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.
