AFMC Project Targets "Super Germs"

A quality improvement project begun in 1996 by the Arkansas Foundation for Medical Care (AFMC), the state's Medicare Peer Review Organization, has resulted in more Arkansas hospitals improving their abilities to proactively target antibiotic resistant bacteria in those facilities. Sixty-nine hospitals in the state have recently adopted new policies that strategically position them to detect, report and prevent the spread of the so-called "super germs."

AFMC initiated the project in response to reports by the national Centers for Disease Control and Prevention (CDC) concerning the growing threat of antibiotic resistant bacteria in U.S. hospitals. Arkansas hospitals eagerly responded to the project after AFMC contacted them about the serious threat posed by the potential spread of these organisms--especially those strains that have developed a resistance to the powerful vancomycin antibiotic--and the need for hospitals to adopt procedures to reduce the potential for organisms to spread. As a result:

• 50% (up from 9%) of participating hospitals now routinely screen organisms for resistance to vancomycin;
• 59% (up from 10.3%) revised their facility's protocol for reporting of vancomycin resistance to state health authorities;
• 73.1% (up from 10.3%) have isolation procedures for patients infected with or carrying resistant organisms; and
• 47.4% (up from 7.7%) have revised policies curtailing the routine use of vancomycin as a safeguard against surgical infection.

Arkansas' Growing Nurse Shortage

Dr. Linda Hodges, Dean of the UAMS College of Nursing, recently met with the Arkansas Hospital Association board to discuss several problems concerning shortages in Arkansas of both registered nurses and of nurse educators to serve as faculty in the nursing education programs throughout the state.

Dr. Hodges reported that in late 1996 some Arkansas hospitals began to experience a slight shortage of RNs, with rural hospitals reporting up to 30% of their budgeted RN positions unfilled. In December 1998, Pulaski County hospital nurse recruiters are reporting 295 vacancies, with most senior nursing students unavailable until May 1999 graduation. She noted that potential May RN graduates from UAMS College of Nursing, UALR Associate Degree Program, and Baptist Diploma School of Nursing would total 257.

She said the nursing shortage was impacted by several factors:

• The rising age and falling RN employment activity: The average age of today's RN is approximately 46, with over 65% 35-54 years of age. Today's hospital patients have an extremely high acuity level, nurses work 12-hour shifts, and there is a decrease in the RN mix, therefore many nurses are at an age that they no longer have the stamina to work as a hospital staff nurse.
• The shift of RNs to community-based care and outpatient services: The older RN workforce is now opting for less physically demanding jobs which offer better pay and benefits.
• Wages and benefits: The Hay Compensation Survey shows inflation-adjusted salaries for RNs increased by only 0.3% in 1995 and decreased by 1.1% in 1996. RN wage growth appears to be consistently at or below the inflation rate over most of this decade. Benefits are reduced. Senior level nurses lack career advancement and increased wages when compared to other professions such as engineering, medicine, law, and physical and occupational therapy.
• Decline in nursing school enrollments and graduation: Applications and enrollment in professional schools of nursing are down for the fourth straight year across the nation. In Arkansas, since 1994 there has been a 12.9% decline in RN student enrollment. Today, traditional male-dominated careers such as law, medicine, pharmacy, and engineering have opened up to women, making nursing less attractive.

Dr. Hodges reported that a task force of nursing educators across the state is working to correct the growing nurse shortage. She said there are obstacles to nursing schools' production of more RNs. They are:

• A decrease in clinical placements for students, particularly in hospitals. With restructuring and a decreased RN mix, higher acuity levels and less mature staff, hospitals are allowing fewer students to be placed on units. Higher demands are then placed on nursing instructors supervising students scattered throughout a hospital.
• An aging faculty who is leaving the teaching profession for retirement or less stressful jobs, or jobs that offer as much as a 30% increase in pay. She noted that of the 223 faculty teaching in Arkansas' RN schools, 119 are 45 years of age or older. It is expected that 36 will be at retirement age in five years and 53% of 119 will be at or near retirement age in 10 years.
• Arkansas is beginning to experience a severe shortage of nursing faculty. Since 1992, the majority of master's degree nursing students have selected clinical specialist, nursing administration, or nurse practitioner preparation instead of the teacher preparation education track at all of the state's three master's programs. These clinical positions now pay beginning salaries of $50,000 to $70,000+ to those new graduates. The beginning salary for the state's master's nursing faculty ranges from $35,000 to $42,000.

The task force suggested several strategies that may influence the career choice of master's prepared graduates. They include:

• Creating a loan/scholarship program similar to the rural nurse practitioner loan scholarship program to prepare rural educators. This program would be available for nurses who want to earn the master's degree in nursing education and who are willing to commit to teach in a state-supported RN nursing program one year for each year they receive funding.
• Increase nurse educators' salaries and benefits to create parity with those in the practice setting.

Arkansas RN Shortage Survey

An Arkansas Hospital Association survey on nursing employment in the state's hospitals shows that most believe there is a growing shortage of Registered Nurses in the state. CEOs or Directors of Nursing in about 55% of the 103 AHA-member hospitals responded to the survey, which was conducted in September and October. Overall findings showed a 6.2% vacancy rate among budgeted RN positions in the hospitals. Individually, the vacancy rate is reported as high as 30%, particularly in some smaller hospitals. Results of the survey also show the difficulty of retaining RNs in hospitals. Almost 23% of the budgeted positions turn over each year, according to the respondents. Sixty-four percent of those responding said there is currently a nursing shortage in Arkansas, while 30% disagreed. More than 56% said the shortage has worsened over the past year, and 9% said the situation has improved. In spite of the perceived shortage, just 18% of the hospitals rely on agency nurses to fill their empty positions.

The AHA survey findings correspond to other studies around the country indicating an increasing RN shortage. In fact, the Department of Health and Human Services predicts demand for RNs will outstrip supply beginning in 2010. Experts cite a number of reasons why fewer nurses are available. Among those are the declining enrollment in nursing programs (enrollments of entry-level bachelor's-level nursing students fell by 5.5% in fall 1998 from a year earlier); a perception that most hospitals are still downsizing nursing staffs; an improved economy, which makes it easier for nurses to leave the field for other opportunities; the failure to attract more males and minorities into nursing; and the increasing average age of the nurse workforce. In 1980, 25% of all nurses were under 30 years old. Today, just 9% are in that age group.

Boozman Named Arkansas Health Director

Dr. Fay Boozman, an ophthalmologist and former state senator, has been selected to serve as director of the Arkansas Department of Health. Boozman, who was a candidate last year for the U. S. Senate seat vacated by former Sen. Dale Bumpers, was named by Governor Mike Huckabee to replace Dr. Sandra Nichols who resigned as Health Department director last August.

Boozman, an eye surgeon, also has a background in primary care medicine, having completed a residency program in pediatrics. He said his focus as the department's director will be on improving the health of all Arkansans, and especially children. Boozman was chosen by the governor in early February after being nominated by the state Board of Health along with two other candidates.

JCAHO Issues Y2K Warning

Hospitals without plans to deal with expected computer problems in 2000 can expect to receive the harshest criticism the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has to dish out in 1999, the accrediting body said in February.

Facilities that have not addressed the effect of improperly programmed computers on their operations face possible Type I recommendations from JCAHO, meaning they have not met the organization's compliance standards.

In follow-up meetings, JCAHO surveyors will determine whether hospitals are trying to identify potential computer-related problems in 2000, upgrade computer programs to avoid those problems or finding manual solutions, develop emergency plans and plan for unforeseen consequences.

The Balanced Budget Act Affects Arkansas Hospitals

At the beginning of the year the Balanced Budget Act (BBA) of 1997 was beginning to have a serious impact on Arkansas hospitals. Two Arkansas hospital organizations announced in January changes that will result in job losses. St. Vincent Health System of Little Rock unveiled an organizational restructuring that resulted in more than 100 employees being laid off from their jobs. Earlier, El Dorado's Medical Center of South Arkansas (MCSA) said it laid off 16 employees--and left another 15 recently-vacated positions unstaffed--in a move that would trim $700,000 from the hospital's costs. Jefferson Regional Medical Center announced recent "outsourcing" of work, possibly eliminating jobs at that hospital. All three medical centers attributed the cost-cutting measures to reduced Medicare revenues related to the BBA.

Diana T. Hueter, president and CEO of St. Vincent Health System, said the layoffs--about 3% of St. Vincent Health's 3,400-employee work force--could be attributed to falling Medicare and managed care payments, and are part of an overall effort to improve the system's efficiency as it finishes absorbing the operations of Doctors Hospital, which the health system acquired last year. St. Vincent expects to lose $45 million in Medicare payments between now and 2002, the period covered by provisions of the BBA. The expected drop in revenue represents about 10% of the $450 million the system normally would receive from Medicare over a five-year period.

In El Dorado, MCSA's chief executive officer Luther Lewis said cuts were made in response to an estimated loss of $1.6 million in Medicare payments for 1999 alone. He said revenue reductions are expected for inpatient and outpatient services, services provided through MCSA's recuperative care unit, and lower Medicare payments for inpatient rehabilitation services, among others.

Jefferson Regional Medical Center's CEO Bob Atkinson said, "With reimbursements decreasing every year, we must seek the most efficient, cost effective means of running our facility and meeting the healthcare needs of our communities." Outsourcing JRMC's materials management department will save the hospital about $1 million a year. Outsourcing additional departments and services was a consideration.

Nationwide, the BBA will reduce Medicare hospital payments about $53 billion below revenues that would have otherwise been paid to hospitals over the five-year period. Altogether, Arkansas hospitals could see their Medicare revenues fall about $600 million because of the various provisions of the act.

Governor Awards Rural Hospital Grant

Arkansas Governor Mike Huckabee announced December 3 that the University of Arkansas for Medical Sciences' Rural Hospital Program has been awarded a state grant of $296,660 for use in the school's telehealth system. The award will allow UAMS to reach the goal of placing an interactive video system in or within 30 miles of every hospital in Arkansas. UAMS vice chancellor for regional programs, Dr. Charles Cranford, said the award lays the capstone on the UAMS Rural Hospital Telehealth Network and opens the door to educational opportunities for many in Arkansas. It also places Arkansas number one in the nation in statewide coverage through an interactive telehealth video system, according to Dr. Cranford. Grant funds are to be administered by the state Office of Information Technology.

The Rural Hospital Program uses the Telehealth Network to deliver programs and services of UAMS and University Hospital to rural sites. Thirty-six Arkansas hospitals, health centers, community colleges, and Area Health Education Centers (AHEC) currently participate in the network. To date, the program has delivered over 3,340 services to rural facilities throughout Arkansas using its network capabilities. Hospitals that are not presently within 30 miles of an interactive video system will be eligible to apply for funds to install a system in their facility. Award money will cover the cost of equipment, installation, and training. The project will allow the Rural Hospital Program's Telehealth Network to expand to additional rural hospitals to meet the goal of having the technology within 30 miles of every hospital. Those interested should contact the UAMS Rural Hospital Program at (501) 686-2590.

Arkansas Opinions About Healthcare

Market Insights, a Little Rock marketing and research firm, periodically conducts opinion surveys to take the pulse of Arkansans on issues of general interest. In its most recent version of these Insights on Arkansas surveys, conducted in September, the company--with the input of the Arkansas Hospital Association--included a few questions about the public's opinion on several healthcare-related matters. A total of 408 interviews were completed for the survey, distributed across the four Congressional districts in the state, and including about the same number of male and female respondents. While the responses to the healthcare questions aren't necessarily surprising, they convey some interesting public perceptions.

The first question sought respondents' opinions about who holds the greatest influence over decisions regarding healthcare services they receive. Participants could choose among themselves or their family, their physician, insurer, employer or hospital. Most (34%) said their insurance company has the greatest influence. However, a combined majority (53%) said they/their family (28%) or their physician (25%) still retains deciding influence over their healthcare services. Five percent responded the decisions are most influenced by the hospital; and, another 5% said their employer determines healthcare services to be received.

When asked to rate the most important ways they view quality of healthcare, survey participants could choose among keeping up with technology, treating patients with respect, the availability of adequate numbers of nurses to care for patients and having healthcare services and facilities available and accessible in the community. Availability/accessibility of services and keeping up with technology both garnered 35% of total responses as the most important way to measure quality, followed by treating patients with respect (19%) and adequate numbers of nurses (8%).

On another quality matter, the survey showed that 55% of Arkansans believe that overall healthcare quality in their communities has improved over the past five years, although an alarming 26% said the quality of healthcare services they receive has declined. Finally, of the respondents who live in communities served by a single local community hospital--58% of all who participated--38% said their community would suffer a strong negative impact if that hospital closed. Another 28% said there would be some negative impact if their hospital closed. Twelve percent said the closing of their local hospital would have a positive impact on their community.