Case Study: The Weekend Shift with CLABSI

Healthcare-associated infections rarely result from a single event. More often, they emerge when multiple risks accumulate across people, processes, environments, and systems. The TRACE Framework helps investigators move beyond isolated observations to develop a comprehensive understanding of what happened, why it happened, and what conditions allowed it to occur.

In this exercise, you will review a realistic healthcare-associated infection case and use the TRACE Framework to conduct your own analysis.

Learning Objectives

This case is designed to help you:

Identify how prevention bundles can gradually weaken over time.
Recognize how multiple small deviations can combine to increase risk.
Practice reconstructing an event timeline from scattered information.
Identify risks and contributing factors across clinical, operational, environmental, staffing, workflow, communication, and organizational domains.
Develop potential corrective actions and enabling conditions for sustainable improvement.

Instructions

Download the TRACE Framework template.
Read the case study completely before beginning your analysis.
Use the information provided to complete each section of the TRACE Framework:
- Event Summary
- Timeline Reconstruction
- Risks and Contributing Factors
- Analysis
- Corrective Actions
- Enabling Conditions
After completing your review, proceed to Part 2, the TRACE Reviewer’s Guide, to compare your findings and strengthen your systems-thinking skills.

Part 1

The Case

The medical intensive care unit had been operating near capacity for several weeks. Hospital leaders had discussed elevated census during multiple operational huddles, and several units had been asked to accept patients outside their usual service lines to improve patient flow. Although staff described the situation as manageable, charge nurses frequently adjusted assignments throughout shifts as admissions and transfers occurred.

Mr. James Carter, a 59-year-old patient with septic shock secondary to pneumonia, was admitted through the emergency department after requiring escalating vasopressor support. A central venous catheter was inserted shortly after arrival. Documentation indicated that the insertion procedure was completed successfully and that the line was available for immediate use.

Several nurses later recalled that central line supply carts had recently been reorganized. The change had been made as part of a broader supply standardization initiative affecting multiple departments. While most staff had adapted, some reported needing additional time to locate items during procedures. One nurse commented that “everything is technically there, just not where it used to be.”

At the time of admission, the ICU census exceeded 95%. Two nurses were caring for patient assignments that included higher-acuity patients than usual. A traveler nurse had joined the unit several weeks earlier and was still becoming familiar with local workflows. Staffing schedules showed multiple overtime shifts during the preceding month.

Environmental services records documented ongoing construction activity on a patient care floor located directly above the ICU. Noise complaints had been reported intermittently, although no environmental concerns had been identified during routine inspections.

During the patient’s first several days in the ICU, numerous interdisciplinary notes referenced frequent changes in clinical status. Vasopressor requirements fluctuated, respiratory support increased, and several diagnostic tests were ordered to evaluate new findings. Progress notes repeatedly described the patient as critically ill but stable enough to remain in the ICU.

A review of nursing documentation showed that central line assessments were generally completed each shift. However, assessment times varied considerably. Several entries referenced dressing reinforcement, while others documented dressings as clean, dry, and intact. One dressing change was recorded during a period when multiple admissions arrived within a few hours of one another.

The ICU manager had recently begun covering responsibilities for another unit following a leadership vacancy. Staff meetings had been shortened over the previous month, and several education sessions had been postponed. Meeting minutes noted ongoing efforts to balance staffing resources across departments.

A pharmacy intervention note described temporary shortages of several commonly used products earlier in the month. Alternative products were made available through approved substitution processes. Staff reported adapting to the changes without major difficulty.

One physician recalled discussing central line necessity during morning rounds but could not remember the exact day. Daily goals sheets were completed inconsistently because the unit had been piloting a revised documentation format. Some staff preferred the new version, while others continued using previous workflows.

Near the end of the patient’s second week in the ICU, nursing staff observed new signs concerning for infection. Blood cultures were obtained, and additional diagnostic testing was ordered. Clinical documentation reflected uncertainty regarding the source of infection during the initial evaluation.

Laboratory results later confirmed bloodstream infection. The central venous catheter remained in place at the time cultures were collected. Subsequent reviews found multiple references to line access for medication administration, blood sampling, and other routine clinical activities throughout the patient’s stay.

Interviews conducted after the event revealed varying perspectives regarding workload. Some staff described conditions as typical for a busy ICU, while others reported frequent interruptions, competing priorities, and difficulty completing non-urgent tasks on schedule. Several employees noted that patient turnover had increased compared with earlier in the year.

When discussing the event, one team member mentioned that the patient had family members visiting frequently and occasionally bringing personal blankets from home. Another staff member recalled that the patient’s room was located near a busy corridor where equipment and personnel moved regularly throughout the day.

At the time the bloodstream infection was identified, the hospital continued to experience sustained high occupancy levels. Unit performance dashboards showed no significant increase in reported safety events during the preceding months, although several quality indicators were still being compiled and had not yet been finalized.

Part 2

TRACE Framework Reviewer’s Guide

Event Summary

Review the case and identify the key facts that describe the event. Focus on what happened, who was involved, the clinical situation, and the outcome. Avoid interpreting causes at this stage.

Coaching Questions

HAI Type

What healthcare-associated infection is being investigated?
What evidence in the case supports classification of the event?

Organism

What microbiology information is provided?
What microbiology information is missing and would normally be helpful?

Patient Factors

What patient characteristics may be relevant to understanding the event?
What aspects of the patient’s clinical condition may have influenced care delivery?
How did the patient’s acuity change during the hospitalization?

Device Information

What device is involved?
When was the device inserted?
How long did the device remain in place?
How was the device used during the hospitalization?
What information is available regarding device maintenance and monitoring?

Outcome

What was the identified outcome?
When was the outcome recognized?
What impact did the event have on the patient?

Reflection Questions

Which information is essential to describing the event?
Which information provides context but does not belong in the event summary?
What additional information would strengthen your understanding of the event?

Possible Findings

Patient admitted with septic shock secondary to pneumonia.
Central venous catheter inserted shortly after admission.
Patient remained critically ill during hospitalization.
Bloodstream infection identified near the end of the second week of ICU care.
Blood cultures confirmed infection.
Central line remained in place when cultures were obtained.
Central line was accessed repeatedly for ongoing clinical care.

Model Example

A 59-year-old ICU patient admitted with septic shock secondary to pneumonia required placement of a central venous catheter shortly after admission. The patient remained critically ill throughout hospitalization and required ongoing intensive treatment. Near the end of the second week of care, signs concerning for infection prompted blood culture collection. Laboratory testing subsequently confirmed a bloodstream infection while the central venous catheter remained in place and in active use.

Timeline Reconstruction

Reconstruct the sequence of events using information distributed throughout the case. Focus on both clinical events and operational conditions.

Coaching Questions

What was occurring in the hospital before the patient’s admission?
What conditions existed within the ICU at the time of admission?
When was the central line inserted?
What operational pressures were present during the patient’s stay?
What evidence exists regarding line maintenance activities?
When were concerns about infection first documented?
When was bloodstream infection confirmed?
What staffing, workflow, or organizational changes occurred during the hospitalization?
Were there transitions of care, changes in assignments, or workflow modifications that may have affected care delivery?

Reflection Prompt

At which points in the timeline do you see conditions that may have increased, decreased, or changed risk?

Suggested Timeline

Hospital experiences sustained high census for several weeks.
Units begin accepting patients outside normal service lines to support patient flow.
ICU operates above 95% census.
Central line supply carts are reorganized as part of a standardization initiative.
ICU manager begins covering responsibilities for an additional unit.
Staffing schedules show increased overtime and use of traveler staff.
Patient admitted with septic shock and pneumonia.
Central venous catheter inserted shortly after admission.
Patient remains critically ill with fluctuating clinical status.
Central line assessments documented throughout hospitalization.
Dressing reinforcement documented on multiple occasions.
One dressing change occurs during a period of multiple ICU admissions.
Daily goals documentation becomes inconsistent during pilot workflow changes.
Discussion of line necessity occurs during rounds but timing is unclear.
Central line continues to be used for medications, blood sampling, and routine care.
Signs concerning for infection emerge near the end of the second week.
Blood cultures obtained.
Bloodstream infection confirmed.
Hospital and ICU continue operating under elevated census conditions.

Risks and Contributing Factors

a) System Factors

Coaching Questions

What organizational conditions existed before the event?
What operational pressures were present?
What changes were occurring within the system?
What competing priorities may have affected reliability?

Possible Findings

Sustained high hospital census.
ICU occupancy above 95%.
Frequent patient flow adjustments.
Increased patient turnover.
Leadership vacancy requiring expanded management responsibilities.
Postponed education sessions.
Ongoing workflow and documentation changes.
Supply standardization initiative.
Product shortages requiring substitutions.

b) Knowledge

Coaching Questions

Were there circumstances that may have affected access to information or guidance?
Were staff adapting to new processes or systems?
Were opportunities for reinforcement or education reduced?

Possible Findings

New supply cart configuration required staff adaptation.
Traveler nurse was still learning local workflows.
Education sessions had been postponed.
Staff were adapting to revised documentation processes.

c) Attitudes

Coaching Questions

How did staff perceive workload conditions?
Were there differing perceptions of operational strain?
How might normalization of busy conditions influence behavior?

Possible Findings

Some staff viewed conditions as manageable.
Others described interruptions and competing priorities.
Variable perceptions of workload existed across the team.
High census conditions may have become routine.

d) Beliefs

Coaching Questions

What assumptions may have influenced decisions?
How might staff have balanced competing priorities?
Were there indications that existing processes were viewed as sufficient?

Possible Findings

Confidence that staffing challenges were being managed.
Belief that approved substitutions adequately addressed supply shortages.
Assumption that existing workflows remained functional despite increased demand.
Confidence that routine assessments were maintaining oversight.

e) Practices

Coaching Questions

What routine care activities occurred throughout the hospitalization?
Were practices consistent or variable?
Where is evidence of workflow variation?

Possible Findings

Central line remained in use throughout hospitalization.
Multiple line accesses occurred for clinical care.
Assessment timing varied.
Dressing reinforcement was documented.
Daily goals documentation was inconsistent.
Workflow variation existed during documentation pilot activities.

4a. Analysis

Coaching Questions

How did clinical, operational, and organizational factors interact?
Where do you see risk accumulation rather than isolated risk?
Which factors may have amplified the effects of other factors?
How might workload and interruptions influence reliability?
How could multiple small variations combine over time?
Which conditions appear persistent versus temporary?

Model Analysis

The case illustrates multiple conditions occurring simultaneously across clinical, operational, and organizational domains. Sustained high census created ongoing workload pressure while frequent admissions, transfers, and changing assignments increased operational complexity. Staffing demands were reflected through overtime use, high-acuity assignments, and onboarding of a traveler nurse.

At the same time, several organizational changes were underway, including supply cart reorganization, documentation workflow modifications, leadership coverage changes, and product substitutions. Individually, each change may have been manageable. Collectively, they increased the number of adaptations required by frontline staff.

The patient’s prolonged critical illness required continued central line use and repeated line access. Over time, variation in assessments, dressing management activities, competing priorities, interruptions, and workflow adjustments created opportunities for risk to accumulate. Rather than a single breakdown, the case demonstrates how multiple system pressures can interact and gradually weaken the reliability of prevention processes.

4b. Corrective Actions

Coaching Questions

How could system design better support bundle reliability during high census periods?
Which processes would benefit from standardization?
How can workflow variability be reduced?
What barriers prevent consistent execution of preventive practices?
What human factors should be considered when redesigning processes?

Model Corrective Actions

Implement structured central line maintenance audits during periods of elevated census.
Standardize central line supply organization and verify usability before implementation.
Establish escalation triggers when census or workload thresholds are exceeded.
Strengthen daily line necessity review processes through standardized workflows.
Reduce documentation variation by simplifying and standardizing daily goals processes.
Develop staffing contingency plans for sustained high-acuity periods.
Create structured onboarding support for temporary and traveler staff.
Monitor bundle reliability measures during operational surges.

4c. Enabling Conditions

Coaching Questions

What leadership support is needed?
What staffing conditions support reliable performance?
What infrastructure is required?
How will improvement efforts be monitored?
What barriers may affect sustainability?

Model Enabling Conditions

Leadership commitment to maintaining prevention activities during operational surges.
Adequate staffing resources and surge planning processes.
Reliable supply management and standardization processes.
Consistent auditing and feedback systems.
Clear accountability for central line maintenance oversight.
Routine review of bundle compliance and process reliability measures.
Mechanisms for identifying emerging workload pressures.
Ongoing support for education, onboarding, and competency maintenance.

TRACE Summary

Most Significant Risks Identified

Sustained high census and operational strain.
Increased workload and competing priorities.
Prolonged central line utilization.
Frequent line access.
Workflow variation and ongoing organizational change.
Inconsistent documentation processes.
Staffing pressures and adaptation demands.

How Risks Accumulated Over Time

Risk accumulated through the interaction of prolonged device use, repeated care activities, sustained workload pressures, workflow variation, and multiple concurrent organizational changes. No single condition stands out independently; rather, risk increased through the combined effect of numerous system influences over time.