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
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
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
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
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
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-
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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.
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(FMEA) Battleman, D., Callahan, M., & Thaler, H. (2002). Rapid
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