BPMN process for Catheter Related Bloodstream Infections

Below is an example of using?Temporal Delta Duration Decision BPMN pattern?for managing vascular catheters. It shows the main steps for the detection and treatment of CR-BSIs in intensive care units, simplified from the well-known IDSA guideline.

#ClinicalGuidelines underline the need for modeling temporal constraints, as they are temporally oriented, they involve temporal reasoning, they can be easily described in terms of conditional decisions, and their applicability is often constrained by time conditions.

Among catheter saving criteria, Differential Time to Positivity (DTP) is the most used for diagnosing CR-BSIs. DTP measures how much time is necessary for a catheter-drawn blood culture to become positive for a given microorganism with respect to a simultaneously drawn peripheral blood culture. If the catheter culture becomes positive at least 2 hours earlier than the peripheral one, the catheter is considered to be the source of bacteremia. If this condition is not observed, physicians look for other sources of infection.

Let's see how this #ClinicalPathway is modeled as #BPMN process for #BPMPlusHealth.

A decision table for CR-BSI is used in the diagram below:

1.?A simple top-level diagram for the treatment of Catheter-Related Bloodstream Infections (CR-BSIs):

2a.?Top part of the sub-process for the treatment of CR-BSI:

2b.?Bottom part of the sub-process for the treatment of CR-BSI:

3a.?Maximum delta duration (a little longer than the delta duration):

3b.?Conditional event for the catheter culture:

3c.?Conditional event for the peripheral culture:

4.?Administer Staphylococcus aureus treatment?

This activity showcases the importance of overrides in dealing with uncertainty during the course of an infection treatment. The JHH CGs state the following: “Criteria for a 14-day course of therapy: patient is clinically stable; follow-up blood cultures drawn 2-4 days after the initial cultures are negative for S. aureus; the patient defervesces with 72 hours of initiation of effective antistaphylococcal therapy. All other patients should receive 4-6 weeks of therapy based on extent of infection”.

4a.?Administer Staphylococcus aureus treatment sub-process:

5.?A relative time constraint between "Confirm the onset of CR-BSI" and "Trans-Esophageal Echocardiography (TEE)" is depicted through a parallel activities "Start TEE timer" and "End TEE timer".?

If endocarditis is suspected, a TEE is performed 5–7 days after the onset of bacteremia, in order to minimize false-negative results.?

5a.?Start TEE timer properties:

5b.?End TEE timer properties:

5c.?Start TEE timer sub-process:

5d.?End TEE timer sub-process:

Full explanation and simulation of this process is available at https://medicalflows.com/bpmn/examples/catheter-related-bloodstream-infections