The purpose of this letter is to notify and remind general acute care hospitals of changes to the minimum nurse-to-patient ratios for “step down”, ‘telemetry” and “specialty care” units, effective January 1, 2008.

As provided under Title 22 of the California Code of Regulations, Section 70217(a):

“(9) The licensed nurse-to-patient ratio in a step-down unit shall be 1:4 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a step-down unit shall be 1:3 or fewer at all times. A step down unit is defined as a unit which is organized, operated, and maintained to provide for the monitoring and care of patients with moderate or potentially severe physiologic instability requiring technical support but not necessarily artificial life support. Step-down patients are those patients who require less care than intensive care, but more than that which is available from medical/surgical care. Artificial life support is defined as a system that uses medical technology to aid, support, or replace a vital function of the body that has been seriously damaged. Technical support is defined as specialized equipment and/or personnel providing for invasive monitoring, telemetry, or mechanical ventilation, for the immediate amelioration or remediation of severe pathology.”

“(10) The licensed nurse-to-patient ratio in a telemetry unit shall be 1:5 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a telemetry unit shall be 1:4 or fewer at all times. Telemetry unit is defined as a unit organized, operated, and maintained to provide care for and continuous cardiac monitoring of patients in a stable condition, having or suspected of having a cardiac condition or a disease requiring the electronic monitoring, recording, retrieval, and display of cardiac electrical signals. Telemetry unit as defined in these regulations does not include fetal monitoring nor fetal surveillance.”

“(12) The licensed nurse-to-patient ratio in a specialty care unit shall be 1:5 or fewer at all times. Commencing January 1, 2008, the licensed nurse-to-patient ratio in a specialty care unit shall be 1:4 or fewer at all times. A specialty care unit is defined as a unit which is organized, operated, and maintained to provide care for a specific medical condition or a specific patient population. Services provided in these units are more specialized to meet the needs of patients with the specific condition or disease process than that which is required on medical/surgical units, and is not otherwise covered by subdivision (a).”

In addition, Title 22 of the California Code of Regulations, Section 70217 addresses the licensed nurse-to-patient ratio in medical/surgical care units which may include mixed patient populations.

“(a)(11) The licensed nurse-to-patient ratio in medical/surgical care units shall be 1:6 or fewer at all times. Commencing January 1, 2005, the licensed nurse-to-patient ratio in medical/surgical care units shall be 1:5 or fewer at all times. A medical/surgical unit is a unit with beds classified as medical/surgical in which patients, who require less care than that which is available in intensive care units, step-down units, or specialty care units receive 24 hour inpatient general medical services, post-surgical services, or both general medical and post-surgical services. These units may include mixed patient populations of diverse diagnoses and diverse age groups who require care appropriate to a medical/surgical unit.”

It is imperative that hospitals staff according to patient acuity. Hospitals must ensure that they are staffed to assure that the needs of the patients are met. It is far more important that hospitals pay attention to the patient classification system and the needs of the patient rather than the minimum staffing requirements. Hospitals are reminded that the regulations only reflect the minimum standards for staffing and that to be in compliance with the regulations refer to Section 70217(b).

The CDPH wants to emphasize that these regulations have been in effect and this should serve as an immediate reminder. As a result of these regulations, hospital policy and procedure changes should be made accordingly.

Sincerely,

Original Signed by Pamela Dickfoss for

Kathleen Billingsley, R.N.
Deputy Director
Center for Healthcare Quality