My name is Beth Goetz. I am a Registered Nurse in rural eastern Washington at a 25 bed Critical Access Hospital (CAH) located in Grand Coulee, Washington. Coulee Medical Center is my second home, and my second family. Both of my biological children were born at CMC, delivered by my coworkers. Awkward at times yes, but that’s who I trusted. I knew that both them and I were in the best hands we could have been, and that made up for the few awkward moments. Both of them have been in the emergency department, undergone surgical procedures, and receive their yearly checkups there. My husband and I as well. CMC employs some of the highest skilled nurses I have ever had the pleasure of working with. Many of us will assist in delivering your baby one minute, and run to the emergency department the next to help save the life of someone having the worst day of their life, and end our day back on the med/surg floor taking care of someone with pneumonia. And we love it. You couldn’t pay most of us enough money to go to a big hospital and only work in one department with every resource we could imagine at our fingertips. It isn’t us. We are rural nurses. We can make splints we don’t have out of egg crates and tape, start the most difficult IV’s, do our own breathing treatments and EKG’s. We don’t have a lot of resources to call on, so we learn and perform the tasks ourselves.

I have worked at CAHs since I was 16 years old, 21 years, starting as a Certified Nursing Assistant during high school and college, and now as a RN. Currently I am in a management role managing the Emergency Department, Obstetrical Department, and our Outpatient Services Department. I also actively work in these departments, I don’t do well sitting behind a desk all the time. I am writing this letter in response to the purposed HB 1886/SB 5751. I would like to shed light on the detrimental impacts that these bills will have on our healthcare system, our ability to provide high quality patient care, and the ability for Critical Access Hospitals to provide specialty service lines, and to keep our doors open to provide care for our families and rural communities.

In the media, these bills have been largely advertised as bills to provide “Safe staffing ratios” for nurses. What I don’t see widely discussed and addressed are the pieces included in these bills that will severely limit the ability of hospitals to continue to provide care for patients, staff specialty services, maintain Long Term Swing Units, and for some of us, keep our doors open at all.

These bills do not address the current nursing shortages that hospitals in Washington State are facing. They do not attempt to help hospitals fill the current 6,000+ openings that we have open for RN’s. They simply demand more RN’s and take away the ability and right of our elected Nurse Staffing Committee’s to determine safe staffing levels and safe nurse to patient ratios.

Neither HB 1886 nor SB 5751 take into account patient acuity when determining maximum staffing ratios. Acuity levels of patients is the one constant measurable driving force of patient care. Since the dawn of nursing, nurses have prioritized their patient care based on the acuity of patients. How sick are they, how fast do I need to tend to them, who needs help first? Patient care is not a “one size fits all”, nor are hospitals. Basing decisions that have direct impact on patient safety, and whether someone lives or dies cannot effectively be done by comparing apples to oranges or a Level 1/2 trauma center to a Critical Access Hospital. Proposed staffing ratios from these bills are a maximum of 1:4, 1 nurse to 4 patients, regardless of patient acuity. Let me put this into real life scenarios for you. Coulee Medical Center has 25 beds. Currently 8 of those beds are filled with “long term swing patients.” These patients are elderly and live at our hospital, very similar to what most would consider nursing home patients. We do not have a nursing home in our community; having the ability to have long term swing residents at our hospital allows us to keep our own in our community as they become unable to take care of themselves. This is a common practice with Critical Access Hospitals, and often a main source of income for these hospitals. The acuity of these patients is extremely low, and requiring a 1:4 staffing ratio for these patients will make it financially impossible for CAH’s to continue to have long term swing residents in our hospitals.

Have you ever had to make a trip to your local emergency department? Maybe you fell and broke a bone, cut yourself to the point of needing sutures, or even worse- were having a stroke or heart attack? I would hope it is common knowledge, that being the first person taken back in an emergency department, usually means you’re the sickest right? It is not a first come, first serve like at your local restaurant, you can’t call ahead and schedule an appointment, and sometimes you wait to be seen. The EMERGENCY department, is meant exactly for that. Emergencies, something that may kill you or cause significant harm in the next 12-24 hours if left untreated. That is why the majority of us go to the ER. That being said, not every ER patient has a high acuity. Someone slips and cuts their finger with a steak knife, its bleeding, but controllable, but deep enough to need sutured together. Lacerations need to be closed in a timely manner to ensure proper tissue healing and prevent infections. However, these are normally a lower acuity patient. They are usually stable, pain is easily controlled, and do not require a lot of hospital resources to treat. Many ER patients fit this profile. Many ER patients also need diagnostics done. Whether that is an x-ray, CT scan, ultrasound, or labs drawn and resulted, these tests take time and man power to complete. Completion of these tests is also based on the patient’s acuity- the patient having chest pain is going to have labs completed prior to the patient with a history of 3 days of generalized weakness. The patient complaining of neck pain and numb extremities after a motor vehicle accident is going to go the CT scanner before the patient who fell playing basketball and is having wrist pain goes in for an x-ray. The ER is all about patient and treatment prioritization. Now that you have some understanding of this picture, imagine you’re on vacation in a rural community. Let’s say you come over those big beautiful mountains from western Washington to eastern Washington in July. You bring your kids, families, some friends and are going to enjoy a few days on the beach and some amazing boating on Lake Roosevelt. Go hiking around Steam Boat Rock and Northrup Canyon, enjoy all of the beauty that nature has to offer over here. Now imagine that your young daughter falls on one of those hikes and is complaining that her arm hurts. It swells up and is bruising, probably fractured, she is in obvious pain. You get her back to your vehicle and drive her to the emergency department at CMC. Now, if you’ve ever broken your arm or wrist, you probably know that once we are able to splint it, give you some pain medication, and some ice it usually feels a lot better! CMC is a small hospital, so we staff 1 RN in the ED most of the time to care for the average 18-20 patients we see in a 24-hour period. When you arrive, that RN already has 3 low acuity patients roomed. 1:3 is the max nurse to patient ratio purposed by this bill. Let’s say these 3 patients are all waiting for diagnostic tests to come back for definitive treatment, are all stable, pain is controlled, and that nurse could very easily take your daughter back and get to work on making her pain go away, however, that nurse can’t. It is against the law now, and that arm fracture does not meet the definition the bill provides as an “unforeseeable emergency circumstance”, the only way we would be allowed some patient care flexibility to bring back a fourth ER patient. So your daughter waits in the waiting room, in pain, while we wait for diagnostic tests to come back, provide additional treatment, and discharge a patient, freeing us up to bring back another. That is what will happen if these bills are passed.

I would imagine that most people would not know what a “Critical Access Hospital” is or means. Critical Access Hospitals were created when congress created the Critical Access Hospital designation through the Balanced Budget Act of 1997. This act was enacted in response to over 400 rural hospital closures during the 1980’s and early 1990’s. The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAH’s receive certain benefits, such as cost-based reimbursement for Medicare services. There are certain criteria hospitals must meet in order to obtain CAH designation, including being more than 35 miles from another hospital (in most cases). That means CAHs are rural hospitals. Serving small communities that are not in close proximity to a metropolitan or suburban area. Unfortunately, the CAH designation does not provide reimbursement for obstetrical services or surgical services. That does not mean that these services cannot be offered at a CAH, just that they don’t fall under the cost-based reimbursement. Fewer than half of all rural counties have hospital based obstetrical services in the United States. This lack of prenatal care increases the likelihood by 3-4 times that women will die a pregnancy-related death and also contributes to higher rates of infant mortality. According to the Wall Street Journal, pregnant women in rural areas of the US die of pregnancy related complications 64% more often than women in Urban areas. These mortality rates are even higher in the Native American population. In fact, according to the Washington State Department of Health, Native American Women have over double the amount of pregnancy associated maternal mortality rates than any other race. If you don’t know, eastern Washington is home to the Colville Indian Reservation. This reservation is 1.4 million acres. There are no hospitals located on the reservation, and no obstetrical services. These patients seek obstetrical services, emergency services, surgical services, etc. off of the reservation. CMC is located approximately 5 miles from the boarder of the Colville Reservation. On average, over half of the women delivering babies at CMC are Native American. So what does this have to do with HB 1886 or SB 5751? If passed these bills would limit the amount of on-call hours for RN’s to no more than 20 hours/week. What does it take for a rural facility to offer OB or surgical services? For CMC, it requires having up to 5 people to be on-call in case of an obstetrical emergency that requires a cesarean section. This includes an OB RN, which may or may not be scheduled to be in-house working on the med/surg floor, a circulating RN, a Scrub RN or Tech, an OB provider, and a CRNA (certified registered nurse anesthetist). This human infrastructure is what supports our obstetrical and surgical services. This is not reimbursed under the CAH designation. Limiting the amount of call hours that nursing staff are allowed to take will require some hospitals to hire upwards of double their staff to comply with the on-call restrictions. Where do these nurses come from? This bill does not support getting more people through nursing school, it does not fund nursing programs, it does not “create” more nurses, in adds to the already devastating nursing shortage. What is the purpose of limiting on-call hours to 20 hours/week or less for a CAH? Our nurses agree to call, rarely get called in after hours, and are well supported by management and administration. More CAHs will be forced to close their emergent surgical services and their obstetrical services. This will result in pregnant women driving hundreds of miles to a facility capable of safely delivering their unborn child. In rural eastern Washington, this involves driving over mountain passes, on unmaintained dirt roads, in snow, ice, and dense fog in the winter months. More women will die delivering on the side of the road, more newborns will die because they will not receive the necessary medical attention they need. And pregnant women will still present to these hospitals because they have nowhere else to go. These hospitals now will not have the infrastructure necessary to perform an emergency cesarean section if necessary, resulting in more deaths. Imagine being a nurse or a doctor that cannot do what is necessary to save the life of a mom, an unborn child or newborn because someone outside of healthcare wrote a bill that stripped you of your ability to provide necessary care for your patients- LIFE SAVING care. You are forced to sit there and watch a mother, unborn child, or newborn die. These occurrences ruin nurses and providers. They cause moral injury. They lead to burn out. They lead to healthcare professionals leaving the profession because they devastate our emotional wellbeing, and we cannot continue to place ourselves in those situations and risk having it happen over and over again. We did not go into healthcare to be told what we are personally capable of handling, we went into the healthcare profession because we care. We have an innate drive to put others needs before our own. We care about our patients. We pour our blood, sweat, and tears into our professions to provide the best possible care of our patients. Please do not take that ability away from us.

Let’s talk breaks. Nursing staff getting their much earned and deserved breaks has been in the news for as long as I can remember. I 100% agree that everyone should get the breaks they deserve. At CMC, this happens the majority of the time. We do not have to file complaints that we were not allowed to take a break even though we asked for one because we work together to ensure that everyone is allowed to take their much deserved breaks. We track breaks on our break log as required by the department of health, and keep those logs so that they can be reviewed if we ever need to provide them. I do not agree with someone else dictating when I take those breaks, or saying that I am not allowed to skip my break or take it at a later time if my patient needs me. If passed, these bills will take away the ability of nurses to choose to skip or take their break at a later time. In nursing school, we are taught you never abandon your patients. Duh…. I don’t know any nurses who would purposely abandon their patients in an emergency situation. Why would we dedicate ourselves to this profession if we did not care about our patients and were willing to walk away to eat a sandwich when they needed us most? Common sense right? I can wait an hour to go take my lunch break when someone isn’t dying or having a baby. Flexibility and nursing go hand in hand. People are counting on you on what is often the worst day of their lives, or maybe the best day of their lives as they welcome their precious child into this world that they have waited for for so long! But wait… If passed, these bills would strip me of the right to say no, I can and want to wait to take my break. Nurses would be forced to abandon their patients, something we have always been taught not to do, and really didn’t need taught, we were born knowing this already. This goes against every moral and ethical bone in most of our bodies, and would require someone literally dragging us kicking and screaming to get us away from our patients.

I could go on forever on how these bills are not in the best interest of patients or nurses. But I will stop here and hope that I have created an accurate image in your mind of what will happen to some hospitals if these bills are passed. They do not have the best interest of nurses, or you as patients in mind. They do not address the current needs of hospitals, and are not supported by the majority of the nurses I personally know. If you want to help nurses, create more nursing schools. Provide more opportunities for people who want to become nurses, to become nurses. These bills will not help rural hospitals in Washington, they will devastate them and ultimately result in the deaths of more patients and the loss of highly skilled healthcare professionals.

I encourage everyone who can to click on this link and share your opinions with your law makers regarding these bills: https://p2a.co/RIjyomw.

Thank you for taking the time to read this letter.

Respectfully,

Beth Goetz