Case Study: A Busy Week on 4 South with CAUTI

Introduction

Welcome to this TRACE Framework learning exercise.

In Part 1, you will review a healthcare-associated infection case involving a patient who developed a catheter-associated urinary tract infection (CAUTI). The case contains information commonly encountered during a real-world investigation, including clinical details, staffing challenges, workflow issues, communication patterns, environmental observations, and operational pressures.

Your task is to use the information provided to complete the TRACE Framework independently. As you review the case, identify relevant facts, reconstruct the timeline, recognize risks and contributing factors, analyze what may have influenced the event, and consider opportunities for improvement.

After completing your review, proceed to Part 2, which contains the TRACE Framework Reviewer’s Guide. The guide will help you evaluate your thinking and compare your findings with example approaches to completing each section of the framework.

Learning Objectives

By completing this exercise, you will be able to:

• Identify how staffing decisions and cross-unit assignments create conditions that may increase healthcare-associated infection risk.
• Evaluate the interaction between unfamiliar workflows, competing priorities, and infection prevention practices.
• Apply systems thinking to develop sustainable strategies that support safe care across varying staffing models.

Instructions

1. Download the TRACE Framework template.
2. Read the case in its entirety before making notes.
3. Complete each section of the TRACE Framework using information from the case.
4. Use the Reviewer’s Guide in Part 2 to compare your analysis and identify additional insights.

Part 1

The Case

The medical-surgical unit on 4 South had experienced unusually high patient volumes throughout much of the month. Several staff members described the previous two weeks as particularly challenging due to increased admissions, multiple employee vacations, and a series of unexpected call-offs.

One patient, Mr. Ramirez, a 76-year-old man admitted with heart failure exacerbation and reduced mobility, had been on the unit for several days before developing symptoms that later prompted evaluation for a urinary tract infection. During discussions following the event, staff recalled numerous operational challenges occurring around the same period, although no single issue initially appeared unusual.

The unit manager noted that staffing schedules had required frequent use of float personnel from other inpatient areas. Several nurses who normally worked on telemetry and orthopedic units had been assigned shifts on 4 South. One float nurse commented that the unit’s admission process and documentation requirements differed from those used on her home unit. Another recalled that urinary catheter documentation was located in a different section of the electronic record than she expected.

Review of staffing schedules showed that multiple float nurses had cared for Mr. Ramirez during his stay. Some worked only a single shift on the unit. Several reported receiving brief shift huddles but no formal orientation to unit-specific workflows.

At the time of admission, Mr. Ramirez arrived with an indwelling urinary catheter that had been placed in the emergency department. Documentation regarding the indication for continued catheter use appeared in multiple locations within the medical record. During interviews, staff provided differing recollections regarding whether catheter necessity had been discussed during bedside rounds.

A nurse who cared for the patient later recalled intending to raise the issue during multidisciplinary rounds but was interrupted by a rapid response event involving another patient. Several team members remembered multiple interruptions throughout that shift, including frequent admissions and discharges.

Environmental services records showed routine cleaning activities were completed as scheduled. During the same week, however, a water leak had temporarily closed two patient rooms on the unit. Patients were reassigned, and several staff described the resulting room changes as disruptive. Although the leak occurred on the opposite side of the unit from Mr. Ramirez’s room, it remained a common topic during staff interviews.

One charge nurse described frequent bed management pressures. Census levels remained high, and staff reported efforts to move patients efficiently to accommodate incoming admissions. Several nurses noted that assignment changes occurred repeatedly during some shifts.

Supply records indicated no shortages of urinary catheter supplies. However, staff reported that bladder scanners had recently been relocated following equipment maintenance activities. Some nurses stated they occasionally needed additional time to locate equipment.

Clinical notes documented that Mr. Ramirez gradually became more mobile during hospitalization. Physical therapy entries reflected improvement over several days. Nursing documentation regarding catheter assessment and ongoing need appeared inconsistent, with entries varying between shifts.

Several staff members mentioned that the unit had recently adopted revised interdisciplinary rounding practices intended to improve efficiency. While leadership viewed the changes positively, some employees reported continuing adjustment to the new workflow. One nurse stated that discussions regarding device removal occasionally occurred earlier in the day than staff were accustomed to.

During one weekend shift, staffing levels met organizational requirements but included a larger-than-usual proportion of float personnel. A float nurse assigned to Mr. Ramirez also cared for several newly admitted patients. She later recalled spending substantial time learning unit-specific processes while managing competing priorities.

Three days before symptoms were documented, nursing notes indicated routine catheter care. Subsequent records reflected continued catheter use, though explanations for ongoing necessity were not consistently documented. Two days later, the patient reported discomfort, and additional assessment was performed. Laboratory testing was ordered the following day.

When interviewed, several staff members expressed confidence in catheter maintenance practices on the unit. At the same time, they described challenges associated with fluctuating staffing patterns, unfamiliar workflows, frequent interruptions, and ongoing operational demands.

Mr. Ramirez was eventually diagnosed with a catheter-associated urinary tract infection during his hospitalization. Leadership initiated a review to better understand the circumstances surrounding the event.

Part 2

TRACE Framework Reviewer’s Guide

1. Event Summary

Orientation

Before identifying risks or developing solutions, begin by summarizing the event. Focus on what happened, who was involved, the type of infection, and the relevant context. Avoid jumping to conclusions about why the event occurred.

Coaching Questions

HAI Type

• What healthcare-associated infection occurred?
• When was the infection identified?

Organism

• Does the case identify a specific organism?
• If not provided, how should this be reflected in the Event Summary?

Patient Factors

• What patient characteristics may be relevant to understanding the event?
• What clinical conditions were present during hospitalization?
• How did the patient’s condition change over time?

Device Information

• What invasive device was present?
• When was the device inserted?
• What information is available regarding continued need for the device?
• What documentation issues are described?

Outcome

• What was the final outcome described in the case?
• What organizational response followed identification of the event?

Reflection Questions

• Which details are essential to understanding the event versus simply providing context?
• What additional information would strengthen your understanding of the event?

Possible Findings

• Patient admitted with heart failure exacerbation and reduced mobility.
• Indwelling urinary catheter inserted in the emergency department.
• Catheter remained in place during hospitalization.
• Documentation regarding catheter necessity appeared inconsistent.
• Patient mobility improved during hospitalization.
• Symptoms later prompted evaluation for urinary tract infection.
• Patient was diagnosed with a CAUTI.
• Leadership initiated a review.

Model Example

A 76-year-old patient admitted with heart failure exacerbation and reduced mobility arrived on the medical-surgical unit with an indwelling urinary catheter placed in the emergency department. During hospitalization, documentation regarding catheter necessity varied across shifts, and the patient was cared for by multiple staff members. The patient’s mobility improved over time, but the catheter remained in use. Following development of urinary symptoms, evaluation was performed and a catheter-associated urinary tract infection was identified. Leadership initiated a review of the circumstances surrounding the event.

2. Timeline Reconstruction

Orientation

The purpose of timeline reconstruction is to organize information into a sequence that helps reveal changing conditions, decision points, and operational pressures.

Coaching Questions

• What occurred before admission to the unit?
• What device-related events occurred during hospitalization?
• What staffing conditions were present throughout the stay?
• When were workflow changes occurring on the unit?
• When did mobility improve?
• When were symptoms first documented?
• What events occurred between routine catheter care and symptom development?
• What transitions in staffing or care responsibility occurred?
• What operational pressures were present at different points in time?

Reflection Prompt

• Where do you observe changes in patient condition, staffing, workflow, or operational demands that may have altered risk conditions?

Suggested Timeline

1. Unit experiences sustained high census, increased admissions, vacations, and unexpected call-offs.
2. Revised interdisciplinary rounding process is introduced.
3. Patient admitted with heart failure exacerbation and reduced mobility.
4. Urinary catheter inserted in the emergency department before arrival to the unit.
5. Patient cared for by multiple nurses, including several float staff.
6. Float nurses report unfamiliar documentation locations and workflow differences.
7. Catheter necessity documentation appears in multiple locations within the record.
8. Unit experiences bed management pressures, assignment changes, and frequent interruptions.
9. Water leak temporarily closes rooms and contributes to patient relocations.
10. Bladder scanners are relocated following maintenance activities.
11. Physical therapy notes indicate improving mobility over several days.
12. Nursing documentation regarding catheter assessment and necessity varies across shifts.
13. Three days before symptoms, routine catheter care is documented.
14. One weekend shift includes a higher-than-normal proportion of float staff.
15. Patient reports discomfort two days later.
16. Additional assessment is performed.
17. Laboratory testing is ordered the following day.
18. CAUTI diagnosis is made.
19. Leadership initiates review.

3. Risks and Contributing Factors

a) System Factors

Coaching Questions

• What organizational conditions were affecting unit operations?
• What system changes were occurring during the event period?
• How did staffing patterns influence care delivery?
• Where do you see workflow complexity increasing?

Possible Findings

• High census.
• Increased admissions.
• Staff vacations and call-offs.
• Frequent use of float staff.
• Revised rounding process.
• Repeated assignment changes.
• Bed management pressures.
• Frequent interruptions.

Model Example

Multiple operational pressures were present simultaneously, including high census, staffing variability, workflow changes, and competing priorities. These conditions may have increased complexity and reduced consistency across care processes.

b) Knowledge

Coaching Questions

• What evidence suggests staff may have been unfamiliar with unit-specific processes?
• Were there indications that information was difficult to locate?

Possible Findings

• Float staff unfamiliar with documentation locations.
• Limited orientation to unit-specific workflows.
• Different admission and documentation processes from home units.

Model Example

Variation in familiarity with unit-specific workflows may have created challenges in locating information and navigating documentation processes consistently.

c) Attitudes

Coaching Questions

• How did staff describe catheter maintenance practices?
• What perceptions did staff express regarding current workflows?

Possible Findings

• Confidence in catheter maintenance practices.
• Positive leadership view of new rounding process.
• Staff still adjusting to workflow changes.

Model Example

Staff generally expressed confidence in routine practices while also acknowledging operational challenges and ongoing adjustment to workflow changes.

d) Beliefs

Coaching Questions

• What assumptions may have influenced how work was prioritized?
• How might competing priorities affect attention to device management?

Possible Findings

• Focus on managing admissions and throughput.
• Assumption that routine processes were functioning adequately.
• Emphasis on efficiency during periods of high demand.

Model Example

Operational priorities focused on maintaining patient flow and managing workload may have influenced how attention and resources were distributed across competing tasks.

e) Practices

Coaching Questions

• What care practices appeared variable?
• Where do you see inconsistencies in execution or documentation?

Possible Findings

• Inconsistent catheter necessity documentation.
• Variation across shifts.
• Missed opportunities to discuss catheter necessity.
• Multiple interruptions during rounds.
• Difficulty locating equipment.

Model Example

Several routine practices showed variability, particularly related to documentation, communication during rounds, and execution of device review processes.

4a. Analysis

Orientation

Analysis should focus on how conditions interacted across the system rather than identifying a single cause.

Coaching Questions

• How did staffing conditions interact with workflow complexity?
• How did interruptions influence communication opportunities?
• How might workload pressures affect reliability?
• What factors accumulated over time?
• Where do you see multiple risks converging?
• How did organizational changes influence frontline work?

Model Analysis

The case describes a healthcare environment operating under sustained operational pressure. High census, staffing variability, frequent admissions, and assignment changes created a complex care environment. At the same time, the unit was adapting to revised rounding practices and relying heavily on float staff who were unfamiliar with certain unit-specific workflows.

These conditions interacted with documentation variability, communication interruptions, and competing priorities. Opportunities to review catheter necessity may have been influenced by workflow disruptions, differing documentation practices, and challenges associated with coordinating care across multiple caregivers.

Rather than a single breakdown, the case reflects the accumulation of multiple conditions that may have reduced consistency in device management processes. Staffing pressures, workflow adaptation, communication challenges, and operational demands appear to have overlapped throughout the hospitalization, creating an environment in which risk could accumulate over time.

4b. Corrective Actions

Orientation

Focus on system redesign and reliability rather than individual performance.

Coaching Questions

• How could workflows be simplified?
• How could device review processes become more reliable?
• What support do float staff need?
• How can communication processes be standardized?
• How can important information become easier to find?

Model Corrective Actions

• Standardize catheter necessity documentation location within the electronic record.
• Implement structured daily device review processes during interdisciplinary rounds.
• Develop unit-specific onboarding resources for float staff.
• Create standardized workflow aids for temporary staff assignments.
• Establish escalation processes when device necessity documentation is unclear.
• Reduce reliance on memory-dependent communication processes.
• Improve visibility and accessibility of equipment needed to support catheter assessment and removal decisions.
• Evaluate workflow changes before and after implementation to identify unintended effects.

4c. Enabling Conditions

Orientation

Successful improvements require supporting conditions that make desired practices easier to sustain.

Coaching Questions

• What leadership actions would support improvement?
• What staffing supports are needed?
• What infrastructure changes would help?
• How should reliability be monitored?
• What barriers could undermine sustainability?

Model Enabling Conditions

• Leadership commitment to balancing efficiency and safety goals.
• Adequate staffing plans during periods of high census.
• Structured support for float staff assignments.
• Clear ownership of device utilization monitoring.
• Reliable access to equipment and documentation tools.
• Ongoing review of workflow changes and frontline feedback.
• Monitoring systems that track documentation consistency and device review practices.
• Resources to support sustained process improvement efforts.

TRACE Summary

1. Most Significant Risks Identified

• Frequent use of float staff unfamiliar with unit workflows.
• Inconsistent documentation regarding catheter necessity.
• High census and workload pressures.
• Frequent interruptions and competing priorities.
• Ongoing adaptation to revised rounding processes.

2. How Risks Accumulated Over Time

Risk conditions developed through the interaction of staffing variability, workflow changes, documentation challenges, communication interruptions, and operational demands. These conditions existed simultaneously and evolved throughout the hospitalization.

3. Major Risk Themes

• Staffing and workforce flexibility.
• Workflow reliability.
• Communication and coordination.
• Documentation consistency.
• Operational pressure and competing priorities.

4. Highest-Priority Improvement Opportunities

• Standardize device review processes.
• Improve documentation reliability.
• Strengthen support for float staff.
• Reduce workflow variation.
• Improve communication reliability during rounds.

5. Critical Enabling Conditions

• Leadership support.
• Sustainable staffing strategies.
• Standardized workflows.
• Effective monitoring systems.
• Infrastructure that supports reliable execution of key infection prevention practices.

The TRACE Framework encourages examination of how multiple system conditions interact over time. In this case, the learning opportunity lies in understanding how staffing patterns, workflow variation, communication processes, and operational pressures may collectively influence infection prevention performance.