.

In this day and age, where the healthcare industry continues to grow and the population continues to age, it is important for the registered nurse to stay up to date on changes to patient safety and care. Research indicates that reduced nurse-patient ratios, higher levels of education, and updated protocols are necessary to maintain patient safety. As registered nurses, we are trusted with the lives of the patients we are assigned to care for. We are advocates for our patients. If we do not stay current with changes, how can we pledge to provide the best care possible? It is our duty to maintain a safe environment.

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