Institutional members access full text with Ovid®

Share this article on:

Statewide and National Impact of California's Staffing Law on Pediatric Cardiac Surgery Outcomes

Hickey, Patricia A. PhD, MBA, RN, NEA-BC, FAAN; Gauvreau, Kimberlee ScD; Jenkins, Kathy MD, MPH; Fawcett, Jacqueline PhD, RN, FAAN; Hayman, Laura PhD, RN, FAAN

Journal of Nursing Administration: May 2011 - Volume 41 - Issue 5 - p 218-225
doi: 10.1097/NNA.0b013e3182171b2e

Objective: The objective of the study was to examine the impact of staffing ratios on risk-adjusted outcomes for pediatric cardiac surgery programs in California and relative to other states combined.

Background: California performs 20% of the nation's pediatric cardiac surgery and is the only state with a nurse ratio law. Understanding the imposition of mandated ratios on pediatric outcomes is necessary to inform the debate about nurse staffing.

Data Sources: Patient variables were extracted from the Healthcare Cost and Utilization Project Kids' Inpatient Database. The American Hospital Association database was used for institutional variables.

Methods: Descriptive analyses were used to identify and describe patient, nursing, and hospital characteristics. Changes in nursing ratios and full-time equivalents (FTEs) between 2003 and 2006 were examined. Associations between nursing characteristics and each outcome variable were examined using general estimating equation models. The RACHS-1 (Risk Adjustment for Congenital Heart Surgery) risk adjustment method was used for mortality.

Results: Hospitals in California significantly increased RN FTEs (P = .025) and RN ratios (P = .036) after enactment of AB 394 in 2006. Neither RN FTEs nor RN ratios were associated with mortality, complications, or resource utilization after risk adjustment. After the law, California's standardized mortality ratio (SMR) decreased more (33%) than in all other states combined (29%). Standardized complication ratio (SCR) increased by 5% but decreased by 5% for all other states combined, and the increase in charge differential ($53,443) was more than twice the increase ($23,119) for other states combined.

Conclusion: Hospitals in California made upward adjustments in nursing FTEs and ratios after enactment of AB 394. There was a substantial increase in California's charge differential, a decrease in SMR, and an increase in SCR after enactment of the legislation.

Supplemental Digital Content is available in the text.

Author Affiliations: Vice President, Cardiovascular and Critical Care Services, Department of Nursing Patient Services (Dr Hickey), Research Associate in Cardiology, Department of Cardiology (Dr Gauvreau), Senior Vice President, Chief Patient Safety and Quality Officer, Program for Patient Safety and Quality (Dr Jenkins), Children's Hospital Boston; Department Chair (Dr Fawcett), Professor (Dr Hayman), College of Nursing and Health Sciences, University of Massachusetts, Boston.

Correspondence: Dr Hickey, Cardiovascular and Critical Care Services, Bader 664, Children's Hospital Boston, 300 Longwood Ave, Boston, MA 02115 (

Funding: This study was supported by funding from the Department of Nursing and the Cardiovascular Program, Children's Hospital Boston.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

© 2011 Lippincott Williams & Wilkins, Inc.