Original scientific article
Use of Corporate Six Sigma Performance-Improvement Strategies to Reduce Incidence of Catheter-Related Bloodstream Infections in a Surgical ICU

https://doi.org/10.1016/j.jamcollsurg.2005.04.027Get rights and content

Background

Corporate performance-improvement methodologies can outperform traditional ones in addressing ICU-based adverse events. My colleagues and I used Six Sigma methodology to address our catheter-related bloodstream infection (CR-BSI) rate, which considerably exceeded the nationally established median over a 9-year period. We hypothesized that use of Six Sigma methodology would result in a substantial and sustainable decrease in our CR-BSI rate.

Study design

All patients were directly cared for by a geographically localized surgical ICU team in an academic tertiary referral center. CR-BSIs were identified by infection control staff using CDC definitions. Personnel trained in Six Sigma techniques facilitated performance-improvement efforts. Interventions included barrier precaution kits, new policies for catheter changes over guide wires, adoption of a new site-preparation antiseptic, direct attending supervision of catheter insertions, video training for housestaff, and increased frequency of dressing changes. After additional data analysis, chlorhexidine-silver catheters were used selectively in high-risk patients. The impact of interventions was assessed by monitoring the number of catheters placed between CR-BSIs.

Results

Before the intervention period, 27 catheters were placed, on average, between individual CR-BSIs, a CR-BSI rate of 11 per 1,000 catheter days. After all operations were implemented, 175 catheters were placed between line infections, and average CR-BSI rate of 1.7/1,000 catheter days, a 650% improvement (p < 0.0001). Compared with historic controls, adoption of chlorhexidine-silver catheters in high-risk patients had a considerable impact (50% reduction; p < 0.05).

Conclusions

This represents the first successful application of Six Sigma corporate performance-improvement method impacting purely clinical outcomes. CR-BSI reduction was highly substantial and sustained after other traditional strategies had failed.

Section snippets

Methods

This performance-improvement effort centered on the Leapfrog-compliant, semi-closed SICU at Yale New Haven Hospital, an urban university hospital with trauma, transplantation, and elective and emergent surgical patients, exclusive of cardiac surgery and burns. The SICU team placed all invasive catheters and approved all orders, admissions, and discharges by the primary team. Second-year surgical, anesthesia, and emergency department residents staffed the SICU with fellow supervision and

Results

Yale New Haven Hospital is a participant in the CDC’s NNIS program. For the 9 years from 1992 to 2001 our CR-BSI rate of 11 per 1,000 catheter days exceeded the NNIS median for more than 200 other SICUs (∼5 per 1,000).

From April 1, 2001 through April 2003, the YNHH SICU reduced its CR-BSI rate from an average of 11 infections per 1,000 catheters days to 1.7 infections per 1,000 days. This represents a highly notable improvement (p < 0.0001) from the January 1993 through March 2001 baseline mean

Discussion

This work represents the successful deployment of a statistically rigorous corporate quality-management tool in a patient-safety arena, resulting in and sustained performance improvement. CR-BSIs have an attributable mortality in some series of 12% to 28% and up to a 22-day excess hospital length of stay.10, 11 A very conservative estimate of cost, based on excess medication, meals, diagnostic tests, and other services directly used by the patient, is $3,000 per CR-BSI. In this study, CR-BSI

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    Competing Interests Declared: None.

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