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  1. Hickey, Patricia A. PhD, MBA, RN, NEA-BC, FAAN
  2. Gauvreau, Kimberlee ScD
  3. Jenkins, Kathy MD, MPH
  4. Fawcett, Jacqueline PhD, RN, FAAN
  5. Hayman, Laura PhD, RN, FAAN


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.