Respect my authority

There was an article recently that sort of triggered me, and I wanted to talk about it a bit.  It’s about being the only voice in Infection Prevention, and sometimes being frustratingly powerless to make necessary changes for patient safety.  If you work in a large organization, you might not know what I’m talking about.  But I’ve spent most of my time in small places where I am the only voice. It doesn’t happen always, but often enough that it has made me wonder why I do this job.

I have worked in a few different arrangements:

• A mid-sized hospital, with another ICP, and 2 ID physicians who: saw patients, chaired the IC committee, provided consults to colleagues, took call overnight, and were involved in antibiotic usage.
• A small hospital, where I was the only IP.  One ID physician who: covered many facilities on consult and had an outpatient practice, was supportive, but very busy, came to IC committee, but I did all the work.
• A small hospital where I was the only IP. All calls were mine. The ID physician was on consult to the IC program, did not see patients at the facility, employed elsewhere, engaged at quarterly IC committee, but mostly unavailable otherwise.
• A very small hospital where I was a consultant ICP for just a few hours a week.  No ID physician.  All calls were mine. I ran committee, and an MD was present and signed off.

When there is an issue in infection control, and there is no readily available physician or other staff, it is up to me to present the issue and my suggestion for ameliorating it.  I am confident in my knowledge and skills, but frequently this is not enough.  I simply have no authority to implement significant changes without support from administration.

When a CRE patient presents from an outside facility, I gather the key players, and explain current CDC guidance for patient care.  I print fact sheets for patients and staff.  I make myself available on the unit for questions and support. But I cannot implement the recommended staffing changes.  I am told that it isn’t possible for the nurse to have only one patient.  Maybe it’s a budget issue, or a planning issue, or they don’t completely understand the implications of CRE spreading.  But I cannot control it.

When the OR staff reports that a surgeon doesn’t wash his hands due to a skin condition, I approach my boss.  She agrees this is serious.  She arranges a meeting with the surgeon.  He explains his issue.  I grit my teeth while she suggests other options out loud: double gloves, a dermatology consult, different soap.  I explain the standards.  She asks me to see if he has a higher rate of infections in his patients.  The numbers are too small for meaningful comparison.  She takes this as ‘no.’  She tells me we can’t take away his job. He continues to practice.

I find expired skin antiseptics in a supply closet.  I let staff know they need to be thrown away and replaced.  They tell me that then they won’t have any because the secretary does the ordering and she’s off next week.  I ask how they check for expired supplies.  Blank stares.  I find many more.  I have no boss in this small organization.  He left 6 months ago, and they haven’t found a replacement.  Next in line is the CEO.  I do not know who he is, and he likely can’t order supplies.  At the next committee meeting, it’s agreed that someone should be in charge of checking and ordering supplies.  The nurse manager says her staff don’t have time. There is literally no solution anyone can agree to, and I am stunned.

The majority of us in the US are ICPs in small facilities.  It can be very frustrating to be expected to maintain the same standards that large facilities have.  I want everything for my patients--the safest care, according to recommended practice standards.  But in all but one site I have worked in, the IC department didn’t even have its own budget.  Nothing specifically allocated to education, to supplies.  Just a salary, for someone to come in and fill that CMS required role.  And directors who look surprised when you show up holding guidelines and asking for support and action.  Perhaps they hoped I would just sit in the office and tabulate things.  Instead, I sit in the office and document things.  Because when something goes wrong, I will have evidence that I did everything I could within my power to inform those who do have the power.  And it will not be on me.