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All Children's staffing levels called into question

ST. PETERSBURG

Melody Taylor's premature baby was 8 days old and progressing well at All Children's Hospital when something went wrong. An intravenous line pumping nutritional supplement and antibiotics into his tiny wrist became dislodged from the vein. No one is saying how long it went unnoticed, but by the time his nurse caught the problem, fluid had flooded under the baby's skin, making his tiny arm balloon up to the elbow. The area surrounding the IV became swollen and blanched, like a freezer-burned chicken. Dead tissue around the puncture site turned black.

Taylor, a 34-year-old mother of four, was returning to the hospital that mid-September evening when she ran into her son's nurse in the lobby.

"The nurse said, 'Oh, Ms. Taylor, I'm so sorry,' then she started giving me this whole clinical explanation of what had happened,'' Taylor said of the incident, known as an IV infiltrate. "I didn't understand what she was saying until I walked into his room and saw his arm. All night long, other nurses came by and they'd whisper, 'That's really bad.' "

Over the next six weeks, the silver dollar-size wound on her baby's arm turned yellow, then black. It required special treatment from All Children's skin care team, as well as a consultation by a plastic surgeon. By the time Taylor's son Grayson was released from All Children's in late October, he had a red scar on his wrist, which turned slightly inward.

Taylor, who worries the accident may have caused nerve damage, initially didn't blame the nurse. But after spending nearly every waking hour for seven weeks in the hospital's neonatal intensive care units, she's convinced of one thing.

"The place is understaffed," Taylor said. "When my son had the infiltrate, that nurse was trying to watch more than four babies and that's impossible.''

All Children's, which has been treating the sickest kids on Florida's west coast for more than 80 years, has seldom been the target of public criticism. Widely respected and nationally recognized, it is best known for its telethons and the strong community support that has helped fund a major new hospital complex to open in 2009.

But now All Children's has come under fire, and not just from one patient. Some of its own staff worry that patient safety has been compromised due to staffing shortages in the unit that handles the most fragile newborns.

Hospital officials denied there were problems and strongly defended All Children's staffing in the unit.

"We're right in the middle of the pack (in the number of staff per bed) compared to other freestanding children's hospitals,'' said Gary Carnes, who has been president and chief executive of All Children's Health System since 2003. "We're not hearing those complaints. And believe me, I'd be hearing them, especially from the doctors."

Carnes said Taylor's son did not suffer permanent damage from the IV infiltrate but said he was unable to comment further on the case without the mother's written permission. Taylor, who is considering a lawsuit, declined to open her and her son's medical records on the advice of her lawyer, Peter Meros of St. Petersburg.

• • •

Recent interviews with 12 All Children's nurses, including several former employees, echo Taylor's contention that the hospital is constantly scrambling for nurses to care for extremely sick and needy babies.

State standards require at least one nurse for every two babies in the most acute neonatal unit, called a Level 3 NICU, but these nurses say the ratio is frequently one to three.

Assignment sheets for a recent week at All Children's show that about half of the nurses on night shift had three babies; on day shift, an average of 40 percent of the nurses landed a three-patient assignment.

Carnes said the assignment sheets are merely "snapshots" of a particular shift and do not accurately reflect staffing throughout the 12-hour period. "The way staffing is counted is not a finite science,'' he said.

But All Children's nurses said that on one recent evening, two NICU nurses were each assigned three babies and each of those babies was on a ventilator, requiring constant attention. It's a scenario the nurses said is repeated a couple of times a month in the unit.

Katherine Kennedy, a Level 3 NICU nurse at Kaiser Permanente hospital in Sacramento, Calif., said that even with more than 20 years of experience, she would never be able to handle three ventilator babies. "Absolutely not,'' said Kennedy, who is on the board of the California Nurses Association. "To me, that is not providing safe care."

In California, state law requires one nurse for, at most, two of the sickest NICU babies, and preferably a 1-1 ratio. Nurses at All Children's, which handles some of the region's most precarious newborns, said they see a 1-1 ratio in their NICU maybe once a year.

Florida regulators have made three site visits to review the NICU's staffing level over the past five years. When a site review in late 2003 found compliance at All Children's Level 3 NICU fell at times to a low of 77 percent, the hospital was put on a monthly review until it met standards. In site reviews in 2005 and 2007, All Children's was found in compliance, meeting state standards up to 92 percent of the time.

The Level 3 NICU at Tampa General, meanwhile, had 100 percent compliance during three site visits over the same time period.

"Tampa General has a much smaller NICU,'' said Carnes. "We've been told by the state to take these babies and care for them the best we can."

Tampa General has 52 licensed NICU beds, compared to 60 at All Children's. All Children's NICU has accommodated as many as 74.

While All Children's administrators say staffing in its NICU has grown 4 percent over the past two years, the unit has also operated at 100 percent capacity for the past several years. Nurses said that means charge nurses, who are supposed to be free to pitch in during emergencies, often have patient assignments, especially at night.

These nurses said it's not unusual for floor nurses, who are unfamiliar with the high-tech machines and medicines tailored to tiny newborns, to be pulled into the NICU in a pinch. That might explain why Melody Taylor found a nurse searching for supplies at her son's bedside one evening.

"He said, 'I've never worked this unit before, so I don't know where anything is,' '' Taylor said of the pinch-hitter. "That doesn't give a mother confidence."

Linda Aiken, a professor of nursing at the University of Pennsylvania, said floating nurses around different diagnostic units, from dealing with a teenager with cancer to a preemie on a ventilator, for instance, is bad for both the nurse and the patients. "It's not something doctors do,'' she said. "As soon as the diagnostic diversity increases, there's a major risk for poorer patient outcomes. It's a known risk factor."

Aiken, who has done extensive research on nursing issues, said studies also show that the job satisfaction of nurses is directly related to patient satisfaction. She was not surprised by the correlation between Taylor's complaint and nurses' dissatisfaction over staffing at All Children's.

"What you're hearing anecdotally is consistent with what researchers find," she said. "Nursing is one of, if not the most important factor in patient satisfaction."

• • •

Most of the nurses interviewed, whose tenure at All Children's ranged from four years to more than 20, declined to be named out of fear they would be disciplined or even fired. While a reporter was contacting All Children's nurses, seeking reactions to Taylor's complaints, two NICU nurses were called in by their supervisors and warned not to speak to the news media.

One of the few nurses willing to be identified left All Children's last year to work in the well-baby unit at Morton Plant hospital in Clearwater. Michelle Devivo had been at All Children's for 12 years, working as charge nurse in the pediatric intensive care unit. She said about four years before she left, staffing ratios changed and she became responsible for two patients in addition to her supervisory duties.

"Every day we were working short and unsafe,'' Devivo, 37, said of her last years at All Children's. "Every day we were to the wall, just hoping to get through the day. There just was not enough time, staff or support to care for the patients. It turned into a thing where the bottom line was money."

Devivo and other nurses said they were repeatedly told All Children's had to cut costs because of financial pressures created by the new facility being built a stone's throw away from the old hospital. The gleaming white, nine-story hospital, part of a $400-million complex, is slated to open in December 2009.

"Our director said we had to build a reserve because the new hospital would be operating in the red for a while until it got going,'' Devivo said.

But All Children's CEO Carnes dismissed suggestions that the nonprofit system was suffering from money strains.

"We're ahead of our financial plan, our cash flow is good," he said of the hospital, which had net income of nearly $39-million in 2007. "We're a conservative organization by nature, we've got a conservative (financial) pro forma and we're ahead of that. And our business plan is to break even or reach our operating margin the first year in the new building."

Carnes said the new complex, which includes a medical building, parking garage and power plant, will be financed with about $200-million cash and community donations and $200-million debt. "We haven't been affected too much by the credit crunch, because most of our debt is in place at fixed rates,'' he said, countering the complaints of many nonprofit hospitals. "We're one of the very few hospitals to get a double-A rating."

Carnes said All Children's historically has benefited from low debt, conservative investments and strong community support. The hospital has raised $45-million from local donors for the new facility, and Carnes doesn't expect any problem in reaching the campaign's goal of $75-million, even though the hospital's longtime lead fundraiser, Joel Momberg, is leaving.

"People don't give to Joel or Gary, they give to the mission, they give to the kids,'' said Carnes, whose compensation package in 2007 totaled $1.16-million. "People have been very generous."

• • •

Nurses in All Children's intensive care units would like to see a little more of that generosity filter down to the staff at bedside. Although administrators insist pay at their institution is competitive, some former All Children's nurses said they walked into less demanding positions at other area hospitals and made more money.

"I'm making $5 an hour more at Morton Plant,'' said Julia Ann Scott, who left a NICU nursing job at All Children's in October and now works on a medical/surgical floor. "I'm not looking after anyone on a ventilator or on significant drugs. It's certainly, skill-wise, less demanding."

Though All Children's administrators say staffing is adequate, they said there are five vacancies in the pediatric intensive care unit where Devivo once worked and three vacancies in the neo­natal unit. The hospital sent automated calls seeking overtime volunteers for the NICU seven times in the last two weeks of November.

Nurses say the desperation to fill slots in the NICU has been exacerbated by a policy change in October that eliminated bonus payments for working additional overtime shifts.

Carnes said he wanted to crack down on overtime abuse. "You shouldn't be working 25 percent more than full-time, even if you want to,'' he said.

As All Children's prepares for next year's move, the demand will be acute in the intensive care units, which will account for more than half of the new hospital's 253 beds. The NICU, where Melody Taylor's baby was injured, will grow by more than 60 percent to 97 beds.

Enlarging the NICU makes sense financially for All Children's because the highly specialized care allows the hospital to qualify for additional state funding.

When the hospital was looking for financial backing for its new facility, Moody's rating agency said in a report to potential creditors: "Medicaid reimbursement for NICU services generates a healthy margin that offsets losses incurred from treating the general Medicaid population." Medicaid patients make up about 60 percent of All Children's NICU admissions.

Because Taylor's son is on Medi­caid, that means the state paid All Children's more for a stay that may have been lengthened by the accident with the IV infiltrate.

Dr. Roberto Sosa, director of neonatology at All Children's, said infiltrates are often unavoidable. "It depends on the size of these babies, but sometimes their veins are like little hairs," he said.

Taylor's son, born seven weeks early, weighed 6 pounds, 9 ounces at birth, making him one of the bigger preemies in the NICU.

All Children's administrators said the frequency of IV infiltrates has decreased in recent years, though they had no documentation to support that. They also said IV infiltrates are not necessarily tied to staffing levels. Nurses, meanwhile, say it is virtually impossible to check IVs hourly, as recommended, to make sure they are properly placed.

Last spring All Children's encouraged all employees to participate in an online survey to assess patient safety and encourage reporting of near-misses. Asked if he thought nurses felt confident enough to voice their concerns, Carnes said: "I sure as hell think so."

Still, one clear message came out of the survey from nurses, many of whom said they had never met the chief executive and knew him only as a face on the hospital's intranet page.

Said Carnes, "There seems to be an issue with communication.''

Times researchers Caryn Baird and Shirl Kennedy contributed to this report. Kris Hundley can be reached at hundley@sptimes.com or (727) 892-2996.

All Children's staffing levels called into question 12/20/08 [Last modified: Friday, December 26, 2008 9:36pm]

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