Question 1: For Massachusetts hospital nurses, 'there is no average day'

At Harrington Hospital on a recent Friday around 10 a.m., the attention of the emergency room was focused on one particular trauma bay.

A man had been brought into the ER with a serious cardiac rhythm. Two doctors, two nurses and an EMS provider were all in that trauma bay, trying to quell the man's lethal arrhythmias.

If the nurse staffing ratios proposed by ballot Question 1 were in place while treating this patient, the emergency room might not be able to keep both nurses on that trauma patient without running the risk of incurring hefty fines, according to Tracy DiGregorio, a Harrington Hospital registered nurse who has worked in the ER for 16 years.

"A nurse could be outside a ratio for that one patient," she said, sitting in the ER of the Southbridge hospital. "And, trust me, you want two nurses in there."

The scenario, DiGregorio said, was a perfect example of how RNs need to self-regulate in the emergency department, something she believes Question 1 will inhibit.

But the Committee to Ensure Safe Patient Care says the measure, if implemented, would never stop a nurse from going over to help in such a scenario.

The ratios apply to a nurse assigned to the case from beginning to end, explained Kate Norton, a spokeswoman for the committee. Typically patients are assigned to one nurse, although other nurses may be involved in the patient's care.

There is "absolutely nothing" in the measure that prevents a nurse from helping another nurse treat a critical patient, she said.

"There's never going to be a scenario where a nurse is taking care of a patient and goes, 'oh no, I have to stop,'" Norton said.

The ballot question seeks to implement nurse-to-patient staffing ratios, which would be mandatory at all times except for in the case of a state or nationally declared public health emergency.

Nurses across the state are split.

The Massachusetts Nurses Association, a union representing about 23,000 nurses in the state, is pushing heavily to pass the measure, arguing that RNs in Massachusetts have too many patients, leading to poor patient care.

However, other RNs, including many emergency room nurses and Massachusetts chapters of the Emergency Nurses Association and American Nurses Association, have come out against the proposed law.

"There is no average day and that's why I think this bill, it doesn't fit," DiGregorio said. "I don't know what I'm coming into. Who's going to be left over. Who's coming in the door, how sick they're going to be."

Some days in the ER, taking care of three patients can be overwhelming, DiGregorio said. Other days, nurses can treat six patients at once with ease.

The hospital serves a community of 170,000 residents and sees more than 30,000 annual emergency room visits.

"Busy doesn't always mean unsafe. I think that's what we need to remember as nurses," DiGregorio said. "I expect to be busy. I expect to put at least 8,000 steps on my Fitbit. That's a normal day for me."

At Mercy Medical Center in Springfield, 100 new nurses have been hired in the last year, according to Dr. Mark Kenton, who has worked in the emergency department at the hospital for 15 years.

However, to keep up with the law if passed, Mercy would need to hire an additional 200 nurses, he said. There are currently seven unfilled nurse positions in the emergency room.

"One of the big problems with this is that it becomes very restrictive from a standpoint of individual needs within our healthcare system," said Kenton, who has taken to Facebook to advocate a "no" vote.

Hospitals across Massachusetts have come out asking voters to say no to Question 1 at the polls on Nov. 6, or before then in communities with early voting.

"Harrington is proud to deliver safe and quality care to those in our community," Jessica Calcidise, the vice president of nursing and ancillary operations at Harrington HealthCare System said in a statement released last month. "The government has no place in implementing cookie-cutter care across all of our patients, all of our departments, and all our hospitals across Massachusetts."

At Harrington, 50 new nurses would need to be hired to keep up with the ratios outlined in Question 1, a spokeswoman said.

Dr. Jeffrey Hopkins the medical director of Milford Regional Medical Center's emergency department wrote in a statement that Question 1 would "skyrocket" wait times for patients and emergency room nurses would be "stripped of using their expertise and judgment when it matters most."

"These arbitrary ratios don't allow for the type of flexibility, discretion or common sense medical decision-making needed to provide emergency care," the statement continued, adding that implementing the measure would set the medical center back $4.7 million.

Beth Israel Deaconess Hospital in Milton has said Question 1 would cost $4.7 million in the first year alone, and that patients and families could face delays or cancellations of surgeries.

For Lawrence General Hospital, the cost of Question 1 would be $7.9 million initially, according to a statement.

"Question 1 will force us to downsize departments, increase wait times in our emergency room, threaten scheduling of elective surgeries, and cut important health programs that our patients depend on," said Dianne Anderson, a registered nurse and the CEO and president of Lawrence General Hospital. "The last thing we want to do is have our patients wait because this law ties our hands and keeps us from giving them timely service."

Cooley Dickinson Health Care, an affiliate of Massachusetts General Hospital located in Northampton, wrote in a statement that the passage of Question 1 would lead to "severe consequences," taking staffing decisions out of the hands of nurses and managers who make those decisions now based on factors like the acuity of patients, the availability of support staff and the experience level of nurses.

Estimates on the cost of the measure vary.

The Coalition to Protect Patient Safety, an anti-Question 1 group funded by hospitals, has estimated the first-year cost of the measure at $1.31 billion and $900 million in subsequent years. Meanwhile, the union-funded Committee to Ensure Safe Patient Care, which supports the measure, predicts a cost of $35 million to $47 million.

Hospital officials have said the law would be especially devastating for small and rural hospitals, like Harrington.

Harrington Hospital says it would cost the hospital $6 million to implement Question 1 as written. The hospital would not face an immediate threat of shutting down, a spokeswoman said, but implementing Question 1 leaves open the possibility of having to close in the future.

Proponents of the measure have said that such claims are scare tactics lead by hospital administrators.

"Nurses wrote and support Question 1 because we have tried for years to convince these executives to provide us with conditions, including safe limits on the number of patients we care for, to ensure we can provide the care our patients need when they need it most," Donna Kelly-Williams, a registered nurse and the president of the MNA and co-chairwoman of the Committee to Ensure Safe Patient Care, said in a statement.

Kelly-Williams and the committee criticize hospital executives for taking in seven-figure salaries while saying the measure will force the medical centers to shut down patient services.

An independent study by MassInsight and BW Research Partners determined the state would need to hire 5,911 new nurses within 37 days to keep up with the measure if it passes.

Massachusetts Health and Hospital Association and Organization of Nurse Leaders estimates that Massachusetts is already short more than 1,200 registered nurses.

On the Harrington Hospital website, there are 28 open positions listed for nursing or nursing support.

Nearly everyone in the industry agrees: It would be ideal to have more nurses at every hospital.

"I'm not against safe staffing," DiGregorio said. "I'm against this bill."

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