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CE_Nov REV 6/30/11 12:45 PM Page 16 complex interventions to stabilize the patient. Or who, in collaboration with the direct-care RN, can make a determination that the patient be transferred to a critical care unit with richer ratios and more sophisticated equipment and technology. Every opportunity was used to do teaching. The goal was to strive for expertise in a designated area of clinical specialty. Today, hospital units have become "combo" units, where patients are housed in non-ICU/CCU "tele"box, "medical monitoring" or centrally monitored beds when, in reality, their condition requires a higher level and intensity of care with a richer direct-care RN-topatient ratio. Couple this with a feeble attempt to substitute the expertise and role of the CNS and Charge Nurse with that of the RRT under more dire and life-threatening situations, and you have a recipe for a disaster. Plus, it drives fragmentation of care through deskilling (dumbing down) of the role of the direct-care RN by concentrating specialized knowledge at the RRT team level only. All direct-care RNs should have the skill and knowledge to recognize early alteration in the patient's physical and cognitive condition. This requires a vibrant education/in-service department, and a commitment to striving for true excellence in patient care and outcomes. Validation of condition deterioration comes from collaboration with a Charge Nurse, CNS or Resource Nurse. As for reporting or referring, in our patient advocacy role, we must at times wake up an attending physician or intern/resident in the middle of the night and report the patient's condition, and secure treatment that will stabilize the patient. Safe Staffing Standards compare this with california's Safe Staffing Standards. These standards are clear as to its priority: (1) Staffing standards based on individual patient acuity of which the ratio is the minimum; (2) Additional licensed and unlicensed staff based on direct-care RN References Aiken LH, Clarke SP, Sloan DM, Sochalski J, Silber JH. Hospital nursing staffing and patient mortality. Nurse burnout, and job dissatisfaction. Journal of the American Medical Association 288(16); 1987-1993. Aiken, L. H., S. P. Clarke, D. M. Sloane, J. Sochalski, R. Busse, H. Clarke, P. Giovannetti, J. Hunt, A. M. Rafferty, and J. Shamian. 2001.''Nurses Reports of Hospital Quality of Care and Working Conditions in Five Countries.'' Health Affairs 20 (3): 43–53. Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A. , Spetz, J. , & Smith, H. L., (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45 (4). 904-21. Chan PS, et al. Hospital – wide Code Rates and Mortality Before and After Implementation of Rapid Response Teams. JAMA. 2008 (21): 2506 – 2513 Dall, T. M., Chen, Y. J., Seifurt, R. F., Maddox, P. J., & Hogan, P. F. (2009). The economic value of professional nursing. Medical Care, 47 (1), 97-104. 16 N AT I O N A L N U R S E assessment and documented patient classification system; (3) The ratios apply at all times including meals and breaks, and authorized absences from the unit. This means that all California acute-care hospitals must first budget for the mandated ratio threshold and the additional RN and non-RN staff needed to meet the patient's requirements and needs. Next, the budget must provide for a Float/ Meals and Break Relief Team, now including relief when the RRT responds to a stat call and is absent from the unit. The mandate requires no doubling-up of the assignment. Research findings have documented significant relationships between failure to rescue and nursing organizational characteristics. Failure to recognize deterioration in the patient condition until major complications, including death, have occurred is referred to as "failure to rescue," which is a measure of the overall performance of a hospital with respect to the healthcare professional's ability to recognize subtle changes in the patient's condition and react independently to post-operative complications such as bleeding or sepsis. Failure to rescue is increasingly studied as a quality-of-care measure. The original research conducted on failure to rescue identified a strong and significant association with nurse-to-patient ratios in a sample of surgical patients (Silber Rosenbaum, & Ross, 1995). They concluded that failure to rescue is an appropriate measure to study quality of care because hospital staffing characteristics are more likely to influence the measure. The complications studied are detectable by nurses and can be managed successfully with timely intervention. Recognition of complications at an early stage and initiation of therapeutic interventions reduces morbidity and mortality. For decades, nurses have reported that there are not enough nurses in hospitals to provide high-quality care. In response to Eastabrooks, C. A., Midodzi, W. K., Cummings, G. C., Tickler, K. L., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30 day mortality. Nursing Research 54 (2); 74-84. Friese CR, Aiken LH. Failure to rescue in the surgical oncology population: Implications for Nursing and Quality Improvement. Oncology Nursing Forum. 2008; 35(5): 779-785. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research 2008;43(4):1145–1163. IOM (Institute of Medicine) 2000. To Err is Human: Building a Safer Healthcare System. Washington, DC. National Academies Press. IOM (Institute of Medicine) 2004. Keeping Patients Safe, Transforming the Work Environment of Nurses. Washington, DC. National Academies Press. Johns Hopkins Medicine News September 2010, Rethinking How Hospitals React When a Patient's Health Deteriorates. Peter J. Pronovost, MD, PhD & Eugene Litvak, PhD JAMA, September 22/29, 2010—Vol 304, No. 12 Rethinking Rapid Response Teams. W W W. N A T I O N A L N U R S E S U N I T E D . O R G JUNE 2011