Using Six Sigma in Infection Prevention

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Using Six Sigma in Infection Prevention

• Brandi Cavegn MSN, RN Green Belt

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Personal Background

• Who am I?
• And what is my background?
• Greenbelt- Certified, part time
• Other Belts? White, Yellow, Green, Black, Master
  Black

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What is Six Sigma

• Six Sigma is a problem solving methodology.
• Six Sigma minimizes mistakes and maximizes value.
• Six Sigma originated in Manufacturing (much like
  LEAN) but can be used in healthcare successfully.
• Six Sigma performance is the statistical term for
  a process that produces fewer than 3.4 defects
  (or errors) per million opportunities for
  defects. (think bell curve).
• Six Sigma is often the goal but rarely reached
• Six Sigma decreases the normal variation in a
  process.

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Sigma Scale
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So what does that mean?
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How Six Sigma tools can be useful to You.

• Variety of tools to be used
• Focus is on decreasing variation
• Full variety of tools can be used without
  initiating entire project.
• DMAIC Methodology
• D- Define
• M- Measure
• A- Analyze
• I- Improve
• C- Control

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Case Study

• NICU CA-BSI project
• Use Six Sigma methodology to reduce variation in
  the insertion and maintenance of Central line
  catheters in the NICU.
• Overall goal was to reduce the infection rate,
  but this was not the goal of the project.
• Disclaimer

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Start with a Charter (Any template will do)
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D-Business Case (Use Evidence)

• An opportunity exists within CHW to reduce the
  number of blood stream infections associated with
  catheters in the NICU. It is important to address
  this issue now because it impacts not only
  patient safety but key business drivers related
  to organizational success.
• The Agency for Healthcare Research and Quality
  (AHRQ) and the Centers for Disease Control and
  Prevention (CDC) have acknowledged that central
  venous lines are critical components of medical
  care for many patients, and their use can lead to
  catheter-associated blood stream infections.
• Bloodstream infections account for 30 of all
  health care associated infections in pediatrics
  according to the CDCs National Nosocomial
  Infection Surveillance System (NNIS). Although
  the association between bloodstream infections
  and death is somewhat controversial, AHRQ
  concluded that findings in the literature are
  consistent with a 10-20 increase in mortality.
• The CDC has reported an average of 2.8 to 12.8
  infections per 1000 catheter-days.
• Directly aligned to the CHW strategic goal to
  provide the Best and Safest care
• The mean cost of a bloodstream infection has been
  estimated at 46,133 due to the longer length of
  stay and additional ancillary utilization (Slonim
  et al), making it the most expensive of all
  nosocomial infections.
• The financial impact may be greater for CHW
  because of the NICU population and the possible
  impact on Neurodevelopment
• Line infections can also be categorized as never
  events which are errors in medical care that are
  clearly identifiable, preventable and serious in
  their consequences for patients. Never events
  are not reimbursable under many insurance plans.
• Results of the project such as standardized
  processes or new staff knowledge regarding line
  insertion, maintenance and infection risks should
  improve employee satisfaction scores and increase
  staffs comfort level dealing with catheters
• Preventing infection will be a positive driver
  for patient satisfaction

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D- Goal Statement

• To reduce bloodstream infections associated with
  catheters to 1.5 per 1,000 catheter days in the
  NICU population by year end 2008
• Double the number of days between bloodstream
  infection occurrences
• 100 of patients receive the insertion central
  line bundle (hand hygiene, maximal barrier
  precautions (sterile gown, sterile gloves, cap,
  mask, insertion site toweled off with sterile
  towels, daily review of line necessity, optimal
  catheter site selection, chlorhexidine skin
  antisepsis for patients over 2 months of age)
• 95 of patients with a CVL were assessed daily
  for necessity of retaining the CVL.
• 95 of patients receive the line maintenance
  bundle
• Improved communication among staff and
  standardized work processes regarding the
  insertion and maintenance of CV lines.
• Sigma level 4.47 (1.5 per 1000) Six Sigma would
  be (.005 per 1000)

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D-Team Members
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D-Project Scope

• The scope of the project includes lines placed in
  the NICU at CHW.
• Central Venous Lines (CVL) include Broviac,
  Peripherally Inserted Central Catheter (PICC),
  Umbilical Arterial Catheter (UAC), Umbilical
  Venous Catheter (UVC)
• The team will focus on the process boundaries of
  line insertion and line maintenance.
• The definition of Blood Stream Infections (BSI)
  as defined by NHSN will be used for data
  collection purposes.
• Catheter Associated Blood Stream Infection
  (CA-BSI) Insertion Bundle compliance in the NICU
• The project begins in May 2008 and will conclude
  at the end of December 2008

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D-Alignment and Authority

• Does this project align with any other business
  initiatives currently underway? How will we
  coordinate with the people leading these
  initiatives?
• Infection control
• Interventional Radiology
• Pharmacy
• CAT
• Anesthesia
• PICU initiatives
• What authority do we have to make decisions and
  implement changes? Include here the authorities
  we must approach for decisions and approvals
  beyond our teams scope. Is there anything that
  is outside the teams boundaries?
• Product Committee must evaluate any
  recommendations on equipment
• Infection Control approval required for any
  changes to surveillance data
• JCPC review of any new policies
• OR stakeholder involved in patient care
  process Rob Omelina is contact person
• Purchasing approval required on recommendation
  to purchase new supplies
• Sterile Processing approval required on
  recommendations for cleaning equipment and
  supplies
• Environmental stakeholder in process and impact
  patient care environment
• Respiratory Care stakeholder providing care to
  patient and would need training on any process
  changes or expectations regarding line insertion
  and maintenance
• Radiology - stakeholder providing care to
  patient and would need training on any process
  changes or expectations regarding line insertion
  and maintenance

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M- Data Measurement Plan
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M-Insertion vs. Maintenance
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M-Days Between Infection
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M-Preliminary Data on CA-BSI

• 10 infections in 2007 1.65 infections per 1000
  line days
• 8/10 were identified as maintenance related
• 2/10 were undetermined (3 and 4 days after
  insertion)
• 2007 Average days between infections- 36.1
• Goal for 2008 is 72.2 (double last year)

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A-Opportunity/ Problem Statement

• 10 Catheter Related Blood stream Infections were
  reported in the NICU for 2007
• 46,133 per infection x 10 infections 461,133
  in additional costs
• Infections can occur during the line insertion or
  maintenance period
• Insertion Bundle Compliance- evidence based
  interventions that should be implemented together
  (hand hygiene, maximal barrier precautions, daily
  review of line necessity, optimal catheter site
  selection, chlorhexidine skin antisepsis for
  patients over 2 months of age)
• Maintenance include dressing and tubing changes
• 1.65 infections per 1000 line days
• Sigma of 4.44

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M- Process Maps or Flow charts

• A graphic model of the flow of activities,
  material, and/or information that occurs during a
  process.
• Sets your baseline.

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A- Use Your Tools
Top-Down the breaking down of a system to gin
insight into its compositional sub-systems
Sub-systems
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Line insertions
Maintenance
Medication
Hand washing
IP practices
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A- SIPOC Tool

• Identifies the Voice of the Customer (VOC)
• S- Suppliers
• Systems, people, organizations, or other sources
  of the materials, information, or other resources
  that are consumed or transformed in the process
• I- Inputs
• Materials, information, and other resources
  provided by the suppliers that are consumed or
  transformed in the process
• P- Process
• The set of actions and activities that transform
  the inputs into outputs
• O-Outputs
• The products or services produced by the process
  and used by the customer
• C- Customer
• Persons, groups of people, companies, systems,
  and downstream processes that receive the output
  of the process

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A- FMEA

• Failure Mode Effects Analysis
• A procedure used to identify, assess, and
  mitigate risks associated with potential failure
  modes in a product, system, or process

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A- FMEA- Dressing Change
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A- FMEA Dressing Change
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A- FMEA Tubing Change
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A-Staff Survey
1)   A Clave (Blue end cap) needs to be primed
before attaching it to a med line or
bifuse.       TRUE/FALSE             Answer
TRUE  2)  You should always wear gloves when
hanging a med or flush and when hanging new
IVF.      TRUE/FALSE             Answer
TRUE  3)  How often do you need to change your
med tubing?      a) with every med      b) every
24 hours          Answer b        c) every 48
hours      d) every 72 hours               4) 
What should you use to clean your patient's PICC
LINE during a sterile dressing change?       a)
Betadine                  Answer a      b)
Alcohol      c) Sali wipes      d) None of the
above  5) Alcohol is used to clean your Broviac
Line during a sterile CVL dressing change.    
TRUE/FALSE                AnswerTRUE  6) How
long should "Scrub the hub" take before breaking
into a line?     a) 1 second     b) 3 seconds    
c) 5 seconds                Answer c     d) 10
seconds  7) A small circle of Betadine should be
left at the insertion site of your PICC/Broviac
during a dressing change.     TRUE/FALSE          
   Answer FALSE  8) How often should you change
the dead ender/blue clave on the end of a capped
CVL or UVC lumen?     a) After any blood draw    
b) After giving blood products     c) Every 7
days     d) All of the above         Answer
d  9) When doing a PICC line dressing change,
where should your heart/disc be located?     a)
Underneath the tegaderm     b) Outside of the
tegaderm     c) Underneath the tegaderm with a
chevron.     Answer c     d) Outside the
tegaderm with a chevron.  10) Who should you
contact if your patient has impaired skin
integrity related to the tegaderm dressing on a
central line?      a) the MD only      b) the
Charge nurse      c) the CAT team (Central Access
Team)      d) Both a and c                        
     Answer d  
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Survey Results
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I- Improve

• Use of improvement tools, project management
  tools, and designing experiments.
• We chose PDSA (Plan, Do, Study, Act)
• Ran small scale experiments
• Captured data
• Reported back to group
• Used for full scale decision making

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I-So what did we do?

• Staff education was 1
• Observation Data Collection Tools Created
• Using the FMEA, we identified those areas that
  could be changed quickly at little cost.
• Performed small scale experiments (IV fluids in
  pharmacy)
• Decreased variation by sharing proper techniques
  and monitoring with audits
• Changed out dressing change kits to help decrease
  need for obtaining supplies outside of the
  sterile field
• Established a partnership with the CAT and
  infection prevention.
• Maintenance and Insertion Checklists implemented
  and monitored
• Measured reduction in defects

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Parking lot

• Track/follow CVL care in OR, how handled and if
  events occur
• Review NICU infection control policy
• General Infection control-ORs scrub routine vs.
  current NICU scrub
• Update CVL PP if changes identified
• Follow/track why CVLs discontinued
• Drsg changes, how done, by whom, when done,
  migration rate and infection occurrence
• Chlorohexadine for line changes
• Tubing change documentation, sticker use
• Electronic documentation
• Medication Tubing change every 72 hours vs.
  every 24 hours
• Closest port to baby
• Reduce amount of times lines are accessed

• New claves/posiflows, impregnated lines, caths
  etc
• Hand washing in pharmacy
• Med. Prep in pharmacy and at bedside
• TPN/IL/meds under the hood
• Patient handling and lines- Rad, PT, OT, RT
• Mechanism that assists with switching from IV to
  PO meds
• Order set re above and for line maintenance
• NICU CVL dressing team- core group vs. whole unit
  super user
• Vanco Hep flushes
• Hub care
• Awareness Education on data/stats
• Utilize on the pot educational sheets

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C-Awareness Board

• Ongoing Meetings
• Created public board that showcases
• Number of days since last infection
• Tip of the week that is determined at prior
  meeting

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Questions?