Hunterdon Medical Center – Case Study 1

The Hunterdon Medical Center is a 176-bed, non-profit community hospital serving the greater Flemington, NJ area.  It provides a full range of preventive, diagnostic, and therapeutic inpatient, outpatient, and community health services.  The center has an active continuous process improvement program focusing on the priorities of safety, quality, patient satisfaction, finances and the community.  DeBaylo Associates was asked to help the organization learn basic Six Sigma tools and apply them to a couple of critical clinical areas.  Two projects resulted.

Project 1 – ICU Central Line-Related Bacteremia (Blood Infections)

Challenge

Prior to the start of the project, the hospital was experiencing 3.3 infections per 1000 central line days. Central line infections in ICU patients not only lead to increased morbidity but had cost the medical center about $240,000 in 2005. The goals of the project were to reduce the infection rate to zero and reduce associated costs. The project scope went from the insertion of the catheter to the decision for discontinuation of use, and included dressing changes. 

Approach

The Six Sigma DMAIC methodology (PEP) was used by a core clinical team of doctors and nurses, an internal process improvement facilitator and an external consultant (DeBaylo Associates). Baseline measures were made observing the level of compliance with hospital protocols, including insertion procedures and dressing change procedures/frequency. Non-compliances were observed in the wearing of caps, skin preparation during dressing, and clave cleaning.

Current processes were reviewed against best practices for possible improvement opportunities. A process FMEA was performed to identify and eliminate high risk areas. Numerous improvements were proposed and implemented.  For example, error proofing techniques were used to assure the doctors wore their masks and caps during the insertion procedures. Behavior monitoring was implemented and the results were provided to the clinical teams. Guidelines for changing tubing, IV medication bags and adhesive skin preps were reviewed with nursing staff and included in their competency training. 

After the changes were made, a control plan was instituted to track insertion and dressing change behaviors. Data continues to be collected on the actual number of insertion and infections.  Education is provided to new intensivists and verified through observation. Education is also provided to new ICU nurses through self-learning packages and their knowledge verified by exam.

Results

During the project, physician compliance with Central Line guidelines continued to improve to the 100% level. Compliance with dressing changes were 100% with the exception of one area, which was later deemed as an optional step in the dressing change process.  Compliance with changing of claves (with each dressing change) increased from 50% to 70%.

During 2006, there were only 2 central line-related infections in the ICU.  One infection occurred prior to process changes being implemented.  The second infection occurred in a very sick patient with a failed immune system (i.e., non-protocol related). Sigma levels have increased by reducing defects (infections) per million opportunities from 4,660 to 330.  As of May 2007, there have been zero central line-related infections in the ICU for the year and during the 4^th quarter of 2006.

Morbidity was reduced and project savings exceeded $160,000.

The project has been published in the February 2007 issue of Critical Care Nurse and the hospital recently received the national Leadership Award in Clinical Excellence from VHA for the results achieved related to this project.