Root Cause Analysis Dr Sinéad O Donnell SpR Clinical Microbiology Sakichi Toyoda (1867-1930) 5 ways 1958 Healthcare Associated Infections & Antimicrobial Resistance 1986 Root Cause Analysis (RCA) Root Cause Analysis is an evidenced based, structured investigation process which utilises tools and techniques to identify the true causes of an incident or problem Root cause if removed prevents event recurring Causal factor - removal benefits outcome but does not prevent recurrence with certainty 1
https://www.thinkreliability.com RCA = System Analysis Investigations Focus on system-level vulnerabilities as opposed to individual performance RCA Goal What happened? Why did it happen? What can be done to prevent it from happening again? 2
Staphylococcus aureus blood stream infection (BSI) Root cause analysis template Medical/Surgical team to complete: Addressograph label Intravascular device (IVD) associated with BSI PVC CVC Portacath Site inserted (hand, ACF etc.) Date inserted Other None Identified Facility inserted If GUH inserted in E/D ICU Theatre Radiology Ward Insertion bundle completed? More than 1 attempt to cannulate? Patient provided with education of good hand hygiene practice? Information leaflet on IV line provided to patient post insertion? PICC line Permcath Documentation of IV maintenance bundle complete? Responsible consultant Date of admission TUH Other hospital Unknown Yes No N/A Yes No N/A Yes No N/A Yes No N/A Yes No N/A Patient informed of device related infection? Verbally Documented in notes No indication patient has been informed Patient Risk Factors (Factors that relate to the patient that may have contributed to the infection tick all that apply) Immunosuppression Hospital admission in last 30 days Recent trauma/surgery/instrumentation Documentation of appropriate prophylaxis given? Yes No N/A Poor IV access Exfoliative skin condition Renal dialysis patients Suitable for AV fistula Listed for AV fistula Date listed Diabetes Other Yes Yes No No Details where necessary Ward IVD required for: (circle as appropriate) Fluids Antimicrobials Drugs (non antimicrobial) Parenteral nutrition Other IVD removed? Yes Date removed Number of days in situ No During this admission how many times was the IVD accessed? (prior to positive blood culture being take) once 2-4 times 5 times Comments Please document any other issues at time of line insertion or maintenance not addressed RCA Focuses on prevention, not blame or punishment To err is Human To cover up is unforgivable To fail to learn is inexcusable Sir Liam Donaldson (cornerstone: no one comes to work to make a mistake or hurt someone) RCA process Adverse event identified Outcomes and action plan Convene a multidisciplinary team Specialist in area of interest Risk management Clinical teams Senior Management Feedback to Institution National level? International level Predefined timeframe Implement recommendations Collect and analyse data Hospital records Staff interviews Workforce rotas HCAI Health Care Associated Infections (HCAI) 5% of hospitalised patients 1 Statistics are collated by the HSE's specialist agency for infectious diseases, the Health Protection Surveillance Centre (HPSC) HCAI s are reported to the Business intelligence unit (BIU) rates used in the National Service plan 1 Point Prevalence Survey of Hospital Acquired Infections & Antimicrobial Use in European Acute Care Hospitals: May 2012 3
HCAI KPI s Key Performance Indicator (KPI) is a measurable indicator that demonstrates progress towards a specific target Staphylococcus aureus Normal body flora Commensal and a opportunistic pathogen Spectrum of infections Skin infections Abscesses Respiratory tract infections Blood stream infections Septic arthritis Infective endocarditis Osteomyelitis Meningitis Medical implant infections S. aureus a well armed pathogen Virulence factors Toxins Enzymes Biofilm formation Antibiotic resistance www.rewire.news 4
S. aureus BSI 34% increase in incidence in Europe (2001-2009) Increased use of prosthetic materials 30 day all cause mortality rate is 17-39% Reduced survival Older age groups Multiple co-morbid conditions Unresolved focus of infection Prolonged bacteraemia Epidemiology and outcome of Staphylococcus aureus bloodstream infection and sepsis in a Norwegian county 1996 2011: an observational study. Paulsen et. al. BMC Infectious Disease 2015 Rate of hospital aquired S. aureus BSI per 10,000 bed days National HA-SABSI rates Number of isolates 1400 1200 1000 800 600 400 200 0 0.30 0.25 0.20 0.15 0.10 0.05 0.00 Rate per 1,000 bed days used Year MRSA MSSA MRSA rate MSSA rate HPSC data 5
Case Blood cultures S. aureus in both bottles Initial assessment Admitted overnight Fevers Erythema at previous cannulation site Discharged 12 hours earlier Previous admission 9 days ago Initial treatment and investigation advised? Intravenous catheter related S. aureus BSI RCA indicated Eoinkelleher.com angelabrook.com Femfusionfitness.com 6
Staphylococcus aureus detected in blood culture Microbiology phone team ascertain if Significant Hospital or community acquired Line related - Advise on treatment and further investigation - Determine if Root Cause Analysis (RCA) indicated RCA not indicated No further action If RCA indicated if hospital acquired line related Convene MDT team Microbiology/IPCN Complete relevant sections of RCA form Partially completed form to be placed in patient chart Notify management of need for RCA Report as part of Business Intelligence Unit (BIU) data Clinical team Inform patient of blood stream infection Complete clinical section of RCA form Management to convene an RCA meeting (2-4 weeks) to include representative from Management Risk management Clinical team Microbiology +/- IPC Facilitate reporting RCA outcomes to Clinical team, relevant wards & directorate Incident report to be filed. Implement recommendations 7
Case 80 year old gentleman Background Type 2 diabetes Bio-prosthetic aortic valve replacement 2013 Atrial fibrillation Congestive cardiac failure (NYHA class 2-3) Hypertension Severe pulmonary hypertension Left ventricular hypertension Lived independently 8
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RCA outcomes What happened? S. aureus blood stream infection Why did it happen? Intravenous cannula in place for 9 days Not recognised, documented or acted upon by» Nursing staff» Medical staff» Patient What can be done to prevent it from happening again? Education all levels including patient Rationalise and simplify documentation Review audit process Consider an IVC team Treatment Culture negative after 6 days ECHO TTE no vegetations TOE unable to tolerate Treatment presumptive infective endocarditis Prolonged bacteraemia Prosthetic valve in situ 4-6 weeks of treatment from first negative blood culture Outcome RIP (3 weeks into treatment) CCF exacerbation Cardiac arrhythmia secondary to hypokalaemia Case discussed with the coroner Not for postmortem? Did BSI contribute to mortality Increased morbidity Inpatient for almost 6 weeks Deranged liver function due to antibiotics Increasing confusion 11
Take Home Messages RCA Focus on prevention not blame Tools to standardise and simplify data collection Learning from analysis outcomes is essential Acknowledgements Colleagues in Microbiology Departments GUH TUH HPSC HCAI/AMR Team To err is Human To cover up is unforgivable To fail to learn is inexcusable Sir Liam Donaldson 12