Catheter-Associated Urinary Tract Infection
Cause Mapping Example:
How does a healthcare facility prevent urinary tract infections (UTIs) associated with urinary catheters? We will perform a root cause analysis investigation, using the Cause Mapping process. There are three steps to the process: 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions. Each step will be discussed below.
Step 1. Define the Problem
The first step of the Cause Mapping approach is to define the problem by asking the four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals? The problem is urinary tract infections. The "when" isn't important, because we're looking at preventing UTIs, so we'll note that this is a "proactive" Cause Map (vs. a reactive Cause Map, made for a specific incident). The physical location is the urinary tract, the equipment being used is a catheter, and the task being done is urinary catheterization. (We're only interested in looking at UTIs that result from catheterization.)
Next we look at the impact to the overall goals. A UTI is an impact to the patient safety goal. Additionally, the cost of the hospital stay (just for the UTI), which is no longer reimbursable under Medicare/Medicaid is approximately $44,000 (Medicare data). Since there are more than 12,000 UTIs associated with urinary catheterization a year, this results in over $536 million in now non-reimbursable costs.
Step 2. Identify the Causes (The Analysis)
We begin the Cause Map by writing down the goals that were affected as defined in the problem outline. For catheter-associated UTIs the safety goal is impacted because of the UTI and the materials/labor goal is impacted because of the cost of the hospital stay. These are the first two cause-and-effect relationships in the analysis.
Next we start with one of the goals and ask "why" questions to fill in the Cause Map to the right. For example, the cost of the hospital stay is caused by the urinary tract infections. Urinary tract infections are caused by pathogens accessing the urinary tract, AND pathogens not being removed from the body. (AND notes that both causes must be present in order for the effect to occur.) We'll look at each of these causes in turn.
Pathogens generally access the urinary tract in one of two ways. Pathogens within the body are pushed into the urinary tract, or external contaminants are introduced to the urinary tract. Here, only one of the causes is necessary to produce the effect, so we use "OR" to join the causes.
Pathogens from within the body can be introduced into the urinary tract by being pushed in by the catheter, or by migrating along the outside of the catheter.
Internal pathogens can be pushed into the urinary tract when a catheter is inserted. A catheter might be inserted as an aid in surgery, to relieve urinary tract obstruction, or to obtain urine, such as for culture/diagnostic tests, or to measure output.
Pathogens can migrate along the outside of a catheter when an indwelling catheter is inserted. An indwelling catheter might be inserted to relieve urinary tract obstruction, when a patient is incontinent, or to permit urinary drainage in the case of bladder dysfunction or urinary retention.
We'll return to the causes for the external contaminants being introduced to the urinary tract. The pathogens could be introduced if they migrate along the inside of the catheter, or the catheter is inserted and its external surface is contaminated. (The reasons for a catheter being inserted are discussed above, so we'll note that here.)
The causes of pathogens migrating along the inside of the catheter are an indwelling catheter being inserted (see above), and pathogens introduced inside the catheter. This could occur if either the collection bag or the drainage tube junction were contaminated, due to damage to the system.
The catheter external surface could be contaminated if there are pathogens on the hands of medical personnel, or if the insertion of the catheter is non-sterile.
Lastly we'll return to the second cause of the urinary tract infection, pathogens not removed from the body. This could occur due to an insufficient immune response, because the patient is ill, or from damage to the urinary tract caused by the catheter being inserted improperly or motion of the catheter if it was improperly secured. Another possible cause of pathogens not being removed from the body is if they were not excreted, due to obstructed urinary flow.
Even more detail can be added to this Cause Map as the analysis continues. As with any investigation the level of detail in the analysis is based on the impact of the incident on the organization’s overall goals.
Step 3. Select the Best Solutions (Reduce the Risk)
Once the Cause Map is built to a sufficient level of detail with supporting evidence the solutions step can be started. The Cause Map is used to identify all the possible solutions for given issue so that the best solutions can be selected. Possible solutions are placed directly on the Cause Map above the cause they control. An example of a solution attached to a cause is shown below.
Now we've built our Cause Map and added possible solutions. The entire Cause Map, with 34 causes, and solutions, is shown below. A slightly less detailed map can be found on the downloadable PDF (view by clicking "Download PDF" above.)
Cause Mapping Improves Problem Solving Skills
The Cause Mapping method focuses on the basics of the cause-and-effect principle so that it can be applied consistently to day-to-day issues as well as catastrophic, high risk issues. The steps of Cause Mapping are the same, but the level of detail is different. Focusing on the basics of the cause-and-effect principle make the Cause Mapping approach to root cause analysis a simple and effective method for investigating safety, environmental, compliance, customer, production, equipment or service issues.
Click on "Download PDF" above to download a PDF showing the Cause Map.
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