Six Sigma Process Management in the Timely Antibiotic Administration

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      Six Sigma Process Management in the Timely Antibiotic Administration for
      Community-Acquired Pneumonia in the Emergency Department
      Ryan Oglesby, RN, MSN, CEN, NREMT-P, MHA

      Upon completion of this course, the participant will be able to:
      1) Define the impact that community-acquired pneumonia has on the health and well-being of the
         public who are increasingly seeking care in emergency departments;
      2) Identify the Six Sigma process steps outlined by the acronym DMAIC (define, measure, analyze,
         improve, control) and describe how they are utilized to recognize deficits and improve quality in
         the care of community-acquired pneumonia patients and timely antibiotic administration for their
         treatment; and
      3) Assess how success from such a project may lend itself to application for other core measures
         within the emergency department (i.e., door to ECG, door to balloon, door to CT scan, etc.).

      I.     Problem Statement:                                     C. Customers most affected are pneumo-
             A. All pneumonia patients presenting to                   nia patients and inpatient nursing units
                the emergency department (ED) are                      who receive those patients
                not receiving antibiotics within 4 hours            D. Critical to quality and cost
                of arrival. Between July 2003 and July              E. Now a JCAHO core measure
                2005, 66.7% of pneumonia patients
                presenting through the ED received          VI.     Community-Acquired Pneumonia (CAP)
                antibiotics within 4 hours, significantly           A. Lower respiratory disease with wide-
                below the established goal of 92.0%.                   spread implications across the health
                                                                       care continuum.
      II.    Primary Metric Graph                                   B. Leading infectious cause of mortality
                                                                       in the United States
      III.   Objective Statements:                                  C. The fifth leading cause of death in
             A. Literature reveals that antibiotics given              those 65 years and older causing
                to community-acquired pneumonia                        approximately 45,000 deaths each year
                patients within 4 hours of arrival to               D. Significant expenditure of already
                the ED improve outcomes and reduce                     scarce health care dollars
                length of stay (LOS). The ED will
                improve the percent of pneumonia            VII.    Community-Acquired Pneumonia and the
                patients receiving antibiotics within 4             Emergency Department
                hours from a baseline level of 75% to               A. Common entry point into the health
                a goal of 92% by May 2006.                             care system for those patients suffering
                                                                       from CAP
      IV.    Describe the Business Problem                          B. Much of the care for these patients is
             A. With much of today’s health care                       initiated here and can have a consider-
                being driven towards benchmark qual-                   able impact on outcome
                ity and patient outcomes, Six Sigma                 C. “It seems intuitive that earlier adminis-
                can use these metrics to define deficits               tration is better than later since antibi-
                and improve quality without losing its                 otics are the definitive treatment for
                impact on efficiency. Prompt recogni-                  most pneumonia in adults”—Houck
                tion and treatment of community-                       and Bratzler
                acquired pneumonia is one such                      D. Early identification and rapid treatment
                benchmark being targeted by the                        of CAP relies heavily on the abilities of
                Centers for Medicare and Medicaid                      the staff and the resources available to
                Services (CMS) and University                          them in the emergency department
                HealthSystem Consortium (UHC).
                                                            VIII.   Community-Acquired Pneumonia and Six
      V.     Project Metrics:                                       Sigma
             A. Business metrics: length of stay, com-               A. Six Sigma process is referred to by the
                 plication rate, mortality rate                         acronym DMAIC (define, measure,
             B. Primary metric: percent of pneumonia                    analyze, improve, control)
                 patients receiving antibiotics within 4             B. Blueprint for the entire continued
H78              hours of arrival
         improvement objectives                                D. Improve
      C. Methodology that assists in the system-                  1. Consistency and reproducibility
         atical application and scientific exami-                 2. CAP order sets
         nation of existing processes which that                      a. Pharmacy/IDSA recommenda-
         fall below set parameters                                        tions
IX.   DMAIC Phases                                                    b. MD input
      A. Define—The project’s purpose and                         3. Radiology MD phones positive
         scope are defined. Background info                          results
         on the process and customer is col-                          a. Decrease delay waiting for CXR
         lected.                                                          findings
         1. Multidisciplinary team formed                         4. Staff training
         2. Problem statement defined                                 a. MD documentation of diagnosis
         3. Process-mapping techniques to                             b. RN documentation of critical
              illustrate entire process of care for                       times
              CAP patients                                        5. Six Sigma Gage R&R (reproducibil-
         4. Visualize and identify internal and                      ity & repeatability)
              external stakeholders                                   a. Triage case studies
         5. Team predicted that primary focus                  E. Control
              for potential solutions would be                    1. Project is placed back in direct
              on the following steps:                                supervision of the process owner
               a. Triage                                             or department who initiated it.
               b. RN education                                       May take a year or more.
               c. Physician evaluation                            2. Evaluate the effectiveness of the
               d. Documentation of clinical find-                    solutions and plan developed.
                   ings                                           3. Process owners have an accounta-
               e. Order sets                                         bility to outline steps for ongoing
      B. Measure                                                     improvements and to develop
         1. Focus improvement efforts where                          opportunities for replication.
              they have the greatest impact                       4. Maintain the gains!
         2. Data collection:
               a. Cycle times from ED tracking        X. Conclusion
                   system                                    A. “Is rapid administration even feasible?”
               b. Other cycle times needed                   B. Core measures/evidenced based
         3. Key interval target times were                   C. Six Sigma definitely suitable in this
              developed                                          application
         4. Understanding what the existing                  D. Success from this project may lend
              ED infrastructure is capable of                    itself to application in other core
      C. Analyze                                                 measures
         1. Competing diagnosis                                  1. Door to balloon
         2. Documentation                                        2. Door to ECG
               a. Exclusion and inclusion criteria               3. Door to CT scan
               b. Critical process times
         3. Communication                             Resources:
               a. RN/MD                               Barlow G., Davey P., & Nathwani, D. (2003).
               b. Pharmacy                            Evaluation of outcomes in community–acquired pneu-
               c. Radiology                           monia: A guide for patients, physicians, and policy-
         4. Lack of standardized process              makers. Lancet Infectious Diseases, 3(8), 476–488.
               a. Order Sets                          Bartlett, J., Breiman, R., Mandell, L., & File, T. (1998).
         5. Focus on greatest impact                  Community-acquired pneumonia in adults: guidelines
               a. Fishbone diagram                    for management. Clinical Infectious Diseases, 26,
         6. Key process elements                      811–838.
               a. Cause and effect matrix             Bartlett, J., Dowell, S., Mandell, L., File, T., Musher, D.,
                   i. What are the failures?          & Fine, M. (2000). Practice guidelines for the manage-
                   ii. What impact do they have?      ment of community-acquired pneumonia in adults.
               b. Failure Mode Effects Analysis       Clinical Infectious Diseases, 31, 347–382.
                   (FMEA)                             Battleman, D., Callahan, M., & Thaler, H. (2002). Rapid
                   i. How severe is this impact?      antibiotic delivery and appropriate antibiotic selection
                   ii. How often does it occur?       reduce length of hospital stay of patients with commu-
                                                      nity-acquired pneumonia. Archive of Internal
                                                      Medicine, 162, 682–688.

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