The Rule Of Law: The Secret To Change In The NICU

Jae Kim, MD, PhD / June 2018

It has been absolutely fascinating over the past year to see our country undergo a true Rule of Law test as political turmoil from all sides challenged pillars of the three independent arms of government. Our country has weathered these hurricane forces quite well so far, and I marvel at the brilliance of the original founders of our country to conceive of a structure of government more than two centuries ago that protects its citizens against any such unforeseen circumstances of unbalanced power.

What is the Rule of Law? Having not grown up on American history, but being riveted by the public discourse through media, now I see it from both perspectives: externally from my past, and internally as a citizen. I do remember getting early glimpses from Canada watching American Saturday morning cartoons (amazing what they taught back then in the guise of cartoons). What intrigues me is the structural purpose of this Rule. The Roman statesman, Cicero, is quoted as saying, “We are all servants of the laws in order to be free.” The Rule of Law involves the restriction of the arbitrary exercise of power by subordinating it to well-defined and established laws. Its overall intent is to protect the citizens of society by requiring them to follow a set of rules and regulations that govern all members of society. No one is above the law, even at the highest position in the country.

Rule of law in the NICU

Observations of the Rule of Law function may instruct us in the NICU in particular, as the Rule relates to the delivery of quality in patient care. In neonatology, we have scenarios where rules firmly apply, and others where rules are less evident. For example, when a child has a definitive systemic bacterial infection, say with a pathogenic gram negative bacteria like E. coli, the initiation of antibiotics is universal. Everyone respects the potential damage that infection can cause, and that antibiotics are the best known treatment to eliminate the infection quickly. Not following the rule could even amount to malpractice. It seems some truths are agreed upon with high universality, and others are more a matter of opinion.

But take the example of when a child is not growing well, and we see the response to poor growth in the NICU can be quite variable. Some react quickly, some choose to watch and wait, some increase volume, some fortify, some draw blood and do tests. When evidence may be less convincing or when there are many choices that have not been compared effectively with each other, high variability in practice ensues. In these cases, we choose not to be defined by rules so much. That means that on any given week, the care of a patient may be subject to the clinical biases of the managing team: the MD provider, bedside nurse, respiratory therapist, occupational therapist, dietitian, or social worker.

But does having rules in the NICU help us to best manage our infants? Should we be even more prescriptive than we have been to offer the best chances for our patients? If the answer is yes, then what should our world of rules look like? We already live in a world that develops guidance in many ways. For instance, we have policies that are mandated at hospital, state, or federal levels. These detail the practices and procedures that we do each day that are required for us to document, as well as others that we feel need structure for the purposes of improved safety. The levels of adherence may still vary with policies within a unit and across units, but the softer areas of practice tend to carry high variation, particularly in the granular details of a given practice.

So what reasons do people give for not following a decided set of rules, guidelines, or protocols?

It’s too much already!

We have all experienced that feeling when someone starts up another protocol or guideline, or even worse, a policy. We often cringe at yet another pathway or process to remember and adhere to, which feels at times forced upon us. I think it is natural for us when we are inundated with greater, not lesser, effort with the advent of the EMR, higher documentation demands, and chronic understaffing that more put on us is not appreciated.

We want to be in control

I think no one likes being controlled by forces outside of themselves. Being pushed or pulled makes us dig our heels into the ground. Anyone with a dog can testify to this natural response. Losing control as a professional is disarming. We feel less respected and less appreciated when we are told to “follow the rules.” Letting go of some of our autonomy as practitioners is really hard.

We think we know better

“I know best, as I have had special training and a breadth of experiences that make me an expert.” Many of us have trained long enough, and have had years of experience, to the point that this autonomy is part of our identity in practicing medicine. This is especially true for those caregivers who have been doing this for more than a decade. Habits are hard to change, and perceived freedom is hard to give up once you have it. Perhaps this perspective will change faster with the newer generation, but we will need to teach them well since we are all human and fall into the same tracks of habits given time.

No one knows what is best, so I am going to do it my way

“There is not enough medical evidence to guide practice so I am going to do what I think is best.” Oftentimes, the less anyone knows about some area, the more opinionated we can become. We easily fill in the void when there is little to challenge our beliefs.

It is too complex and rules just don’t apply

We believe that the human condition is complex, and rules cannot guide every single situation at hand. Sometimes the uniqueness of an individual patient experience cannot be prescribed by a set of rules. Tailoring our practices to the specific patient is better care.

I think that the power of rules can inform us how to deliver the best medical management to care for our infants. By putting faith into a set of guiding principles of establishing both big and small rules, and agreeing to abide to these rules, we may make our working condition much more conducive for streaming the best care and reinforcing with our parents that we are working together.

Our SPIN program, now a decade old, has seen the fruits of putting together pathways that provide guidance and rail tracks to allow for a clear direction of care for most of our infants. It has been responsible for dramatically reducing our rates of necrotizing enterocolitis and optimizing the growth of our infants, despite the large move to a human milk-based diet that is by nature much more variable in content.

We recently agreed to establish reduction of antibiotic use through a mandatory stop date with antibiotics started for suspect sepsis. This was one of the major factors in our unit rapidly reducing our antibiotic use in this situation. There are two factors that were essential to the success of this measure. The first and most important is the acceptance of the rule. Our unit faculty came together, aligned, and agreed to follow some “rules” of antibiotic stewardship in our NICU. This came about from a lot of discussion and negotiation regarding what was possible, and what was too far out and unacceptable. A rule falls apart rapidly when even one individual chooses to defy it. Think jaywalking across a street. Agreeing to follow rules is not so easy.

When I teach trainees now, I try to give equal time to the importance of consistency, following rules of neonatology, and the power of quality improvement as to the intellectual discussion of why a certain therapy or practice works based on medical evidence. I express my humility that what we know and do now is going to be scoffed at and even laughed at in a short time, and so we must always be open to change.

Go ahead and step into the future of neonatology and begin to craft more, not less, “rules” of neonatology, and you may be surprised how freeing it really is and how more holistic your care of your families may end up being. It has certainly been my experience that parents want consistency almost above all else.

Like the Greek word nomocracy (nomos=law, kratos=rule) for a government based on the rule of law, let’s start a “neo-nomocracy” and start taking better care of our infants.

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, He is the co-author of the book, Best Medicine: Human Milk in the NICU. Dr. Kim is a clinical consultant with Medela LLC.