The Quality-Cost Connection: Reduce infections with root-cause analysis
Responding to infection-related sentinel events
By Patrice Spath,
Brown-Spath & Associates
Forest Grove, OR
Infection control practitioners play a vital role in reducing nosocomial infections. Collecting and analyzing surveillance data can identify patterns of occurrence so that steps can be taken to eliminate or reduce the factors that contribute to nosocomial infections. The Joint Commission on Accreditation of Healthcare Organization’s recent expansion of the sentinel event policy to include nosocomial infections could represent a change in what infection control practitioners view as their traditional role. In addition to discovering the root cause of undesirable infection patterns, practitioners now may be called upon to investigate an unexpected death or patient injury.
A knee-jerk response to a possible infection-related sentinel event would be to explain how difficult it is to establish a clear and concise relationship between a patient’s infection and the adverse outcome in question. Often patients who develop nosocomial infections have a host of other medical problems and contributing factors. For example, sepsis from gram-positive pneumonia is a common cause of death among patients hospitalized with severe burns. Is it possible for practitioners to determine if the severely burned patient would have recovered if not for the sepsis? The Joint Commission’s revised sentinel event definition suggests that this question must be answered to determine if a root-cause analysis (RCA) is required.
The difficulty in determining whether an infection-related event is, in fact, a sentinel event may be related to our fundamental reluctance to place blame. If the answer is "yes" then it appears we are admitting that the patient care experience was flawed in some way. But nosocomial infections are common in patients with compromised immune systems (such as the severely burned patient).
Thus it is conceivable to answer "no" and blame the patient’s physical condition for the death. The danger in answering "no" is that the singular event — sepsis due to pneumonia — might be the symptom of a larger system problem that contributes to the development of various types of nosocomial infections in other patients. The infection surveillance data may not suggest the presence of a system problem; nonetheless, it still could be present. The sentinel event RCA can uncover problems requiring corrective actions. A significant adverse event involving an infection represents a "pattern of one" that deserves more in-depth investigation.
Consider the following situation: A 72-year old patient with severe congestive heart failure is admitted to the hospital with a stroke. On the fourth day, the patient develops aspiration pneumonia and is started on IV antibiotics. On the sixth hospital day, the patient has a sudden cardiac arrest and expires. The patient’s attending physician documents the cause of death as cerebrovascular accident and congestive heart failure. Pneumonia is listed as a secondary diagnosis but not labeled as one of the causes of the patient’s death.
Does this mean that the patient’s death should not be treated as a sentinel event?
It really doesn’t matter whether the infection is a known complication or whether it was preventable. Does the event meet the Joint Commission’s definition of a sentinel event? If this question is posed to physicians and other caregivers, you are likely to hear opposing viewpoints coupled with sound rationale supporting the opinions.
It may be impossible to get caregivers to agree on whether a patient death was directly caused by a nosocomial infection. Rather than seek an answer to the sentinel event question, it’s more productive to explore the great question — that is, could further investigation of the care this patient received ultimately lead to a lower rate of aspiration pneumonia cases?
An RCA of the event could uncover any number of system of care problems. For example:
- Are staff members knowledgeable about patient populations at risk and early signs and symptoms indicating dysphagia?
- Are patients at risk of swallowing problems observed for and or questioned about the following factors, for example:
- food remaining on tongue after swallowing;
- pocketing of food on side of mouth;
- excessive drooling;
- coughing or choking while eating or drinking;
- gurgly-sounding voice after eating or drinking.
- Is an individualized care plan developed for patients at risk of swallowing problems that addresses:
- patient’s specific problem or need (i.e., pocketing food, history of aspiration);
- realistic and measurable goals or expected behaviors (i.e., patient will protect airway during swallowing);
- specific actions/interventions to solve the problems/satisfy needs (i.e., sit upright when eating, head slightly flexed forward; when recumbent, change position at least every two hours).
Choosing cases for RCA
Selecting cases for an RCA is not easy, especially if people don’t understand the purpose and value of an in-depth investigation. In the box on below are some initial screening questions that can be used by quality managers or infection control practitioners to determine which situations should be brought to the attention of the patient safety committee or other oversight group responsible for initiating an RCA.
Cases referred to this multidisciplinary committee then can be assessed in greater depth to determine if the nosocomial infection was a significant causative factor in the patient’s death and if an RCA would yield valuable information.
Questions that could be addressed by this committee include:
- Was the infection related to any deficiencies in the systems of care?
- Was the infection a consequence of a medical error or mistake?
- Was the infection an unfortunate but unavoidable complication based on the severity of illness of the patient and other underlying host factors?
Practitioners with epidemiological training have unique skills in the areas of investigation and implementation of interventions that can enhance patient safety improvement efforts.
Hospital infection control should not be limited to collection and analysis of aggregate data. RCAs of single infectious events can uncover factors inherent in the systems or processes of care that need to be corrected. The ultimate goal of the analysis is to help the organization prevent or reduce the likelihood of similar nosocomial infections in the future.