NUR 531 Module 4 Adverse Event Paper Example

Day Twelve: A Case of Healthcare-Associated Legionnaires' Disease on an Oncology Unit and the First 72 Hours of Response

[Student Name]

Southern New Hampshire University

NUR 531: Interprofessional Leadership in Healthcare

Adverse Event Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Day Twelve: A Case of Healthcare-Associated Legionnaires' Disease on an Oncology Unit and the First 72 Hours of Response

On the twelfth day of an admission for lymphoma chemotherapy, a 71-year-old patient on 4 East at Wren Valley Medical Center developed fever, cough and new infiltrates on a chest x-ray. A urinary antigen test was positive for Legionella pneumophila serogroup 1, and a sputum culture later grew the organism. The patient spent five days in intensive care and recovered. The unit had cared for immunosuppressed patients for decades without a known case. This paper describes the event, classifies it, explains why it is a preventable adverse event and examines the leadership decisions of the first 72 hours. It argues that the most important early decisions were interprofessional ones that nursing could not make alone, and that the event exposed a water management program that existed on paper but not in practice.

Classifying the Case

Legionnaires' disease is a severe pneumonia acquired by breathing in aerosolized water containing Legionella bacteria, which can grow in the complex water systems of large buildings. CDC surveillance classifies a case as definitely healthcare-associated when the patient spent the entire ten days before symptom onset in a hospital or long-term care facility, and as possibly healthcare-associated when the patient had some exposure to a healthcare facility during that period (Soda et al., 2017). The patient on 4 East had been hospitalized for eleven days before onset, so the case is definitely healthcare-associated.

A review of the previous twelve months found one more case that fit the possible category: a patient discharged from 4 East who developed Legionnaires' disease six days after going home. That case had been reported to the health department at the time but had not been linked to the hospital's water.

The classification matters because of what it implies. In the surveillance data Soda et al. (2017) analyzed, most definite healthcare-associated cases occurred in adults aged 60 or older, and one in four of those patients died. A patient on chemotherapy is among the most vulnerable people a hospital's water can reach.

Why This Is a Preventable Adverse Event

What makes an event adverse is that the harm came from care or its setting, not from the disease that brought the patient in. The patient's pneumonia came from the building, not from lymphoma or chemotherapy, and the harm was serious: an intensive care stay and a delay in the next chemotherapy cycle. Whether it was preventable depends on whether known measures could have stopped Legionella from growing and spreading in the unit's water.

The evidence says they usually can. CDC investigators reviewed 27 outbreaks of Legionnaires' disease in North America between 2000 and 2014 and found that every one had at least one deficiency in how the building's water was managed; healthcare-associated outbreaks accounted for 57% of the cases (Garrison et al., 2016). Since 2017, federal requirements have directed hospitals to assess where Legionella could grow in their water systems and to operate a water management program that considers industry standards and CDC's toolkit (Centers for Medicare & Medicaid Services [CMS], 2018). The existence of these measures makes this event preventable in principle, and the root cause analysis will show whether it was preventable in practice.

Reporting and Disclosure

Three kinds of reporting followed. Legionellosis is a nationally notifiable condition, so the laboratory result went to the state health department, and the hospital's infection preventionist notified the department that the case was healthcare-associated. Internally, the event was entered in the incident reporting system and classified as a serious safety event, which starts a root cause analysis. Finally, the attending physician and I met with the patient and the patient's daughter on the second day to explain what was known: that the infection had probably come from the hospital's water, that an investigation was under way and that we were sorry. We committed to sharing what the investigation found.

The First 72 Hours

Table 1 summarizes the main actions taken in the first three days and who led each one.

Table 1

Actions in the First 72 Hours After the Case Was Confirmed

Note. Composite timeline.

Two decisions shaped the response. The first was closing the showers and switching to bottled water within hours, before any sample confirmed the source. Nursing staff objected because patients value showers and bottled water added work to every medication pass, but the risk to immunosuppressed patients outweighed the inconvenience. The filters that followed within a day are among the control measures a water management program can call on when hazardous conditions are found (Centers for Disease Control and Prevention [CDC], 2021). The second decision was testing every patient with new pneumonia, which found no further cases. Neither decision belonged to nursing alone. Facilities controlled the water, infection prevention controlled the case review and physicians ordered the tests. My role was to make sure each group knew what the others were doing and that the unit's patients were protected while they worked.

What the Event Revealed

Early findings suggested that the hospital's water management program existed mainly on paper. A plan had been written in 2018, but the water management team had not met since 2021. Six rooms on 4 East had been closed for five months during a neighboring renovation, and no one had flushed their showers or faucets. Hot water at several of the unit's outlets was running cooler than the plan specified. Garrison et al. (2016) found that deficiencies in outbreaks fell into four categories: process failures, human errors, equipment failures and changes outside the building that nobody managed, and the early findings on 4 East touch at least three of them.

Conclusion

A patient on 4 East developed a definitely healthcare-associated case of Legionnaires' disease, a serious and probably preventable adverse event. The first 72 hours showed that the protective actions that mattered most, restricting water use, installing filters, testing patients and sampling the system, depended on departments outside nursing, and that the nurse manager's job was to connect them and protect patients in the meantime. The root cause analysis must now answer three questions: why the water management program stopped operating, why the closed rooms were not flushed and why no one noticed the change in water temperature.

References

Centers for Disease Control and Prevention. (2021). Developing a water management program to reduce Legionella growth and spread in buildings: A practical guide to implementing industry standards (Version 1.1). https://stacks.cdc.gov/view/cdc/114167

Centers for Medicare & Medicaid Services. (2018). Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires' disease (LD) (QSO-17-30, revised). https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/downloads/qso17-30-hospitalcah-nh-revised-.pdf

Garrison, L. E., Kunz, J. M., Cooley, L. A., Moore, M. R., Lucas, C., Schrag, S., Sarisky, J., & Whitney, C. G. (2016). Vital signs: Deficiencies in environmental control identified in outbreaks of Legionnaires' disease: North America, 2000-2014. Morbidity and Mortality Weekly Report, 65(22), 576-584. https://doi.org/10.15585/mmwr.mm6522e1

Soda, E. A., Barskey, A. E., Shah, P. P., Schrag, S., Whitney, C. G., Arduino, M. J., Reddy, S. C., Kunz, J. M., Hunter, C. M., Raphael, B. H., & Cooley, L. A. (2017). Vital signs: Health care-associated Legionnaires' disease surveillance data from 20 states and a large metropolitan area: United States, 2015. Morbidity and Mortality Weekly Report, 66(22), 584-589. https://doi.org/10.15585/mmwr.mm6622e1