1. Sentinel Events: Managing the Process When Healthcare- Associated Infection is Involved Ruth Carrico PhD RN CIC Assistant Professor, School of Public Health and Information Sciences. University of Louisville

2. Objectives Demonstrate a process for evaluating death related to healthcare associated infection as a possible sentinel event Describe a process that differentiates between death with infection and death due to infection Discuss use of tools for the root cause analysis process including fishbone diagrams Review the processes using case scenarios

3. Sentinel Event An unexpected occurrence that results in death or serious physical or psychological injury to a patient Death, permanent injury or loss of function as a result of a nosocomial infection Anticipation of death usually determined at time of admission A big question involves death with infection versus death due to infection

4. Sentinel Event Challenges Identifying patients whose death can be attributed to an infection acquired in a given healthcare facility Identifying factors that promoted the acquisition of that infection Identifying critical stop points in the process Correcting gaps in practice

5. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

6. No Unanticipated death sentinel event Yes Anticipated death No sentinel event Medical condition likely to result in death Medical condition likely to result in death No Yes Death due to HAI Death with HAI Day of hospitalizationDay of diagnosis with HAI

7. Case Scenarios During the month of April, there were 10 deaths in the hospital 2- died in the Emergency Department due to MVA, other trauma, or overdose 3- died in the hospital within 48 hours of admission (no prior admission to the hospital) and their deaths were anticipated 5- died during hospitalization >48 hours after admission 10 total patients

8. Case Scenarios 10 deaths 2 not evaluated due to death in ED unrelated to any prior hospitalization or event 3 not evaluated due to death within 48 hours of admission and no prior hospitalization. Deaths were anticipated due to their medical conditions 5 left for review

9. Case Scenarios 5 deaths all occurring >48 hours after admission 2 without evidence of healthcare-associated infection (HAI) 3 left for review

10. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

11. Step 1: Identification of all deaths occurring during hospitalization Sources include Death reports, summaries, occurrence reports, verbal notifications, physician/hospital committees (e.g., mortality and morbidity conferences) Line list developed

12. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

13. Step 2: Identification of anticipated deaths from that initial list Primarily based on condition at time of hospitalization (but this is not absolute) If at admission, death was anticipated (due to current illness/injury) it is not considered to be a sentinel event If at admission, death was not anticipated it IS considered to be a sentinel event Move toward root cause analysis process

14. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

15. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

16. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

17. Step 3: Sentinel event associated with HAI We have a sentinel event but is HAI involved? Surveillance uses standard case definitions Did patient have an HAI at the time of death or even within the previous 2 weeks prior to death If no evidence of HAI, the evaluation of the sentinel event continues through the process without infection control leadership

18. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

19. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

20. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

21. Step 4: Sentinel event related to HAI We have a sentinel event and there was an HAI. Now we determine if death was due to HAI or with HAI Most difficult part of the process Full review by collaborative team If condition of patient at the time he/she developed HAI was likely to produce death within 3-6 months, death with an HAI If condition not likely to produce death, death due to HAI

22. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

23. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

24. Step 5: Root cause analysis according to site of HAI Sentinel event, death anticipated, patient death due to HAI Multidisciplinary team Evaluate adherence with best practices

25. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

26. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

27. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

28. Case 1 80 year old female admitted following massive stroke Ventilator in ICU 10 days post stroke she develops fever, leukocytosis and new pulmonary infiltrate Pseudomonas aeruginosa Treated for 10 days but expired following cardiac arrest

29. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

30. Case 2 50 year old male admitted due to uncontrolled diabetes. After hospitalization, he develops GI bleed, hypotension and shock. On mechanical ventilation and develops Ventilator Associated Pneumonia (P. aeruginosa). Died 24 hours after VAP diagnosis and start of antibiotics.

31. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

32. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

33. Case 3 36 year old male hospitalized for bone marrow transplantation for leukemia treatment Day 40 of hospitalization he is ready for discharge but spike temperature of 102º F New pulmonary infiltrate, Acinetobacter baumannii identified Expires 5 days later from severe sepsis

34. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

35. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

37. Case 4 67 year old male admitted to SICU following MVA with severe orthopedic trauma 18 days into hospitalization, develops positive blood cultures for MRSA Treated but cultures persistently positive Vegetation on mitral valve leads to MVR 4 days post op, patient suffers an MI and dies

38. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

40. Case 5 67 year old male admitted to SICU following MVA with severe orthopedic trauma On admission, MRSA surveillance culture + 18 days into hospitalization, develops positive blood cultures for MRSA Treated but cultures persistently positive Vegetation on mitral valve leads to MVR 4 days post op, patient suffers an MI and dies

41. Death after hospitalization Step 1 Stop Death associated with HAI? Sentinel event team without HAI main focus Sentinel Event HAI Root cause analysis Step 2 Step 3 Step 4 Step 5 Death anticipated at time of hospitalization Death not anticipated at time of hospitalization Death not associated with HAI? Death not anticipated at the time of HAI diagnosis Death anticipated at the time of HAI diagnosis Death due to HAI?Death with HAI? Determine primary site of HAI Convene multidisciplinary team

43. Sentinel Event Challenges Biggest problem is knowing which patient(s) to evaluate in terms of sentinel event root cause analysis Challenge is determining death with infection or death due to infection Some element of judgment required Controversial! What about the bigger picture?

44. Additional Tools Infection prevention and control requires a structured approach Approach must be dynamic and meet the changing needs of the organization, patients, and staff Dynamic approach requires continuous evaluation of which tools help achieve the goals of prevention through ongoing process improvement

45. Contact Me Ruth Carrico ruth.carrico@louisville.edu