EP282 Revising the RCA; Streamlining Root- Cause Analyses for bacteraemias on ITU

Published Date: 13th August 2019

Publication Authors: Saunders R, Clark S, Stubbington Y, Tridente A

Abstract

Sepsis is a leading cause of mortality within the Intensive care environment.1 Over the last 3 decades, the recognition of sepsis has greatly improved and blood cultures form an integral part of both diagnosis and management. At the authors’ institution, any detected bacteraemia is examined through a process of Root Cause Analysis (RCA) to ensure that, where necessary, lessons are learnt and any improvement to patient care is implemented.

The current RCA process is extremely cumbersome, with potential for streamlining for specific pathogens, particularly Gram negatives. A large proportion of bacteraemias within our institution are due to Gram negative organisms and often do not represent Healthcare Associated Infections. We aimed to create a separate process tailored to succinctly evaluate the cause of Gram negative bacteraemias, without compromising on the quality of the process.

In collaboration with the infection control and medical microbiology teams, while satisfying the mandatory requirements of the Department of Health, we redesigned the RCA process for ITU bacteraemias. We identified two different pathways; one dedicated to those bacteraemias requiring full investigation (usually MRSA, MSSA, CDI and VRE), and a second, more succinct, process for the initial screening of the Gram negative and other low-risk bacteraemias.

Saunders, R; Clark, S; Stubbington Y; Tridente, A. (2019). EP282 Revising the RCA; Streamlining Root- Cause Analyses for bacteraemias on ITU . Journal of the Intensive Care Society. 20 (Suppl 2), 212

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