Driving On The Neonatal Autobahn
Jae Kim, MD, PhD
The neonatal “highway” of clinical practice is often a challenging place to be. First of all, there are many and varied health care providers in our NICU. And like a typical highway, everyone has a slightly different way of driving.
But neonatology is one of the best medical team sports I know and, for the most part, neonatal care providers do a great job getting things done to improve neonates’ health, and trying to drive at a similar speed. More and more, however, our practices are being measured against higher and higher quality and safety standards. With these demands it is even more essential for us to re-evaluate how we practice both individually and as a team.
Why is it so hard to change?
Habit literature teaches us that practices that we do frequently and repetitively are brought down into our subconscious so that many times we forget that we are doing our habits. Driving to work is a great example for most people. How many times have you found yourself arriving to work and asking yourself how you got there, not recollecting the past half hour drive experience? Our nature to bury repeated practice is effective and protective for us to keep enough space for new things to be processed in our consciousness. Interestingly, when reviewing medical errors, some of the most serious risks for medical mistakes occur when new practices are executed, when they require a lot of conscious resources. This hardwired protective process though presents a challenge when it comes to times when we really want to or need to break our habits.
Reasons for standardizing practice
Most of us have heard of the Plan-Do-Study-Act (PDSA) cycles of quality improvement. The root of the PDSA cycle is the consistency of the “Do”. By establish a clear framework and guideline in a practice or practices, one can specifically evaluate the benefits of this change. Quality improvement happens much more quickly if you do things consistently. One of the biggest reasons for all practising similarly is that it is far easier to figure out what was working or not working well than if multiple practices were in place. Of course a good amount of data collection is really important in order to make sense of a set of practice changes. Hopefully most of you are learning or becoming expert in what it takes to carry on quality improvement in your NICUs.
Attending of the Day
The “attending du jour” (attending of the day) is a very popular style of neonatology practiced in our country. In this model, the attending on dictates changes in respiratory management, choice of medications and feeding practices that revolve with changes in the attending. This can be on a weekly basis or in some cases on a daily basis. The wiseness of this practice would never be accepted in how we have our food handled, our cars repaired or our computers built and yet we practice this way very often in our country (judging from the number of hands that go up when I ask an audience).
In the absence of evidence, practice has large variability. Some areas of neonatology lack good evidence to guide our practice. I have learned over and over the value of standardizing care even when there is no definitive answer. The reason for this is the same reason why it is safer to drive on the highway with speed signs than it is to drive at varying speeds. Consistency introduces efficiency in practice. Regardless of the evidence present at a given time, standardization is better care!
What is so hard about following rules?
I think there are several strong possibilities why making change and following a set of rules is difficult. In some cases we simple have too many rules to deal with. Each of our institutions have many policies and practices that chiseled out and reviewed annually. There are revolving emails that remind us of of the changes as they appear or develop. There are signs that remind of new guidelines or critical things to practice when JCAHO or other auditing bodies comes by. Sometimes there are just TOO MANY RULES! A natural tendency for some is to balk at the rules and do what we think is best. Particularly if experience is on our side. In rare cases there is a reckless and careless practitioner. In other cases, perhaps more common, is the individual who has been practising a certain way for more than 20 years and is not about to change no matter what has changed. Can you think of people that fit these descriptions? For some physicians, it is because of a strong and unfounded belief that experience has taught us how to be a good astute clinicians and that our visceral reactions are to be trusted when we practice the art of medicine. Experience needs to be checked with quality improvement and clinical research information in order to provide checks and balances to our responses to clinical scenarios. Think how counterintuitive it was to see a small vulnerable 700 gram go through resuscitation without rushing to intubate them.
How do we move forward?
So how do we make steps forward. The first is to ensure that we are of the same purpose. If people have different goals then moving forward is not that easy. The good news is that many times even when practice looks like a train wreck, everyone is trying to do the best they can to make babies better. As a matter of fact, “making babies better” is a phrase I use to guide my own practice and thinking to decide what to focus on and how to emphasize my medical convictions. So, common purpose in the NICU is probably not the major problem.
While inner drive to improve our patients in front of us may be similar, how we believe is the best way to do so is where we often fray apart. A universal awareness of the power of standardization and data collection is essential. A different kind of teamwork is needed where we all become part of a common mission for each baby following a script as best we can but improvising when we need to in order to adjust to the nuances that present themselves every day. Our roles could be more akin to that of astronauts and less like cowboys. Imagine a NASA mission where team members decided to handle critical decisions in completely different manners. Building a NASA-like team culture needs more nurturing to help us play our respective roles in neonatology. In this way and like NASA we can all share in the spoils of success at the end of each mission. Happy holidays and see all in the new year!
Enjoy more blog insight from Dr. Kim!
View his recent entry on neonatal pain, Baby Whisperers That We Are.
About the Author
Jae Kim is an academic neonatologist and pediatric gastroenterologist and nutritionist at UC San Diego Medical Center and Rady Children’s Hospital of San Diego. He has been practicing medicine for over 23 years both in Canada and the USA. He has published numerous journal articles, book chapters, and speaks nationally on a variety of neonatal topics. He is the Director for the Neonatal-Perinatal Medicine Fellowship Program at UC San Diego and the Nutrition Director of an innovative multidisciplinary program to advance premature infant nutrition called SPIN (Supporting Premature Infant Nutrition, spinprogram.ucsd.edu). He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela, Inc.