title: Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Department of Surgery, Section of Trauma and Surgical Critical Care, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Heidi L
authors.initials: HL
authors.lastname: Frankel
authors.forename: William B
authors.initials: WB
authors.lastname: Crede
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Topal
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Roumanis
authors.forename: Marie W
authors.initials: MW
authors.lastname: Devlin
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Foley
mesh_terms: D000465:Algorithms; D016470:Bacteremia / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D002404:Catheterization / Q000009:adverse effects*; D003428:Cross Infection / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D016469:Fungemia / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units / Q000458:organization & administration*; D019982:Organizational Case Studies; D017064:Process Assessment, Health Care; D017749:Total Quality Management / Q000379:methods*