Using Six Sigma in Infection Prevention Brandi Cavegn MSN, RN – Green Belt Personal Background • Who am I? • And what is my background? • Greenbelt- Certified, part time • Other Belts? White, Yellow, Green, Black, Master Black 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. Sigma Scale Sigma Percent Defects per Defective Million 1 69% 691,462 2 31% 308,538 3 6.7% 66,807 4 0.62% 6,210 5 0.023% 233 6 0.00034% 3.4 7 0.0000019% 0.019 So what does that mean? 3.8 Sigma (99% good) 6 Sigma (99.99966% good) 5000 incorrect surgical 1.7 incorrect surgical operations per week operations per week 200,000 incorrect drug 68 incorrect drug prescriptions each year prescriptions each year Unsafe drinking water for One unsafe minute of almost 15 minutes per drinking water every day seven months 48,000 to 96,000 deaths 17 to 34 deaths attributed attributed to hospital to hospital errors each errors each year year. 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 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 Start with a Charter (Any template will do) Team Charter D M A I C Project : ? Prevention of Surgical site infections Business Case: Opportunity Statement Goal Statement Project Scope Process : Start Point : End Point : Project Plan Team Members Task/Phase Start Date End Date Actual End Champion : Process Owner : Master BB : Black Belt : Member : Member : 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 CDC’s 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 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) D-Team Members Team Member Name Responsibility Areas* Dr Uhing – NICU Medical Director Executive sponsor Brandi Cavegn (Clinical Transformation Project Managers / Greenbelts Project Mgr) Amy Stecker (Patient Care Regulatory Compliance Mgr. ) Tia Luangrath Liaison to project manager, Team communicator Carla Clemens (NICU) Team Member Kari Fixel (NICU) Team Member Kimberly Tritz (NNP) Team Member Amanda Kazda (CAT) Team Member Mary Firary (Pharmacy) Team Member Mary Rotar (Infection Control) Team Member Sunita Hermon (NICU leadership) Team Member Ann Grippe (APN) Team Member 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 Decision made to Line is inserted Line is maintained Line is removed place line 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 team’s scope. Is there anything that is outside the team’s 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 M- Data Measurement Plan Other Data How Data When that Samp Who Will Will Performanc Operational Source Will Data Should be le Collect Data be e Measure Definition and be Collected Size the Data Collect Location Collected at the ed Same Time How will data be used? How will data be displayed? M-Insertion vs. Maintenance Insertion Onset Date # of days until Insertion vs. date onset Maintenance 1/8/07 1/11/07 3 ?I 1/31/07 2/22/07 22 M 2/26/07 3/2/07 4 ?I 5/12/07 8/21/07 100 M 6/14/07 10/31/07 139 M 6/22/07 7/20/07 28 M 9/26/07 11/8/07 43 M 12/6/07 12/13/07 7 M 12/6/07 12/13/07 7 M 12/18/07 12/26/07 8 M M-Days Between Infection Rolling # of days 1/11/07 0 2/22/07 42 3/2/07 8 7/20/07 139 8/21/07 31 10/31/07 41 11/8/07 8 12/13/07 43 12/13/07 0 12/26/07 13 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) Rolling # of Days 150 Between infections, 100 Higher is Better Current Average 50 0 Goal 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 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. PICC & Broviac Line Maintance – process if no complications / everything normal Determine Check IV fluid Assess Line Assess date Assess date Secure line location of tip Check line rate & Transfer Document (intact leaking, for dressing for tubing (frequent (central / connections expiration monitoring) patient hourly redness of skin) peripheral) change change date Not everyone tightens PICC & Broviac Line Maintance – change dressing Determine dressing Get Remove old change is required Get second Open kit, 1st & 2nd Other supplies equipment Scan Wash Prepare Put sterile Open dressing (dressing is occlusive, person to person put on gathered & added A from supply supplies hands baby glove on supplies in kit (helper holding leaking, skin red* or heart / assist mask, pull curtain to sterile field baby & line) disk under tegaderm room Use decision criteria to I.D. supplies, where you Getting tegaderm into Trash – disposal determine if physicain should be need to go & where to tray, need smaller issue, maintainging contacted about redness. Do set up tegaderm for little babies, sterile evnironment if not change dressing if physician no sterile scissor, swab & you “hit hand” no new requests culuter H2O2 in kit gloves in kit Sterile person Assess line Apply H2O2 Repeat with Change to hands sterile Q tip (swab in a circular No Proceed Count hash and Wipe off line Betadine Betadine still Wipe off Recount A new sterile to helper and motion moving out with B marks insertion from line – do 3 with H2O2 (wait 2 minutes with wet saline hashmarks gloves placed on insertion betadine in place) Saline site times) site Yes Person holding picks not always up Q tip Dry with dry sterile 2 types documented gauze Note Skin prep Apply Chevron Variance- wipe all off or Loop the Secure dressing leave some, what to you B avoiding tegaderm line line line change & use to clean it line let dry over heart date Respiratory bullets Line might break PICC & Broviac Line Maintance – tip location Tip is not MD where it’s Call determines if Xray = potential failure mode suppose to Physician xray is ordered be needed Rev 7/9/08 Line Maintance – PICC & Broviac Tubing Change RN gathers supplies Get fluids Check Yes Hook to Prime (Syringes, tubing, (pharmacy or against Gloves on Syringe? MUL Get Air Out syringe tubing bedside) tubing extensions, connectors, computer (med tubing) stickers) No Prime Opening it up, Multiple times foam over need Connections (Hx/ Add filter A because multiple cleaning Quad/Bi/T-Com) syringes Alchohol Spike the Prime Bag the port bag tubing Place Purge Yes Clamp patient No Use saline Cut clamps Program Immediately Alcohol Connect A everything syringe line or bend Low rate to fill air Unclamp B with do-jab pumps infuse connection line on pumps pump line pocket No Yes Should we cut before prime Bending line or a New gloves Leave cap on clamp risk People put blunt cap on Use line to fill air pocket End in sterile vol feed Check lure lock – is there really air Secure line high in Infection possible air feeder pocket drip, drip, drip Tape bottle to pole Run Fluids Calc run time Double Push Double B Scan check with Start check second RN Some scan then Prime some prime and scan (policy saty scan when hung) 7/9/08 Entering a line meds Prepare to Syringe tubing No Prime tubing Place connector Scrub the Gather tubing Wash hands Connect to Connect enter line already hooked with normal on line Hub (STH) or Start infusion and meds Put gloves on Clave tubing to clave med up saline or med (alligator clip) Clave Yes Prime with med or NS Take flush off Scrub the Connect Wash hands of med tubing Drip med into Hub (STH) of syringe to Put gloves on and discard tubing med tubing tubing flush Giving Med in closest Port No STH with Wash hands Compatible Clamp STH with Administer Disconnect Gather Med Flush line alcohol Unclamp TPN Put gloves on with TPN TPN line alcohol wipe Med syringe wipe Yes Repeat steps with flush Vigorously rub after medication Place all four (back and forth) STH with corners over for 5 seconds alcohol wipe hub Saying “STH” 3 times = Possible failure mode Prepare medications Prepare Draw NS Cap syringe Yes Wash Needle on Need to in the Wipe prep Gather Alcohol NS off vial into Mix med with Gloves Take to Go to Hood Get med hands put med Obtain Meds Pharmacy area supplies Vial new and Saline needeless off bedside on gloves syringe syringe needle No Difference in Use of spray practice Get med from bottle NS to Med drawer at Med to NS bedside Bedside Process (Amp as example) Get sterile Gather Alcohol tops of Wipe down Gather Put all Shake or roll water from syringes, Go to Wash hands, sterile water and Draw up Inject water counter or med from supplies on Pop tops vial to mix A above needles, and bedside put on gloves amp vials, leave water into amp vial bedside cart drawer clean surface medication computers alcohol wipes wipe on vial Leave for 10 Draw up amp minutes to Mix med with Connect syringe Alcohol top of with new Remove A dissolve with normal saline to tubing or give amp syringe and needle alcohol wipe on for dilution in closest port needle top Difference in Practice Precipitate & clot lines NS-Med Med - NS = Possible failure mode Draw Blood (UAC) Carefully open Know the amt to Enter baby’s Silence gauze, wipes Turn Scrub the Take off STH and Put on waste be drawn and Wash hands area, prepare monitor (this syringes stopcock off stopcock syringe and clean off dries syringe and A gather supplies Put gloves on area on is only good 2 wipes for to patient connection discard it blood draw waste accordingly baby’s bed for 3 minutes) every syringe *What is P&P *Patient can move Place back on *What is literature on & contaminate sterile field “scrub the hub” before & field after syringe *Can cantaminate *Next to diaper change enering isolett area Place waste syringe on Turn Repeat for Hit silence Place all full Give back Place new Take waste Clean A sterile field or STH Stopcock each button as syringes on STH waste and flush on line Flush off stopcock back n back syringe nessecary sterile field STH and STH package *Drip *Silence button – *Get air out not clear *Hand going in & out of isolette handing off syringes = Possible failure mode 7/22/08 A- Use Your Tools Top-Down: the breaking down of a system to gin insight into its compositional sub-systems System: Placement and Care of Central Line in the NICU Sub-systems: Insertion of Maintain Medication Hand General Line Line preparation Washing Infection and Control administrati on Obtain sterile Knowledge of Hand washing Removal of Keep insertion supplies and line Jewelry and nail site dry, intact, cart accessories and covered Set up tray Asses line Obtain aseptic Roll-up sleeves Follow integrity medications or remove lab medication from pharmacy coat administration policy Position and Identification Dilution and Get scrub brush Scrub the Hub restrain and reconstitution of and turn on patient Intervention medication at water of bedside complications Line Maintenance Medication Hand washing IP practices insertions Time out Protect form Preparation Wet hands and Follow line tubing manipulating or of line and scrub brush policy pulling hook up Use of PPE- Dressing Scrub the Scrub hands for Follow isolation Sterile change Hub 2 minutes up to protocols elbows Draping and Tubing/cap/tree Flush before Clean Nails Wear clean gloves prepping change and after and change them patient/area medication when needed Line insertion Medication Rinse and Dry Hand Hygiene administration x-ray to check Blood draws Only direct patient placement care handle lines Line Documentation No ties, long adjustment sleeves, or lab coats and securement Family No food in patient education care areas x-rays (weekly) 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 SIPOC Supplier Input Process Output Customer * Hand washing policy * Decrease line * Babies * Distribution * Scrub Brush infection * Families *Central Supply * Water *Minimized transfer * CHW staff *Maintenance *Finance * Paper towels Hand Washing *Healthy Patient * Community * Type of Sink * Decrease germs * Payers *Peers * Nail Sticks * Clean hands * Regulatory agencies * Environmental * * Maintain skin integrity * Peers Removal of Scrub hands for 2 Roll-up sleeves or Get scrub brush Wet hands and jewlery and nail minutes up to Clean Nails Rinse and Dry remove lab coat and turn on water scrub brush accessories elbows SIPOC Supplier Input Process Output Customer * Decrease line * Distribution * CVL bundle literature infection *Sterile Supply * CVL orderset * Infant *Appropriate Line *Purchasing *Pharmacy orders * Family placement *Supply Techs * Assistant / Staff Line Insertion *Appropriate * Caregivers *NICU staff * Hospital securement / Dressing *Pharmacy * Payers *No Complications * X-Ray *Patient Skin Integrity * Staff safety (ie needle sticks) Line insertion and Obtain Supplies Position and Drape and prep Line adjustment and Set up tray Time out Use of PPE x-ray for and Cart restrain patient patient securement placement SIPOC Supplier Input Process Output Customer * Policy and Procedures * 0 Infections * Distribution * Order sets * Time limited use of * Babies * Purchasing * Med/Fluid Orders line * Families * Pharmacy * CVL Dressing Change * Decrease * CHW staff * Peers * Lab Kit Maintain Line complications to patient * Community * Tubing/Caps * decrease in line * Payers * Finance * Stickers/Labels breakage * Regulatory agencies * Physician * New IV bags * Decrease line * Peers * X-Ray *Med Syringes complications * Lab Vials * Alcohol Wipes * Sterile Gauze * Flushes Entering and Identification and Protect line from Assess Line (Type Tubing/Cap/Tree accessing line Intervention of manipulating or Dressing Change Documentation Family Education Weekly X- rays and Integrity) change (Medication or Complications pulling Blood draws) SIPOC Supplier Input Process Output Customer * Med administration * Babies * Pharmacist Policy * Families *Med Select * Syringe Pump Medication * Aseptic drug * CHW staff administration * Refrigerator * Lexi- Drugs Preparation and * 0 Infection rate * Community * Med Supply Room * Staffing Pharmacist * Payers * Med Drawer * C-Admin Administration * 0 Transfer of Germs * Regulatory agencies * Sunrise * Peers Dilution and Obtain aseptic reconstitution of Preparation of line Flush before and Handwashing medications from Scrub the Hub medication at hook up after medication pharmacy bedside SIPOC Supplier Input Process Output Customer * Line policy * Decrease line * Pump infection *No Complications * Infant * Distribution * Flushes *Clean Hub * Family *Sterile Supply *Alcohol * Caregivers *Supply Techs * Sterile Gauze Scrub the Hub * decrease germs * Hospital *Pharmacy * Gloves * Payers *Med-Select * Needle less system * regulatory agencies * Syringes * Betadine Scrub while Follow hand Gather supplies Prepare Area Open Supplies repeating phrase Hygeine three times 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 A- FMEA- Dressing Change Item Process Steps Potential Failure Mode Potential Effects of Potential Cause's) of Failure Failure Text Text Text Text Determine Dressing Change Not changed Moist Contamination Knowledge deficit (KD), is required lazy, it's not Tuesday, failure to look, assumptions, in a hurry What is literature on 7 day No clear decisions criteria dressing change? What's (occlusive non occlusive, reinforced? red, etc) Drsg may get changed twice KD - RN can get cx before if cx is needed new dressing placed on Get second person to assist Not getting 2nd person Contamination, loose line Too busy, staffing, needs to be changed immediately. A- FMEA Dressing Change Failure Mode Severity Frequency Costs and Ease # 1 Changing dressing H H L when due, & when it is loose #3, #8 Having proper H H M supplies # 11 Removing old H H M-L Dressing, no sterile field under arm/leg #12 Not Changing to new H M L sterile gloves # 13 Q-Tip contamination H H L # 16 Using Solutions out of H H L order # 18 Not letting Betadine H H L dry for 2 minutes # 23 Looping the Line H H L # 25 Correct placement and H H M use of Tegaderm A- FMEA Tubing Change Failure Mode Severity Frequency Costs and Ease #1 Bedside/ H H H Prep area not Clean #5 Priming H H M Connection/ Tubing #6 Alcohol Ports/ H H L “Scrub the Hub” # 7, #8 Spiking Bag, H H-M L Priming Tubing #13 Priming into Volu- H H M Feed/ and in areas where visitors are #16 Alcohol connection H H L point to patient # 18 Wearing gloves to H H L connect line 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 Answer:TRUE 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 Survey Results Incorrect Responses Correct Responses 70 65 60 55 50 45 40 Responses 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 Question Num ber 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 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 Parking lot • Track/follow CVL care in OR, how • New claves/posiflows, impregnated handled and if events occur lines, caths etc • Review NICU infection control policy • Hand washing in pharmacy • General Infection control-OR’s scrub • Med. Prep in pharmacy and at bedside routine vs. current NICU scrub • TPN/IL/meds under the hood • Update CVL P&P if changes identified • Patient handling and lines- Rad, PT, • Follow/track why CVLs discontinued OT, RT • Drsg changes, how done, by whom, • Mechanism that assists with switching when done, migration rate and infection from IV to PO meds occurrence • Order set re; above and for line • Chlorohexadine for line changes maintenance • Tubing change documentation, sticker • NICU CVL dressing team- core group use vs. whole unit – “super user” • Electronic documentation • Vanco Hep flushes • Medication Tubing change every 72 • Hub care hours vs. every 24 hours • Awareness Education on data/stats • Closest port to baby • Utilize on the pot educational sheets • Reduce amount of times lines are accessed 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 Questions?
Pages to are hidden for
"Project Disclaimer"Please download to view full document