Case Study: Cognitive Load and Patient Deterioration

Introduction

This exercise is designed to help you practice using the TRACE Framework to investigate a healthcare-associated infection event from a systems perspective.

In Part 1, you will review a case involving a patient who developed a central line-associated bloodstream infection (CLABSI). The case contains information related to patient care, staffing, workflow, communication, environmental conditions, operational pressures, and organizational factors. As in real investigations, important details are not presented in chronological order and some information may appear more significant than it ultimately proves to be.

Your task is to:

• Reconstruct the timeline of events
• Identify risks and contributing factors
• Analyze how system conditions may have influenced outcomes
• Develop potential corrective actions
• Identify enabling conditions that allowed risks to persist

Before proceeding, download your TRACE Framework template.

Read the case completely before beginning your analysis. After completing your initial review, use the Reviewer’s Guide (Part 2) to compare your thinking and work through each section of the framework.

By completing this exercise, you will strengthen your ability to identify system vulnerabilities, understand how operational conditions influence performance, and apply structured investigation methods to healthcare-associated infection events.

Part 1

The Case

Room 418

The medical-surgical unit had operated above its licensed bed capacity for most of the previous two weeks. Several patients awaiting transfer from the emergency department remained boarded throughout multiple shifts, and hospital leadership had issued daily capacity updates encouraging units to expedite discharges whenever possible.

Among the patients on the unit was Mr. Alvarez, a 68-year-old man admitted with severe pancreatitis complicated by sepsis. During his hospitalization, a central venous catheter had been inserted to support vasopressor administration and ongoing treatment. At the time of admission, his expected length of stay was uncertain.

Several staff members later recalled that the unit felt unusually busy during the period surrounding his hospitalization. One nurse described feeling as though she was “constantly reprioritizing.” Another noted that interruptions had become so common that she routinely carried a notepad to keep track of unfinished tasks.

The unit had recently implemented a revised electronic handoff tool intended to improve communication between shifts. Some staff reported finding the tool helpful, while others continued using handwritten notes in parallel because they felt the electronic format required too many screens to review quickly.

Mr. Alvarez occupied the same room for most of his stay. Environmental services documentation indicated no concerns with room cleaning. During one weekend, however, maintenance personnel were called to evaluate intermittent temperature-control issues affecting several rooms on the unit, including Room 418. No patient safety concerns were documented at the time.

A review of staffing schedules would later show that multiple experienced nurses were on vacation during the same week. Several shifts included float nurses from other inpatient units. Although all float staff had completed required orientation, some reported being less familiar with the location of supplies and local workflow expectations.

One float nurse remembered spending several minutes searching for central line dressing kits during a busy evening shift after discovering the usual supply cart had been relocated during a recent storage-room reorganization. Another nurse recalled borrowing supplies from a neighboring unit when stock appeared low late one evening.

Throughout Mr. Alvarez’s hospitalization, providers from several services participated in his care. Progress notes reflected ongoing concerns about fluctuating blood pressure, renal function changes, electrolyte abnormalities, and increasing oxygen requirements. Multiple diagnostic studies and consultations were ordered over several days.

The charge nurse later commented that patient deterioration events seemed unusually frequent that week. Several rapid response activations occurred on the unit within a short period of time, occasionally drawing staff away from their assigned patients. One nurse recalled being interrupted during documentation on numerous occasions to assist elsewhere on the unit.

At one point, Mr. Alvarez was transported off the unit for imaging while receiving multiple intravenous infusions. Transport documentation indicated no complications. Nursing notes from around the same period referenced difficulties coordinating medication administration, laboratory collection times, and consultant evaluations because of competing demands throughout the day.

During interdisciplinary rounds, providers discussed whether the central line remained necessary. Documentation reflecting those discussions appeared inconsistently across progress notes. One physician note suggested the line could potentially be removed if clinical improvement continued. A later note referenced ongoing need for reliable access because of treatment requirements.

Several nurses documented central line assessments during the hospitalization. Some entries were detailed, while others consisted primarily of checkbox selections within the electronic record. The hospital had recently transitioned portions of nursing documentation into a new charting workflow. Staff feedback submitted through unit leadership meetings indicated that completion times had increased after implementation.

The infection prevention department had distributed educational reminders regarding central line maintenance approximately one month earlier following an increase in device utilization across several inpatient areas. Unit managers reported that staff completed the required review.

On the eighth hospital day, Mr. Alvarez developed a fever. Blood cultures were obtained and additional diagnostic testing was ordered. Nursing documentation during the preceding 48 hours reflected escalating clinical concerns, increasing monitoring requirements, and several modifications to the care plan.

Laboratory testing later identified a bloodstream infection meeting surveillance criteria for a central line-associated bloodstream infection. By that point, Mr. Alvarez had remained hospitalized considerably longer than originally anticipated.

When unit staff were informed of the event, several individuals commented that no single problem stood out in their memory. What they remembered most was the pace of activity, frequent interruptions, changing priorities, and the sense that everyone was trying to manage multiple competing demands at the same time.

Part 2

1. Event Summary

Review the case in its entirety before beginning.

Focus on identifying the key facts that describe the event without interpreting causes or assigning responsibility.

Coaching Questions

HAI Type

• What healthcare-associated infection occurred?
• What information in the case supports the infection classification?

Organism

• What microbiology information is provided?
• What microbiology information is not provided?
• How might missing microbiology information affect your investigation?

Patient Factors

• What patient characteristics may be relevant to understanding the event?
• What clinical conditions required ongoing monitoring or treatment?
• How did the patient’s condition change during hospitalization?

Device Information

• What device was present?
• Why was the device initially placed?
• What information is available regarding device necessity over time?
• What information would you want to gather about device management?

Outcome

• What was the identified outcome?
• When was the outcome recognized?
• How did the outcome affect the patient’s hospitalization?

Reflection Questions

• What information is essential to understanding the event?
• What information appears contextual?
• What additional information would strengthen the event summary?

Possible Findings

• Patient admitted with severe pancreatitis complicated by sepsis
• Central venous catheter placed for vasopressor administration and treatment needs
• Multiple ongoing clinical concerns during hospitalization
• Fever developed on hospital day eight
• Blood cultures obtained
• Bloodstream infection identified meeting CLABSI surveillance criteria
• Hospital stay extended beyond initial expectations

Model Example

Mr. Alvarez, a 68-year-old patient admitted with severe pancreatitis and sepsis, required placement of a central venous catheter during hospitalization. Throughout his stay, he experienced ongoing clinical instability requiring multidisciplinary management. On hospital day eight, he developed a fever and underwent diagnostic evaluation. Blood cultures later identified a bloodstream infection meeting surveillance criteria for CLABSI. The event occurred during a prolonged hospitalization involving multiple clinical and operational demands.

2. Timeline Reconstruction

Reconstruct the sequence of events using clues scattered throughout the case.

Coaching Questions

• What was occurring on the unit before the patient’s infection was identified?
• When was the central line inserted?
• What major clinical events occurred during hospitalization?
• When were staffing and workflow challenges present?
• What organizational changes were occurring?
• When were concerns raised regarding line necessity?
• What changes occurred in the days immediately preceding the infection?
• What transitions of care occurred?
• How did operational conditions evolve throughout the hospitalization?

Reflection Prompt

• Where do you see changes in workload, workflow, communication, or operational pressure over time?
• At which points might risk conditions have increased or decreased?

Suggested Timeline

1. Medical-surgical unit operates above licensed bed capacity for approximately two weeks.
2. Hospital leadership issues ongoing discharge acceleration messaging.
3. Mr. Alvarez admitted with severe pancreatitis and sepsis.
4. Central venous catheter inserted for vasopressor administration and treatment needs.
5. New electronic handoff process recently implemented.
6. Experienced staff members are on vacation; float staff utilized across multiple shifts.
7. Storage-room reorganization changes supply locations.
8. Staff report searching for central line supplies and borrowing stock from other units.
9. Patient receives ongoing multidisciplinary care with multiple consultations and diagnostics.
10. Weekend temperature-control concerns reported in several rooms.
11. Frequent rapid response events occur elsewhere on the unit.
12. Patient transported for imaging while receiving multiple infusions.
13. Discussions regarding ongoing central line necessity documented inconsistently.
14. New nursing documentation workflow increases charting burden.
15. Escalating clinical concerns documented during the 48 hours preceding infection identification.
16. Fever develops on hospital day eight.
17. Blood cultures obtained.
18. CLABSI identified through laboratory testing.

3. Risks and Contributing Factors

a) System Factors

Coaching Questions

• What organizational conditions shaped the care environment?
• How might capacity pressures affect work processes?
• What workflow changes occurred during this period?
• Where do you see competing priorities?
• What system conditions increased task complexity?

Possible Findings

• Sustained operation above licensed bed capacity
• Pressure to expedite discharges
• Frequent interruptions
• Multiple rapid response events
• Recent workflow changes
• Supply location changes
• Increased documentation burden
• Multiple competing clinical demands

b) Knowledge

Coaching Questions

• What evidence suggests staff had access to infection prevention information?
• Were there any indications of unfamiliarity with unit-specific processes?
• What additional information would help assess knowledge-related factors?

Possible Findings

• Infection prevention reminders distributed
• Required review reportedly completed
• Float staff oriented but less familiar with local workflows
• Variable familiarity with supply locations

c) Attitudes

Coaching Questions

• How did staff adapt to operational pressures?
• What workarounds were used?
• What attitudes toward workflow changes are visible in the case?

Possible Findings

• Staff developed personal methods to track interrupted work
• Continued use of handwritten notes alongside electronic tools
• Adaptation to workflow inefficiencies through informal processes

d) Beliefs

Coaching Questions

• What assumptions may have influenced decision making?
• How might staff perceptions of urgency have shaped priorities?
• What beliefs about workflow efficiency are suggested?

Possible Findings

• Perception that electronic handoff process was difficult to navigate
• Emphasis on managing immediate competing demands
• Ongoing balancing of multiple patient priorities

e) Practices

Coaching Questions

• What care processes demonstrate variability?
• Where do you see inconsistencies in workflow execution?
• Which practices may warrant closer review?

Possible Findings

• Variable handoff practices
• Inconsistent documentation of central line necessity discussions
• Variation in central line assessment documentation detail
• Borrowing supplies from neighboring units
• Multiple interruptions during routine work

4a. Analysis

Coaching Questions

• How did operational conditions interact with clinical demands?
• Where do you see cumulative workload developing?
• How might interruptions affect reliability?
• What factors increased cognitive workload?
• Which conditions reinforced one another?
• How did multiple small challenges combine to create a more complex environment?

Model Analysis

The case illustrates the interaction of multiple system conditions occurring simultaneously rather than a single isolated issue. High census levels, discharge pressure, staffing variability, frequent interruptions, and competing patient priorities created an environment characterized by elevated cognitive workload.

At the same time, staff were adapting to several workflow changes, including a new handoff process, revised documentation workflows, and changes to supply storage locations. These conditions increased the number of tasks requiring active attention and created additional opportunities for delays, interruptions, and workflow variation.

The patient’s prolonged hospitalization involved ongoing clinical instability, multiple consultations, changing treatment needs, and repeated reassessment of device necessity. As workload increased and priorities shifted throughout the unit, care processes requiring consistent attention may have become more difficult to execute with the same level of reliability.

Viewed collectively, the case demonstrates how organizational pressures, workflow complexity, staffing conditions, communication challenges, and competing demands can interact over time to increase operational risk.

4b. Corrective Actions

Coaching Questions

• Which system conditions appear most modifiable?
• How could workflows be simplified?
• How could interruptions be reduced?
• What processes could improve reliability under high workload conditions?
• How might device management be standardized?
• What redesigns would reduce dependence on memory and individual vigilance?

Model Corrective Actions

• Standardize central line necessity review processes during daily rounds.
• Implement structured escalation triggers for prolonged device utilization.
• Improve supply organization and ensure consistent supply location management.
• Develop interruption-management strategies for high-risk tasks.
• Simplify documentation workflows where feasible.
• Standardize handoff practices across all staff groups.
• Evaluate staffing contingency plans during periods of sustained high census.
• Incorporate human factors review into workflow redesign initiatives.
• Establish workload monitoring indicators to identify periods of elevated operational risk.

4c. Enabling Conditions

Coaching Questions

• What leadership support would be needed to sustain improvements?
• What staffing conditions support reliable practice?
• What infrastructure is necessary?
• How should performance be monitored?
• What barriers could prevent long-term success?

Model Enabling Conditions

• Leadership commitment to workload and capacity management
• Adequate staffing resources during periods of increased demand
• Reliable supply management systems
• Consistent communication processes across disciplines
• Ongoing monitoring of device utilization and maintenance practices
• Feedback mechanisms for frontline staff
• Structured evaluation of workflow changes before and after implementation
• Human factors expertise integrated into improvement efforts
• Regular review of operational conditions that may increase cognitive workload

TRACE Summary

1. Most Significant Risks Identified

• Sustained high unit workload
• Frequent interruptions
• Staffing variability
• Workflow changes occurring simultaneously
• Communication variation
• Supply accessibility challenges
• Increasing documentation demands

2. How Risks Accumulated Over Time

Multiple operational pressures developed concurrently throughout the hospitalization. Capacity strain, competing clinical priorities, staffing challenges, workflow changes, and interruptions collectively increased cognitive workload and created a more complex care environment.

3. Major Risk Themes

• Cognitive workload
• Workflow complexity
• Communication variability
• Operational strain
• Process reliability under competing demands
• Device management in a high-demand environment

4. Highest-Priority Improvement Opportunities

• Improve reliability of central line necessity review
• Reduce workflow complexity
• Standardize communication processes
• Strengthen supply management systems
• Design work processes that remain reliable during high-demand conditions

5. Critical Enabling Conditions

• Leadership support
• Adequate staffing resources
• Reliable infrastructure
• Ongoing monitoring systems
• Continuous feedback mechanisms
• Human factors-informed process design
• Organizational commitment to sustainable improvement

The case highlights how risk can emerge through the interaction of multiple system conditions rather than a single isolated failure. Understanding how workload, workflow, staffing, communication, and organizational pressures interact is essential for identifying practical and sustainable improvement opportunities.