Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU

J Am Coll Surg. 2005 Sep;201(3):349-58. doi: 10.1016/j.jamcollsurg.2005.04.027.


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.

Study design: 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.

MeSH terms

  • Algorithms
  • Bacteremia / epidemiology
  • Bacteremia / etiology
  • Bacteremia / prevention & control*
  • Catheterization / adverse effects*
  • Cross Infection / epidemiology
  • Cross Infection / etiology
  • Cross Infection / prevention & control*
  • Fungemia / epidemiology
  • Fungemia / etiology
  • Fungemia / prevention & control*
  • Humans
  • Incidence
  • Intensive Care Units / organization & administration*
  • Organizational Case Studies
  • Process Assessment, Health Care
  • Total Quality Management / methods*