Lean Six Sigma Projects

An opportunity to further reduce Primary Blood Stream Infections (BSI's) at Cancer Treatment Centers of America^® at Eastern Regional Medical Center were identified based on the increasing number of immunocompromised patients at the facility. BSI's in this patient population quickly resulted in increased length of stay as well as increased morbidity and mortality rates. In addition, the use of multiple antibiotics to treat BSI's frequently resulted in multi-drug resistant organisms (MDRO's) which further negatively impacted the patient's outcomes.

The goal of this project was to decrease the hospital acquired central line associated bloodstream infection rate from 5.47 per 1000 line days to 2.74 per 1000 line days by May 1, 2010.

• Reinforced competencies for all clinical Stakeholders involved in insertion and maintenance of central lines


• Physician and nurse collaboration process for prevention and early intervention of BSI's


• Quick guides were placed throughout the inpatient areas as visual reminders for best practice


• Education provided to all Registered Nurses and Physicians on The Institute for Healthcare Improvement (IHI) Bundle


• Created electronic BSI Prevention educational programs in the facility's Center for Learning system to allow Stakeholders working all shifts to review the programs at any time


• Created a tool for regular monitoring of all infusion devices by a select team not only to encourage diligent monitoring but to analyze collected data for continuous improvement


• Joined the Pennsylvania "on the Cusp: Stop BSI" program sponsored by The Healthsystem Association of Pennsylvania (HAP) – this is a national initiative to reduce central line associated blood stream infections