State mandate impacts ER classification: But business as usual

8/30/04

At its August 26, 2004 Board meeting, the Mendocino Coast District Hospital approved a motion to begin the process to reclassify its Emergency Department from Basic Emergency Services to Standby.  

"This is the responsible action for the Board to take, to balance service to the community with fiscal responsibility" says Board President Charlene McAllister, in reference to the decision to begin the reclassification process.   McAllister added, "We want to make sure the public understands that a reclassification will not in any way change the level of service provided by our Emergency Department.   The only thing that will change is our sign."

Reclassification to Standby status would allow the Emergency Department to continue to operate at its current level – with a physician on duty 24 hours a day, 7 days a week – while allowing the Hospital to contain its costs at the current level.   

At issue is the new California nurse-to-patient ratio mandate that requires that an Emergency Department that wants to hold Basic Emergency Services classification must have at least two licensed nurses on duty whenever there is a patient present.   This ratio is met during the normal course of the day.   The issue arises during the night shift, when patient volumes are much lower.

The MCDH Emergency Department has an average of only a total of 4 patients during the entire 11pm to 7am shift.   Because of this low volume, MCDH applied for an exemption from the rule requiring two nurses to be on duty during the night shift.   Even though the Emergency Department night shift volumes are so low, the exemption was denied.   A request for a second review, and a subsequent appeal of its denial, have also failed.  

Currently, when the Emergency Department has the patient volume to require additional help during the night shift, the supervisor evaluates the patient's condition and a nurse from another department or an on-call nurse is called in.   A second full time licensed nurse on the night shift is not warranted due to the low volume, and would significantly increase the cost of running the Department.   The additional nurse on the midnight shift seven days a week would cost the Hospital a minimum of $108,000 per year in salary and benefits.  

"Given the Hospital's current financial situation of an annual $1.5 million gap between expenses and revenues, it does not make sense to spend $108,000 per year on something that will not improve our services.   This system of coverage has worked well, and we don't see a reason to change this, except for the mandate," says Board member Camille Ranker.

"Other hospitals similar to ours have been granted an exemption for this rule, while we have not," added Ranker.   It was noted at the Board meeting that 20 rural hospitals had applied for an exemption, and 7 were granted.

The Board decided in a 3-2 vote that MCDH must begin the process to reclassify the Emergency Department to Standby Emergency Services status, to be in compliance with the mandate.   Reclassification is a minimum 90-day process, and includes notification of the California Department of Health Services (DHS), the County, and the public.   The change to Standby status is expected to take effect January 1, 2005.

The Board noted that if an exemption to the regulation becomes available, MCDH will withdraw its application for reclassification immediately.   The Board's preference is to maintain its Basic Emergency Services status if possible.   However, a change to Standby status would not change the level of service provided to the community.

"Frankly, the public will not see a change in service. Our entire staff agrees that no matter what our designation [Basic vs. Standby], our commitment is to always be ready and to provide the same high caliber service," says Marcia Weeks, Manager of Emergency and Critical Care Nurses and the Ambulance Service.   She added, "We'll continue to have trained EMS staff, nurses, and a physician on duty, 24 hours a day, 7 days a week, ready to treat whatever emergency comes our way."