Case Study: When the Numbers are Half the Story

Before reviewing the case below, you will be presented with a structured guide designed to help you work through the TRACE Framework. The purpose of this exercise is to strengthen your ability to assess infection events using a systems-based approach, particularly when surface-level indicators suggest strong performance but outcomes do not align. After reading the case in full, download the TRACE template and use the Reviewer’s Guide to complete each section independently. This practice is intended to help you identify gaps between documentation and real-world practice, reconstruct timelines from dispersed clues, and evaluate risk across clinical and operational domains.

Part 1

The Case

A 24-bed medical-surgical intensive care unit has reported three central line-associated bloodstream infections over a six-week period, all in patients with similar lengths of stay but different admitting diagnoses. During the same period, unit dashboards displayed near-perfect compliance with central line insertion bundles, with audits consistently showing documentation completion above 98 percent. Hand hygiene observations submitted for quality reporting also remained above target for the quarter, although most observations were scheduled in advance by peer reviewers.

A patient in bed 12 had a central line inserted during a late evening admission surge when two additional patients arrived within 40 minutes, requiring rapid room turnover. The insertion checklist was completed and signed in the electronic record shortly after midnight, following a period where staffing was adjusted due to unexpected sick calls earlier in the day. A traveler nurse floated into the unit that week and was assigned to assist with line maintenance tasks, although she had limited orientation to local supply storage locations.

Chlorhexidine bathing documentation appeared consistent across all patients with central lines, though bedside conversations occasionally reflected competing priorities such as respiratory therapy treatments and urgent medication administration. One patient family requested fewer “interruptions for cleaning,” which was noted in progress notes and led to less frequent bedside engagement during evening hours.

Environmental services reported routine daily cleaning of high-touch surfaces, though turnover delays were occasionally documented during peak census days when two discharge orders were processed simultaneously before noon. A supply reorder delay resulted in intermittent unavailability of a specific catheter stabilization device, leading staff to use an alternative securement method that was not consistently documented in the procedure record.

In another case, a central line dressing change was delayed until after shift change due to an ongoing rapid response event in a neighboring room. The incoming nurse documented the dressing as intact and clean during morning rounds, though the previous shift had noted mild dampness under the dressing during a brief assessment that was not escalated.

Unit leadership highlighted strong adherence to protocols during weekly safety huddles, referencing audit data and reinforcing that no procedural deviations were identified in recent reviews. At the same time, informal staff discussions in the break room referenced increasing workload, frequent interruptions during medication preparation, and challenges maintaining focus during high-acuity admissions clustered late in shifts.

One CLABSI case involved a patient with a new fever developing after transfer from radiology, where a portable monitor had been used for transport during a period of equipment shortages. A concurrent investigation briefly considered a potential water source exposure due to recent sink repairs in a nearby room, although maintenance logs indicated completion of required flushing protocols.

Across the unit, documentation frequently reflected timely completion of required elements, while bedside workflow varied depending on staffing mix, competing clinical demands, and time of day. Several staff members noted that while tasks were completed, they were sometimes performed in rapid succession during periods of high activity rather than at the bedside in a controlled sequence.

Part 2

TRACE Framework Reviewer’s Guide

Event Summary

Begin by reviewing the case carefully. Focus on understanding what is happening at a systems level before identifying details.

Coaching Questions

HAI Type

What type of healthcare-associated infection is being described?
Where in the care environment is this occurring?

Organism

Is an organism identified in the case?
If not, what type of information would typically be needed to characterize it?

Patient Factors

What similarities or differences are noted across affected patients?
What patient-level conditions or exposures are mentioned?

Device Information

What type of device is involved?
What aspects of device use or management are described?

Outcome

What outcomes or patterns are observed over time?
How is the issue being recognized within the unit?

Reflection Questions

What details are clearly stated versus implied?
What additional clinical or operational data would help clarify the situation?
Where might assumptions be tempting but not supported by the case?

Possible Findings

Multiple bloodstream infections occurring in a short time period
Central venous catheters present in affected patients
High reported compliance with insertion and maintenance bundles
Documentation showing completion of required elements
Variability in workflow during high-demand periods
Operational strain during admissions and peak census times

Model Example

A series of central line-associated bloodstream infections has been identified in a medical-surgical intensive care unit over several weeks. Affected patients all had central venous catheters in place and shared overlapping exposure to intensive care services. Despite consistently high documented compliance with insertion and maintenance practices, infections have continued to occur, prompting further review of care processes and operational conditions within the unit.

Timeline Reconstruction

Coaching Questions

What events appear to occur during periods of increased workload or staffing disruption?
Where are there indications of delays, interruptions, or workflow adjustments?
What care activities occur during transitions such as shift change, admissions, or transfers?
How do operational pressures appear to vary across time?

Reflection Prompt

Where might the conditions of care delivery have shifted across the observed period?

Suggested Timeline

Early period: baseline central line use across unit with standard protocols in place
Admission surge period: rapid room turnover and staffing adjustments due to unexpected sick calls
Mid-shift and shift change periods: interruptions from rapid response events and competing clinical priorities
Intermittent periods: supply limitations affecting catheter stabilization device availability
Ongoing period: high census and clustered admissions contributing to variable workflow intensity
Radiology transfer event period: patient transport using portable monitoring during equipment shortages
Post-event recognition period: identification of bloodstream infections over a six-week span

Risks and Contributing Factors
a) System Factors

Coaching Questions

What workload, staffing, or operational pressures are described?
How does resource availability appear to influence care delivery?
Where do process variations emerge across the unit?

Possible Findings

Staffing disruptions due to unexpected sick calls
High census and clustered admissions
Equipment and supply limitations affecting device management
Environmental service delays during peak turnover periods
Variable workflow during high-acuity events and rapid response situations

b) Knowledge

Coaching Questions

What information or orientation gaps are suggested?
Where might familiarity with local processes vary?

Possible Findings

Traveler nurse with limited orientation to local supply locations
Potential variation in awareness of device storage and availability processes

c) Attitudes

Coaching Questions

What perspectives on workload or interruptions are reflected?
How might perceptions of priorities influence daily actions?

Possible Findings

Recognition of frequent interruptions during medication preparation
Framing of competing priorities during bedside care activities

d) Beliefs

Coaching Questions

What beliefs about compliance or safety performance are suggested?
How might reporting data influence perceptions of risk?

Possible Findings

Strong confidence in audit data showing high compliance rates
Leadership reinforcement that protocols are being followed based on documentation reviews

e) Practices

Coaching Questions

Where is there variation between documented practice and bedside workflow?
What inconsistencies are suggested in timing or sequencing of care activities?

Possible Findings

Bedside care performed in rapid succession during high activity periods
Delays in dressing changes due to competing clinical demands
Use of alternative equipment methods during supply shortages
Documentation completed even when workflow conditions vary

4a. Analysis

Coaching Questions

How do workload, staffing, and workflow pressures interact in this case?
Where might compliance data differ from real-time practice conditions?
How could multiple small disruptions accumulate across shifts?
What patterns emerge when looking across time rather than single events?

Model Analysis

Across the unit, multiple interacting pressures shaped the conditions under which central line care was delivered. High documented compliance suggests that required steps were being completed and recorded, yet the operational environment introduced variability in how consistently those steps were performed under stable conditions.

Periods of increased admissions, staffing disruptions, and high census created situations where care activities were completed during interruptions or compressed timeframes. These conditions may have influenced the sequence and consistency of device-related care even when documentation reflected completion.

Additional variability emerged during transitions such as shift changes, rapid response events, and patient transfers. In these moments, competing priorities and task overload likely contributed to fragmented workflow patterns, where care steps were completed but not always in a controlled or continuous manner.

Over time, repeated exposure to these operational pressures created a setting where risk could accumulate across multiple small deviations in timing, sequencing, and environmental control, despite stable compliance reporting.

4b. Corrective Actions

Coaching Questions

How could workflow reliability be strengthened during high-demand periods?
What system changes could reduce dependence on memory or individual adaptation?
Where might standardization reduce variability in care delivery?
How could interruptions be better managed at a unit level?

Model Corrective Actions

Standardize central line maintenance workflows with clear sequencing at the bedside during all shifts
Implement structured “no interruption” periods for high-risk tasks such as dressing changes and line access
Strengthen supply chain reliability for catheter stabilization devices with backup stock protocols
Redesign staffing surge response plans for admission clustering periods
Improve orientation processes for float and traveler staff focused on critical device management locations
Shift auditing practices from scheduled observation toward real-time, unscheduled process verification
Enhance handoff communication to include device condition changes and incomplete or delayed tasks

4c. Enabling Conditions

Coaching Questions

What organizational supports are needed to sustain improvements?
Where might monitoring systems fail to capture real workflow conditions?
What infrastructure or staffing stability is required?
How could leadership support influence reliability?

Model Enabling Conditions

Stable staffing models that reduce reliance on last-minute float coverage
Reliable supply chain systems ensuring consistent availability of essential device equipment
Real-time monitoring systems that reflect workflow conditions rather than documentation alone
Leadership structures that support escalation of workload concerns during peak census periods
Sustainable auditing processes that capture both compliance and process reliability
Environmental support systems that reduce delays during turnover and high-volume periods

TRACE Summary

Most Significant Risks Identified

Variability in workflow during high-demand periods
Dependence on documentation as a proxy for reliability
Disruptions from staffing, supply, and environmental constraints
Fragmented care during transitions and rapid response events

How Risks Accumulated Over Time

Repeated exposure to high workload conditions, staffing variability, and operational interruptions created cumulative opportunities for inconsistent execution of central line care processes, despite stable reported compliance.