ETC 57 - Using Root Cause Analysis (RCA) Framework to Assess and Improve Bundle Compliance

Background: A root cause analysis (RCA) aims to identify any breakdowns in processes and systems that contributed to an adverse event. Healthcare-associated infections (HAIs) are a significant source of morbidity/mortality in the United States. A bundle is a set of evidenced based practices that when performed collectively and reliably improve patient outcomes. We introduced a process called Swarm at our facility in 2019. SWARMS are mini-RCAs. Using data gathered from this process, we will determine if we are achieving bundle compliance.

Methods: Swarms are a targeted fact-finding practice used by Infection Prevention for mitigating infection prevention risks. When IP identifies a HAI, a timely Swarm is scheduled. Presence of leadership and bedside staff is facilitated. At the Swarm we focus on the identified HAI and circumstances surrounding it. Bundle compliance is examined. For each Swarm, data is collected for each bundle element. After the Swarm, education occurs regarding teaching points and opportunities identified. Systemic issues are escalated. In order to determine bundle compliance, we compiled Swarm data and compared rates per bundle element.

Results: There were 163 central line bloodstream infection (CLABSI) and 174 catheter-associated urinary tract infections (CAUTI) Swarms conducted from October 2021 through September 2023. Over this time period, CLABSI Swarms results increased by 33% for blood culture checklist usage, 27% for daily chlorhexidine bathing, and 29% for daily bed linens change while decreased by 16% for disinfectant caps usage. CAUTI Swarms results increased by 29% for urinalysis could be done prior to urine culture while there was no significant change for perineal care 1 times a day.

Conclusions: Our Swarm data demonstrated variability regarding bundle compliance. This data demonstrates a need for bundle compliance improvement and education. Using our Swarm framework, we plan to continue to identify and address issues, obtaining optimal compliance in the future.