Six Sigma Approach to Reduction of Central Venous Catheter-Related Bloodstream Infections

Florida Hospital
Orlando, Florida, USA



Jason C. Sniffen, DO, FACOI, Infectious Disease Specialist
Louis M. Guzzi, MD, FCCM
Lois Yingling, RN, MSN, CPHQ, Clinical Best Practice Implementation Coordinator
Christine A. Kaptur, RN, MA, CIC, LHRM, Director of Infection Control and Patient Safety
Lynette Tellefsen, RN, BSN, MPH, CIC, Assistant Director of Infection Control
Lauren Blough, RN, BS, CRNI, Educator/Clinical Specialist Venous Access Specialist Team
Nancy Madejski, RN, BSN, Administrative Nurse Manager, Medical Oncology
Laura Marek, BS, MT (ASCP), Laboratory Performance Improvement Coordinator
P. Gage Gwyn, MSN, ARNP-BC, CNS, OCN, Oncology/Hematology Clinical Nurse Specialist
Alice DeSantola, RN, LHRM, BSN, MS, Nursing Policy and In-service Education Coordinator
Kim Port, RN, CCRN, Assistant Nurse Manager, Cardiac Intensive Care Unit
Nellie Osterman, RN, MSN, CCRN, Cardiac Clinical Nurse Specialist
Lynn Rowe, RN, MSN, Renal and Multisystem Clinical Nurse Specialist
Elizabeth Joannou, Assistant Nurse Manager, Medical Oncology



Reduce the number of central venous catheter (CVC)-related bloodstream infection (BSI) cases within the scope of the project by 20 percent (or 16 cases in 2005) with a subsequent reduction of the overall BSI rate in 2005.



  • Monthly overall BSI rate per 1,000 patients days multiplied by 1,000
  • Monthly number of CVC-related BSIs in the adult population, excluding tunneled catheters, ports, Swan-Ganz, dialysis catheters, peripherals, and peripherally inserted central catheter (PICC) lines


The ongoing journey to reduce the BSI rate began in 2003. Six Sigma methodology was applied in 2004 with respect to the specific reduction of central venous catheter-related bloodstream infections for all adult inpatients system-wide with a confirmed BSI secondary to a CVC line, excluding tunneled catheters, ports, dialysis catheter, Swan-Ganz, peripherals and peripherally inserted central catheters (PICCs).

  • Deployed policy and procedure banning artificial nails for bedside caregivers.
  • Converted to 2 percent chlorhexadine with alcohol skin prep for all supply carts and some trays.
  • Distributed bloodstream infection self-learning packet with post test to nursing.
  • Began conversion to custom trays with maximal barrier precautions, 2 percent chlorhexadine with alcohol skin prep, and antimicrobial catheter for use in emergency department and inpatient nursing units. Trays used by anesthesiologists in the operating suite do not contain maximal barrier precautions.
  • Introduced hand hygiene campaign.
  • Drafted criteria for physician privileges to insert CVCs.
  • Revised infection control policy and procedure to align with changes.
  • Published article in internal physician newsletter.
  • Published an article in the nursing newsletter.
  • Developed Standard Operating Procedures (SOPs) for tray distribution to ensure emergency department and inpatient nursing units received trays with sterile garb.
  • Completed conversion to custom tray.
  • Identified need to “error proof” custom trays by including maximal barrier precautions in all custom trays as anesthesia trays are occasionally distribute to emergency department and inpatient units. IHI checklist to be included with tray.







Summary of Results / Lessons Learned / Next Steps

The overall BSI rate for 2003 was 0.64 with a decline to 0.36 in 2004, representing greater than a forty percent reduction.  The number of CVC-related BSI cases within the defined scope from January 2005 through July 2005 have been reduced by 17 cases which exceeds the target for the entire year of 20 percent (or 16 cases).

Lessons Learned:
  • Be passionate about the initiative.
  • Select team members who are passionate about patient safety and quality and will spread the word.
  • Mentor the team in Six Sigma methodologies.
  • Identify your stakeholders and develop strategies to improve buy-in.
  • Flow chart your process.
  • Identify the few critical Xs or drivers to help reach your goal.
  • Measure baseline data accurately.
  • Use a statistical software program to help analyze data.
  • Measure and communicate outcomes.
  • Use multiple lines of communication.
  • Error proof whenever possible. Maximal barrier precautions in all custom CVC trays would have eliminated distribution of the anesthesia trays without sterile barriers to the emergency room and inpatient nursing units which may not have ready access to maximal barrier precautions.
  • Ask leadership to help remove barriers.
  • Develop a plan to maintain success.


Contact Information

Lois Yingling, RN, MSN, CPHQ, Clinical Best Practice Implementation Coordinator
Florida Hospital

[Storyboard presentation at IHI's National Forum, December 2005]


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