Prescription, Quite Simply, Was a Nurse

By ABIGAIL ZUGER, M.D.

edical journal articles are seldom illustrated with photographs of patients, more's the pity. If they were, perhaps more articles would sock readers in the gut the way they should.

Take a study published last month in The Journal of the American Medical Association that proved a direct correlation between hospital nurses' workloads and patient survival. A full-page head shot of our patient Mr. M. might have run with that one.

Mr. M. was in his 70's, a retiree incapacitated by depression and chronic pain. Every few weeks, he would totter into his doctor's office and beg for something, anything, to ease his intractable headaches. Every month, he would plead with his psychiatrist for something to lift his spirits.

Over time, he accumulated quite a few amber bottles whose potent contents should not have been combined, but he was desperate for relief. He landed in the emergency room, comatose from an accidental prescription-drug overdose.

For a few days, he was unconscious on a respirator in the intensive care unit. Then he woke up, knew where he was, and was able to breathe on his own. After a week, he was taken off the respirator.

By the standard calculus of the hospital, he was soon ready to leave the intensive care unit. He no longer needed the shiny high-tech machinery there. Sicker patients were waiting for his bed.

But Mr. M. was still groggy and feeble, unable to feed himself and prone to choking on his own saliva. He desperately needed the one thing — low tech, not so shiny — that intensive care could give him: the undistracted attention of a nurse.

In the journal article, University of Pennsylvania researchers analyze why nursing care means more to hospitalized patients than pillow plumping and good cheer.

They culled data from more than 200,000 patients and 10,000 nurses to calculate that for every additional patient a nurse is assigned to care for, the odds of a patient's dying within a month of hospital admission rises 7 percent. In other words, when your nurse cares for seven other patients on a shift, your chances of dying from whatever ails you are about 30 percent higher than it would have been if your nurse had only three others.

Mr. M.'s nurse in intensive care had only one other patient. His nurse on the medical floor where he was transferred late one Friday was already assigned to six others scattered down a 100-foot-long hallway.

By Saturday morning, it was clear that Mr. M. needed far more attention than any other patient in that stretch of territory. When his nurse propped him upright and helped clear the mucus from his mouth and throat, Mr. M. breathed easily, smiled, looked at his breakfast tray with judicious interest and announced that he loved vanilla pudding.

When his nurse left to tend other patients, Mr. M. tended to slump down in bed, coughing weakly and increasingly congested, until the nurse returned.

Experts have repeatedly pointed out the vicious circle behind the nursing shortage. The more understaffed hospitals are, the more demoralized nurses become, the fewer recruits join their ranks, the worse nursing shortages grow, and the more understaffed hospitals become. California acted on the problem this year, mandating that hospitals aim at an overall ratio of no more than five patients a nurse in wards like Mr. M.'s.

Cynics pointed out that the state might as well have mandated universal good health for all its residents. Given the availability of trained nurses, it was a similarly achievable goal.

As Saturday wore on, Mr. M.'s nurse raced up and down the hall from one patient to another. The single nursing aide in the ward never ventured far from Mr. M.'s bed. Both could remember quite a few old men as unstable as Mr. M who had to be rushed right back to intensive care.

No one can ever sort these things out for certain, but with fewer sick patients on the ward, the nurses said later, perhaps they could have kept a better eye on him and alerted doctors to trouble ahead.

The article by the Pennsylvania researchers is the latest in a decade's worth of rigorous research into the crisis of nursing staffing levels. In it, they steer clear of the emotional aspects of the situation and confine themselves to the statistics. If staffing in hospitals allowed for four patients a nurse rather than eight, they say, an estimated five lives per 1,000 patients might be saved.

It doesn't hurt to suggest that one of those lives might have the face of a little old man who battled pain and liked pudding, who had a cardiac arrest on Saturday afternoon and never woke up.