The 2014 nurse staffing law will apply to burn units and intensive care for newborns along with intensive care units for adults, under final regulations adopted by the Health Policy Commission on Wednesday.
Passed by the Legislature in part to avoid a ballot referendum, the law required each ICU nurse be assigned only up to two patients, and only one patient if that is what is required.
An acuity tool would be used to determine the nursing needs of patients, under the regulations approved on a voice vote Wednesday.
The final regulations designate March 31, 2016, as the acuity tool deadline for academic hospital ICUs, and push back the deadline at community hospitals and in neonatal ICUs to Jan. 31, 2017.
"All of us are committed to really high quality patient care, and I would really prefer to not see this have to be rigidly written in law and regulation, but that's where we are," Health and Human Services Secretary Marylou Sudders, who is on the commission, said after the vote.
The regulations drew a mixed response from nurses and a warning from a health care workers against cutting hospital jobs.
After some discussion, the commission voted on regulations that include burn units, coronary care units and pediatric intensive care units in the standard.
"My conclusion is that NICUS don't fit into the framework of this regulation," said Dr. Carole Allen, a retired pediatrician from Arlington and commission board member who said her son and grandson were both born premature. Saying that different levels of patient need are often co-located in NICUS, Allen said, "I do see potential harm with limited or no possible benefit."
"I thought that there was a great deal of clarity around the issue that all intensive care units means all intensive care units," said Rep. Denise Garlick, a nurse who is now House chairwoman of the Committee on Elder Affairs and helped forge an agreement leading to the 2014 law.
"These patients that are in the intensive care units are the patients that are the most critical, the most critical, and they require the eyes-on of the registered nurse at their bedside," said Massachusetts Nurses Association President Donna Kelly-Williams, who works at Cambridge Hospital with children and newborns. She said she can detect subtle changes in the children under her care and alert the doctor, and said when she is assigned a patient she stays at the child's bedside.
Sharon Gale, CEO of the Organization of Nurse Leaders, which represents nurse managers, said NICUs are currently set up to accommodate babies in need of intensive care and their siblings, who may not need such extraordinary care.
The Health Policy Commission was established by a 2012 law aiming to reduce health costs, which has been a major policy goal in state government for years.
The 1199SEIU United Healthcare Workers East expressed concern that nurse-staffing requirements could endanger other hospital jobs.
"We are stakeholders in the broader conversation on staffing and the healthcare workers of 1199SEIU are here to remind all parties involved — including employers — that we will not stand idly by if nurse ratios are used as an excuse to cut other staff," said 1199SEIU Executive Vice President Veronica Turner in a statement. "Service, clerical, and technical staff will not be used as a bartering chip in this debate."
David Cutler, a health economist who is on the commission's board, said he wished the law had been drafted to apply the nurse ratio to individual intensive care patients rather than everyone in the unit.
Gale said hospitals have received the message that keeping "boarders" in the ICU is no longer an option if they do not need that level of care.
"There are many issues that we can discuss. The law is the law," Garlick said when asked if referring to individual patients would have been preferable.
David Schildmeier, a spokesman for the Nurses Association, said the one-to-one or two-to-one nurse staffing ratio for ICUs had been a guideline, but it was little known and not enforced before the law.
Kelly-Williams said she has heard of nurses caring for as many as four patients in an ICU, and while declining to name names, she said there have been hospitals that have not complied with the new law.
"I think every hospital in the state is following the laws and regulations that cover them," said Timothy Gens, general counsel to the Massachusetts Hospital Association.
An advisory board that includes nurses will recommend the particulars of the acuity tool used to assess patients, but the hospital will have the ultimate decision of which tool to use, according to Gens. Once the tool is in place, if there is a disagreement, nurse managers will be the ultimate arbiter, Gens told the News Service.
"A nurse should not have three patients in an ICU situation," said Gale.
Sudders said the lag time before the acuity system deadline will allow hospitals to prepare. Gens said the law will not be fully in effect until the acuity systems are adopted.
"Before you can fully follow the law, then you have to have the acuity system," Gens said. "It can't be fully implemented until you have all of the regulations."
Gens also said at nearly every hospital there are people in ICUs that have recovered and are awaiting transfer, but do not need the intensive care.
The Nurses Association said the regulations should have said a one-to-one ratio should be the default at ICUs. The union said it intends "to pursue any and all means to ensure that the true intent of the law and the safe standard of care it dictates for critically ill patients is followed to ensure patients in our hospitals are as safe as possible."
"The regulations fail to clearly state the law's key intent, which was that there is a default one nurse to one patient standard of care for all patients in ALL ICUs," the MNA said in a statement. "Our fear is that the industry will use the vague language in the regulation to avoid meeting the one-to-one standard for patients that clearly need that level of care — which is happening every day in most of our state's hospitals."