Development and implementation of a quality improvement framework for the prevention hospital-onset bacteremia and fungemia

OBJECTIVE: Develop and implement a framework for reviewing hospital-onset bacteremia and fungemia (HOB) events to identify quality improvement opportunities. DESIGN: Prospective, observational study. SETTING: Six hospitals (3 academic and 3 community) associated with two health systems. PARTICIPANTS: Clinical team members involved in the care of patients with eligible HOB events. METHODS: The Joint Commission Patient Safety Event Taxonomy was adapted to develop a framework for HOB, eliciting potential contributing factors in four categories: general infection prevention, infection-site-specific, system, and human factors. From 9/2022 to 4/2024, HOB events identified from hospital blood culture databases were selected using convenience sampling to a target enrollment of 75 events, limiting inclusion of events associated with neutropenia or central line infections. Multidisciplinary case reviews were performed, and the framework was refined using feedback from the first 17 reviews. We summarized HOB sources, contributing factors, and improvement opportunities using descriptive analyses. RESULTS: Seventy-four HOB case reviews were analyzed, evenly distributed between academic and community hospitals, and 42% occurred in an ICU setting. A median of 3 care team members (IQR 2-4) participated in each review. At least one infection-site-specific factor was identified in 48% of case reviews, representing 63% of HOB events with a known source of infection. 50% of cases identified a general infection prevention factor, 35% a system factor, and 34% a human factor. 57% of the cases had an actionable finding. CONCLUSIONS: HOB events have diverse causes and elements of preventability, and multidisciplinary review can generate actionable findings beyond the current guideline-defined measures.