The Joint Commission for the Accreditation of Healthcare Organizations [JCAHO] August 2002 media alert stated that, “Nursing shortage puts lives at risk: Joint Commission expert panel issues urgent call to action.” Why has JCAHO issued this urgent alert? Because “patient care is suffering from a dramatic shortage of nurses, who are the front line of care and support for patients . . . too few nurses results in increased deaths, complications and other undesirable patient outcomes.” Although Annex Legal is one of the many legal nurse consultancy firms, the nursing shortage makes it hard for attorneys to correctly assess complex injury claims.
Attorneys are facing the effects of the nursing shortage in their cases. It has affected the complexion and complexity of injury claims and compounds the case analysis. What should have been a fairly straightforward PI case becomes a complex medical malpractice case, presenting difficult liability and causation issues. Further, the already complicated medical malpractice case becomes a veritable maze because understaffing in a hospital setting leads to system-wide failures resulting in multiple negligent omissions or commissions during a single hospitalization.
Nurses are the eyes and ears of the doctors and hospital and have the most contact with patients on a routine basis. If the ability to monitor and observe patients is reduced, a critical link in the system is weakened. Nurses are being required to work longer hours and attend to more patients. With the increased demand on nurses to do more with less, the function of the nurse as a checkpoint in the process to assure appropriate treatment is compromised.
A recent study published in the Journal of the American Medical Association (JAMA) found a 31% increased risk of death at hospitals where there is understaffing of nurses involved in patient care. The JCAHO is studying the issue and is expected to publish mandated nurse staffing levels. Through legislation, California has already mandated safe nurse/patient ratios.
When the attorney suspects substandard hospital care, a detailed review of the records, including nursing notes, is required. The attorney should look for continuity of care. For example, if a physician orders monitoring of a patient’s vital signs at 15-minute intervals, the nursing notes should reflect this pattern. If the pattern varies widely, with vitals signs checked at 15 then 30 then 60 minutes, this could be indicative of the lack of appropriate monitoring and other negligent omissions.
Documentation other than the patient’s medical record is important to substantiate a claim that understaffing has affected a patient’s outcome. The attorney should request nurse staffing records and patient census reports. These should be analyzed for nurse/patient ratios, patient acuity levels (how sick they were and, therefore, how labor intensive were their care needs), and compared to hospital Policies and Protocols on nurse/patient ratios.
Nosocomial (hospital-acquired) infections occur at a significantly increased rate at understaffed hospitals. A simple procedure can turn into a complicated infectious disease process, increasing costs, prolonging hospitalizations, worsening outcomes and complicating prognoses. Understaffing contributes to the infection rates by cutting corners and reducing important monitoring tasks. Statistics regarding the hospital’s infection rate should be obtained. The hospital’s Policy and Protocol manuals should be reviewed for evidence of how the institution should identify, track and resolve nosocomial infections. If the patient underwent surgery, culture records from the surgical suite and equipment should be scrutinized for common links to the patient’s illness.
The issues presented here are only the beginning. If the trial lawyer suspects understaffing of nurses has lead to complications during a hospitalization, please call or contact us to discuss the additional areas to be analyzed.