At large academic medical centers—like UCLA Health, where we work—infection preventionists, or IPs for short, keep patients and healthcare workers from catching and spreading communicable diseases. We come from a variety of backgrounds. Some of us are nurses, some are lab technicians, others have training in public health. We understand how infections spread, and how different infections spread, and how health care workers can keep patients (and themselves) safe when there is no easy cure for a contagious and dangerous illness.

Our role is often hidden. We don’t treat patients, but we touch many aspects of hospital life.

In normal times, our days involve preventing infections patients could get from external devices such as urinary catheters or central lines. We enforce protocols for dealing with viruses like the flu, or stomach bugs. We function as the “hand hygiene police,” constantly reminding our colleagues on the medical units to wash their hands, to wash their hands more, and to remember, later on, to wash their hands again. We inspect patient rooms for hazards, and conduct trainings for staff. We answer questions, and prioritize concerns.

No two days are the same, but the goal never changes: make the healthcare system safer for all. It is the driving force behind the work we do every day—especially now, in the era of COVID-19. This virus has consumed our daily lives at work and at home, focusing our attention on a single, vexing subject.

Before this year, none of us had ever experienced a major pandemic, and while we had prepared for various exotic contagions like SARS or Ebola, we’d never confronted patients with those illnesses. We always realized it might happen one day, and the idea of it was kind of exciting, since we had trained for so long in preparation. But we had no idea how big this outbreak was going to become, and never really anticipated its devastating outcome.

In February 2020, we began receiving many pages, late at night, concerning patients with travel history and respiratory symptoms. Historically, many of these people would have been thought to have the flu, but now there was an added potential diagnosis: Could they have the novel coronavirus? The pages triggered a frenzy of activity. First, a multidisciplinary team, comprised of experts in emergency preparedness, infection prevention, nursing, physicians, hospital leadership, and operations, would hop onto a conference call to determine if the patient met the criteria for COVID-19 testing. Were they displaying symptoms of respiratory disease due to unknown cause, such as cough, fever, difficulty breathing, and shortness of breath? Had they traveled to an area with known transmission—at that time, China, Iran, Italy, South Korea, or Japan?

More and more patients qualified for testing as we reached the middle of March. And as soon as we deemed someone a person under investigation for COVID-19, the on-call team would head into the hospital. For IPs, this meant consulting a fat binder, prepared by the emerging infectious diseases team, that contained all the official COVID precautions and protocols: what protective clothing to wear, what disinfectants to use, and so on.

We conducted on-the-spot trainings to prepare the staff on the most recent guidance, collecting personal protective equipment (PPE)—N95 masks, gowns, gloves, and face shields—and showing doctors, nurses, and respiratory therapists how to take these items on and off, step by meticulous step. If a nurse was going to take a nasopharyngeal specimen, we advised them to double bag the sample and wipe the outer bag with a bleach wipe. As we helped a doctor put on the appropriate PPE, we reminded them of crucial precautions such as sanitizing their gloves before removing them.

As the care team got to work, we stood watch outside patient rooms, peeking through interior windows, ready to answer questions or provide tips. No one really understood much about COVID then, so IPs had to exercise extreme caution. We did not know how COVID spread, so the PPE we gave health workers was extensive (including extended-cuff, doubled gloves) and completely disposable (today we wear reusable gowns that we wash between uses). We instructed nurses to wipe outer biohazard bags with bleach (now that we know this refuse isn’t dangerous, we follow standard disposal processes). When staff rolled a patient in a gurney down a hallway, environmental services workers followed alongside with a Swiffer-style mop, decontaminating the path the bed traveled over the floor.

Treatment teams started utilizing cell phones or white boards to speak to one another, flashing written messages instead of entering and leaving a patient’s room and wasting precious, disposable PPE. Stationed outside of a room in one of these moments, we were dying to know what a nurse was scribbling on her white board. Often the message was something like, “Do I wipe the specimen bag with a bleach wipe or alcohol wipe?” We’d write, “Bleach wipe.” The nurse would give a thumbs up, and continue with her work.

To minimize risk and PPE use, we did a lot to try to prevent people from walking in and out of patient rooms if they didn’t absolutely have to. Visitors, of course, were not allowed at all, but we tried to keep staff away as well when it was feasible. This meant teaching doctors, nurses, and others new ways to do their work. IPs coordinated with hospital supply workers to make sure rooms remained stocked with ample supplies: receptables for removing PPE, wipes for cleaning surfaces, gloves for patient care, hand sanitizer, biohazard bags for specimens. Usually such items would have been kept in a central supply room, with care workers going in and out to grab what they needed whenever they needed it.

We worked with the facilities team to minimize potential maintenance issues and repairs. We made sure they aggressively monitored sinks, doors, patient care equipment, and ventilation systems. Normally, nutrition staff delivered meals directly to patients. Early on in our pandemic response, we instructed them to hand trays of food to nurses, who would then take the meal into the room. We also worked to remind nurses to help disinfect highly used surfaces when they were in a patient room, since the environmental services team couldn’t enter until discharge.

Anyone who did need to enter a potential COVID-19 patient’s room had to add their name to the Patient Room Log, which listed employee ID numbers, names, times in/out of the room, any safety concerns, and their preferred contact information. If this patient’s test results came back positive, every person who had been in the room would be monitored for 14 days.

In March and April, as we realized that COVID-19 was not going away, we expanded our education efforts to the entire hospital, creating new policies, conducting large trainings on PPE guidance, and walking through units to answer any questions that staff may have had.

We hit a stride that never really slowed. Every day, you would come to work with a blank slate approach. Things changed so often that guidelines provided one day might be radically modified the next, based on new information. Every month, you would think things were going to get better—but they never did.

The worst-case scenario we had planned for in April finally hit us over the holidays—cases in the Los Angeles area exploded. We went back to our binders to remember all of the systemwide protocols that the hospital had laid out—adjustments like setting up intensive care units in surgical areas, housing adults on pediatric floors, and “cohorting” more than one COVID patient in a room.

Inside and outside the healthcare setting, COVID-19 became all anyone talked about. We are all fortunate to have received the first dose of the vaccine. There is light at the end of the tunnel.

This work is exhausting, but we’re thrilled to be doing it. It’s what we trained for, and it’s helping keep people safe.

The post The Hidden Health Care Workers Keeping Hospitals Safe appeared first on Zócalo Public Square.

I wish California children were doing as well as California children’s hospitals.

Even as the Golden State has maintained the nation’s highest child poverty rate, underfunded its schools, and made housing prohibitively expensive for families, California has developed a system of children’s hospitals that seems to occupy a parallel universe in which kids’ needs actually come first.

California has 13 children’s hospitals—eight private not-for-profits (in San Diego, Orange, Los Angeles, Long Beach, Loma Linda, Oakland, Palo Alto, and Madera) and five within University of California medical centers. Collectively, they receive more than two million visits from injured, disabled, and sick children annually.

In these children’s hospitals, you can see California’s ability to be kind, egalitarian, and generous to a fault—and also how our budget politics and piecemeal policymaking frustrate our aspirations for children.

Children’s hospitals offer a rare place where California’s rich and poor mix; the surgeon who operated on TV comedian Jimmy Kimmel’s son also performs surgery on kids on Medi-Cal, California’s version of Medicaid. These hospitals treat everyone; nearly two-thirds of their patients are eligible for Medi-Cal, compared to about one-third of patients in community hospitals. And virtually everyone is covered, since all California children, even undocumented kids, are insured because of Obamacare and state law.

Children’s hospitals thrive on this mandate: While they lose money on Medi-Cal patients, they make up for it by being aggressive with commercial insurers who cover a minority of their patients, through other government programs, and through powerful fundraising operations for private donations.

And, like other interest groups, children’s hospitals have won taxpayer dollars through the ballot. This November, California voters are all but certain to approve Prop 4, the third general obligation bond to support children’s hospitals in the past 14 years. Through this and other support, these hospitals have become juggernauts, with sprawling medical centers, top pediatric research and training operations, suburban satellites, and well-paid executives.

California’s children’s hospitals have come a long way from their mostly humble origins. Children’s Hospital Los Angeles started in 1902 as a small Chinatown building with 14 patients and one doctor who made house calls on horseback. UCSF Benioff Children’s Hospital Oakland was founded as a hospital for babies in 1912. Rady Children’s Hospital in San Diego and the predecessor hospital of Lucile Packard Children’s Hospital at Stanford both began their lives as convalescent facilities for children crippled by chronic illnesses like polio.

The greater scale of such facilities today reflects changes in the state’s health care and demographics. Even though the number of children in California has stagnated, demand has grown for specialized care for pediatrics, and visits to the hospitals have soared. Technological advances have created new avenues for care, especially for children with rare or difficult-to-treat diseases.

A McKinsey study of children’s hospitals found greater scale—which involves building regional pediatric networks with outlying clinics and partnerships with other institutions—is essential if such institutions are to survive and grow in an era of market consolidation and attempts to cut costs. Packard Children’s Hospital at Stanford has been particularly aggressive in expanding its network, and children’s hospitals have supported federal legislation that would allow them to expand their networks across state lines.

Because the populations of California and America are rapidly aging, most traditional hospitals are handling older, Medicare patients. Since Medicare reimburses at higher rates than Medicaid (especially in California, which has some of the country’s lowest reimbursement rates), it’s inefficient for hospitals to accommodate the special needs of children patients, who are overwhelmingly on Medicaid.

The result: California kids are increasingly referred to these specialized children’s hospitals. As a Southern California father of three, I’ve been redirected to Children’s Hospital Los Angeles by my pediatrician, by local after-hours clinics, and by the Huntington Hospital emergency room for my kids’ minor maladies—a broken finger, a small piece of a plastic toy stuck up a nose, a painless bit of swelling in the groin. A generation ago, my two siblings and I never saw the inside of a children’s hospital.

These hospitals are not merely comfortable; they are among the nicest buildings you’ll ever encounter, period. I’ve found the children’s hospitals in both L.A. and Orange counties to be carefully designed for juvenile happiness. My only problem with one visit to a Children’s Hospital Los Angeles outpatient center in Arcadia was tearing my sons away from the most robust entertainment system they had ever encountered.

“The hospital is somewhere you feel safe and have support,” says Max Page, a 13-year-old actor (known best for a Super Bowl car commercial in which he played Darth Vader), who has spent his life in and out of children’s hospitals in Southern California for heart procedures. His mother, Jennifer, told me that Children’s Hospital Los Angeles is reliably “colorful, loud, and fun,” with good food and a farmers market in the hospital. Such additional comfort services are funded by private donations, hospitals officials note.

These comforts also reflect a growing marketplace: As children’s hospitals grow, parents now have choices and can shop among them; competition also comes from lower-cost retail clinics and telehealth services. That’s healthy. So is new pressure for children’s hospitals to produce more data that allows for better evaluation of their quality.

While the hospitals are nice, they aren’t heavens. They face challenges —in the slow growth of the child population, the pressure on Medicaid funding by congressional Republicans (avoid mentioning the name of House Speaker Paul Ryan, who wants to turn Medicaid into block grants, inside any California children’s hospital), and health insurers’ efforts to control costs via narrower provider networks and the tiering of health insurance plans. And as children’s hospitals grow in importance, they will likely face more scrutiny of their operations, their charitable care, and their results in the future.

You probably won’t hear much of this context in the run-up to November voting on Prop 4, the $1.5 billion bond for children’s hospitals. But the measure should spur debate. Should we help fund the children’s hospitals’ capital needs through general obligation bonds? Those bonds must be paid back from the general fund—the repayment for $1.5 billion in bonds is estimated at $2.9 billion over 35 years—which cuts into funds that would go to other programs serving children.

I, for one, would prefer a dedicated stream of tax revenues to avoid the debt service costs, or perhaps even a payment from rainy day fund revenues. But securing either might be politically impossible. And relying on our volatile state budget is dicey. In fact, the children’s hospitals turned to bond measures after a general fund program for hospital infrastructure was eliminated during the 1990s.

And to the children’s hospitals’ credit, spending on previous bonds has been responsible. The new Prop 4 bonds is small, especially compared to November’s $8.9 billion Prop 3 bond for water, which comes on top of another $4 billion water bond passed by voters in June.

So yes, one could ask whether children’s hospitals offer children too much. But the better question is why other programs for California children offer so little compared to our children’s hospitals.

The post Why Are California’s Children’s Hospitals So Much Nicer Than Other Services for Kids? appeared first on Zócalo Public Square.

Surprisingly, these lovely images were taken on the grounds of a hospital—a place not often associated with beauty or peace.

“It’s much more than 30 acres of buildings,” says Lerner of Cedars-Sinai Medical Center, where he has snapped more than 4,000 photos in the last seven years. “It’s a big old hospital with a lot of wonderful things in it.”

Those photos have now been turned into not one but two exhibitions. “Roger Lerner: Form in Light” is currently on view at the Couturier Gallery on La Brea Avenue. And you can see a collection of Lerner’s black-and-white photos of Cedars-Sinai at the Sulkin/Secant Gallery at Bergamot Station in Santa Monica.

Lerner, an endocrinologist and internal medicine doctor, first became familiar with the Cedars-Sinai campus in the late ’70s while working on a research grant. Since then, he’s spent countless hours at the hospital in the intensive care unit with post-op patients—“day and night,” and in every season.

In 2009, he first used an iPhone to take a photo of the bridge connecting the hospital’s north tower to the ICU. From that day forward, he’s been taking photos with his phone, with the goal of capturing how the interplay of light changes the appearance of a structure.

For example, in one photo the light seems to turn the concrete ICU building from grey to purple. “I was walking out of the building, turned, and looked at the sky. I thought, there is a fabulous photo. It was begging to be taken,” he says.

Lerner is currently in private practice, but has an office about 10 blocks from Cedars-Sinai. He often swings by the complex in the morning or on his lunch break to take photos.

None of the images are edited or cropped. “I want people to see what I saw—not an idealized version of what I saw,” he says.

Last year, he also wanted people who visited the hospital to see “what they’re walking by and not looking at.” At first, he had hoped to create a slideshow for projection on screens throughout the hospital—but he quickly learned the hospital only accepted work from established artists.

Instead, he worked with his longtime friend Darrel Couturier, the owner of Couturier Gallery, to whittle down his photographs to 30 color and 30 black-and-white prints. These are the photos now hanging on the walls of the two L.A. galleries.

Lerner continues to fill the moments of his workday not devoted to his patients with photography. “Most of us are in a hurry; we don’t stop to smell the roses, so to speak,” he says. “We don’t stop to look at things that are architecturally interesting.”

 
“Roger Lerner: Form in Light” is on view through August 22, 2015, at Couturier Gallery.

An exhibition of Roger Lerner’s black-and-white photos, “…Light, Interrupted” opened on August 15, 2015 at Sulkin/Secant Gallery.

The post The Steel, Glass, and Shadows of L.A.’s Cedar-Sinai appeared first on Zócalo Public Square.

enter: bodies
faces slack
on back
possessions bagged
click
case: male, biker, legs torn, tattoos
paled, muscles gleaming
click
strip body
click
case: female, frail, daisy-print skirt, wounds
beneath
click
cleave skull
snip brain
click
case: male, 23, 36 pills,
blue ball-point etched in thigh: I just can’t
click
incise trunk—
shoulders chest pubic bone—
saw ribs
click
case: male, child, high cheekbones,
27 bullet holes, bystander
click
snip heart
snip lung
snip stomach
snip gut
avoid food
click
case: plane crash, male torso, male foot,
female torso, baby’s arm and golden
bracelet, female thigh and ring finger,
male torso, baby’s torso?
click
wrap up
bag up
sew up
bag up
click.

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