DEVELOPMENTAL CARE
Healing takes more than doing no harm
By Jin Paul de Guzman
Millions of Americans are unnecessarily injured and over 100,000 die annually because of quality problems in our health-care system," said Dr. Henry Simmons, president of the National Coalition on Health Care. "The system is plagued with errors, overuse, underuse, and misuse of medical services. And nowhere are these problems more acute in the [intensive care units]."
Many deaths occur during hospitalization, and quite a number suffer preventable adverse events. In addition, health care is expensive-inensive care alone accounts for 30 percent of acute hospital costs, which runs up to US$180 billion yearly. And yet intensive care in different US hospitals differ in terms of quality of care and patient safety.
In September last year the National Coalition on Health Care, together with the Institute for Healthcare Improvement, met in Washington, D.C. to launch a report on efforts throughout the United States to improve dramatically the quality of care by adopting "best practices." The National Coalition is America's largest and most broadly representative alliance that aims to improve the US health-care system, while the Institute for Healthcare Improvement is a nonprofit research and education organization that exhorts different health-care organizations to work with each other in improving the health-care system.
The report, titled Care in the ICU: Teaming Up to Improve Quality, looked at 11 different institutions that have introduced and implemented innovations in intensive care. If the standards instituted by these hospitals were to be used in nonrural American hospitals, the report pointed out, as many as 54,000 deaths would be prevented, and up to US$5.4 billion saved.
Putting the "Care" in Intensive Care
The different institutions profiled in the report are considered as among those who have "made major advances in how care is delivered in the ICU, including systems approaches to improving patient safety, bridging the use of technology with 'caring' components, environmental issues, and the use of telemedicine, among others." They were selected from among a pool of 200 health-care facilities that responded to a call made by the American Society of Critical Care Medicine for examples of approaches that led to the improvement of intensive care.
One of the institutions featured in the report is the Regional Intensive Care Nursery (RICN) of Pennsylvania's Memorial Medical Center, the flagship of the Conemaugh Health System. It serves as a referral base of critically ill premature and full-term babies.
Although most institutions boast of a patient-centered approach, the RICN goes one step further by also making the role of the patient's family central to healing. This entails an open visiting policy-parents are allowed to observe medical procedures, join in medical rounds, and act like parents to (and not just visitors of) their own child. They are even allowed to change their critically ill baby's diapers, or give the baby a bath. "We try to establish from the beginning that it's your baby, and we're here to help. The more we can empower the patients, the better for everybody," the report quoted an RICN nurse as saying.
Other innovations include a comprehensive parent safety protocol, with training on home and car safety and infant cardiopulmonary resuscitation. Even after patients are discharged, parents are encouraged to call staff members if they have questions.
Evidence-based Common Sense
Also, the developmental approach to care has long been the guiding principle of the RICN. Medical interventions and the monitoring of vital signs are "clustered" with feeding and diaper-changing times, so as not to give babies more time of uninterrupted sleep. Twins/triplets are allowed to "co-bed" with each other-a practice that stemmed from research that suggested a special capacity between twins to support each other postterm. Kangaroo care-the practice of allowing parents to hold their babies to their chest, to make skin-to-skin connection-is also encouraged.
The developmental approach "strives to enable preemies to mature in a more 'womb-like' environment, based on their gestational age and appropriate level of stimulation for their age." The RICN's innovations also protect infants from overly bright lights, noise, invasive medical procedures, and overstimulation of the senses-things that typify most ICUs.
Some of these "innovations" mostly stemmed from common sense. For instance, protection from bright lights came from the observation that perhaps, an infant can take only so much of being made to lie under harsh lights all the time. So they decided to occasionally turn down the lights, or put patches on the baby's eyes, to transform the unit "from a chaos to a calmer environment." They also soon developed protocols on infant massage, identifying the likes and dislikes of the infant, and positioning for comfort.
It turned out that the "commonsensical" changes they have made in the ICU were part of an emerging, evidence-based approach to infant care called "developmental care." Filipino neonatologist John Chan, medical director of the RICN, attended a conference on developmental care in 1996; the following year the RICN sent a multidisciplinary team to further study this new approach. Soon, they started putting a system to applying what they learned-and even sooner, they got incontrovertible proof that the approach works.
Now the outcomes of these changes compare favorably with US neonatal ICU averages-for instance, infants weighing under 1.5kg stay in ICUs on an average of 52 days; in RICN, the average is 39 days. Also, 78 percent of the infants discharged go home without any medical problem.
Fully Human
But the RICN staff insist that there is something about their approach that goes beyond quantitative measurement. It is ruled by a totally human, if not spiritual, dimension. All the methods of environmental enhancement, quality improvement, and other technical changes are only secondary to their approach, which is primarily about healing the patient. Said Chan: "We agree that we have to hone our skills so that we don't harm the patient. But now that we have not harmed the patient, have we truly healed that patient?"
He added: "Until we realize that what we are trying to improve is the care of a human being, we can be as technical as we want. [But] it will always fall short."
And this totally human approach to care can be seen in the frequent visits made by former patients and their families to the center. The report, which interviewed many of these patients and their families, noted their approval of the environment and the staff's competence. But more importantly, the families valued the "human face of caring and the personal relationships that developed" between the professionals and patients' parents. As one mother noted: "From the moment I arrived, they made me feel like I was the most important person in that room, and all of my questions and concerns were important. Every baby, they treat it as if it were their own."
But while parents feel the warmth of caring, so do the medical staff. Said Dr. Chan: "It works both ways. It is the lives we have touched and those lives that have touched ours, in a systematic rekindling of the spirit."
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