I could tell I was being watched as I walked into the neonatal intensive care unit.
I took off my white coat, folded my stethoscope in a pocket, and hung the coat in a closet. In a nearby sink I washed my hands for a full minute, scrubbing between each finger before drying my hands.
I approached a high-tech isolette and leaned in to examine my patient, the pink baby within.
A voice stopped me: “Doctor!”
There were footsteps behind me. I pulled back and thought, what did I miss? I retraced each step. Coat. Stethoscope. Hands.
The desk clerk pointed a finger. “Your ring, doctor. You forgot to take off your wedding ring.”
She was right. I rolled my eyes, pocketed my ring, washed again, and went back to my little patient.
Small interactions like these make hospitals safer for children by reducing rates of hospital-acquired infections. Now a new article shows exactly how much safer.
Children are getting far fewer infections in American hospitals, according to a very large study released this week in the journal Pediatrics. From 2007 to 2012, using data collected in 173 U.S. hospitals and over five million days of hospitalization, investigators tracked rates of multiple hospital infections, including bloodstream infections among children with intravenous lines and pneumonias in children on mechanical ventilators. The results were impressive. They found that children developed bloodstream infections from intravenous lines less than a third as often as they did five years earlier, and in the same time period children on mechanical ventilators developed pneumonia less than half as often.
These are impressive improvements resulting from a massive nationwide effort to track and prevent childhood infections in hospitals. But the success story is just beginning. Dr. Grace Lee, the study’s senior author and an associate professor at Harvard Medical School, points out, “Data is incredibly important, but so is partnership.”
The prevention of hospital infections in children on this scale required doctors, nurses and a whole host of other staff members to partner in standard infection control protocols. From how we wash our hands to how we insert intravenous lines to the way we manage children on ventilators, we have to keep each other up-to-date and vigilant. Just as the desk clerk in the neonatal intensive care unit helped make sure I had clean hands for my small patient, there are thousands of moments every day in which staff can support each other to keep children safe.
Interprofessional efforts like these prevent infections in children but they can run contrary to deeply-ingrained hierarchies in medicine. Consider how the desk clerk stopped me, a physician, on my way to examine a patient. Traditionally, doctors are at the top of a hierarchical hospital culture, and people lower down the historical hierarchy like nurses and desk clerks would fear reprisal if they had the temerity to question a physician. Yet of course physicians make mistakes and sometimes are the source of hospital outbreaks, so such nonsensical barriers to good patient care must be abolished. This takes time and concerted institutional effort; it also requires doctors like me to check our egos at the door.
Dr. Gautham Suresh is a neonatologist who studies patient safety and quality improvement at the Dartmouth Institute of Health Policy and Clinical Practice. “You need a culture where the NICU constantly monitors its infection rates," he said, "and refuses to accept infections as inevitable.” By contrast, Suresh said, infection rates in children can climb if hospitals get complacent or refuse to take ownership of the problem. If staff members pass blame onto others or refuse to work together as a team to fight infections, for instance, improvements in infection rates never happen.
Beyond day-to-day prevention of infections in children, each time an infection control team detects excessive rates of infection in a hospital unit, they have to do detective work to identify the problem and fix it. A different interprofessional team tasked with tracking and stamping out mini-outbreaks thus has to visit the hospital unit where the outbreak is detected so they can interview staff, observe routine clinical care (sometimes in secret), and develop a team intervention. Each intervention is tailored to each hospital unit and each particular runaway infection. “I don't think there's a simple answer for every hospital,” Lee said.
Dr. Antonia Altomare agrees. Altomare is an infectious diseases specialist and head of infection control at Dartmouth-Hitchcock Medical Center, where I work. When we met, her computer screen was filled with a dizzying array of graphs and spreadsheets representing the up-to-date rates of infectious diseases in children in our hospital. Pointing to one graph, Altomare recounted how her team addressed an outbreak of staphylococcal infections among neonates in our hospital a few years ago by enhancing hand-washing efforts among all staff and even quarantining some high-risk patients.
Such efforts to keep children safe from infections can be expensive for hospitals. Most hospitals generate revenue by doing more procedures and seeing more patients. By contrast, when hospitals pay people like Dr. Altomare to track and stamp out hospital infections in children, she cannot bill insurance companies for her work, so that money is all investment in prevention. In fact, now that Medicare no longer pays hospitals to treat hospital-acquired infections, hospital revenues are even lower for this work.
Lee sees this change of Medicare policy as a good development. Lee and co-authors argued the old approach set up “perverse financial incentives” in which, as Lee says, “it was possible to have complications of care occur result in higher payment.” Yet Lee reports we have not yet figured out the optimal way to incentivize infection control measures in hospitals. As a result, during budget cuts today, hospital administrators may be tempted to cut funding for programs that prevent infections in children tomorrow.
As I passed her on the way out of the NICU, I waved to the desk clerk.
“Doctor!” she yelled after me.
“What is it this time?” I thought as she ran up behind me again.
“You forgot your laptop!” she said, handing it to me.
I walked out of the NICU with my laptop in hand, feeling grateful for people like her who keep our children safe and the rest of us in line.