Abstract：
BACKGROUND: Beta-lactam antibiotics are widely used in the intensive care unit due to their favorable effectiveness and safety profiles. Beta-lactams given to patients with sepsis must be delivered as soon as possible after infection recognition (early), treat the suspected organism (appropriate), and at a dose that eradicates the infection (adequate). Early and appropriate antibiotic delivery occurs in >90% of patients, but less than half of patients with sepsis achieve adequate antibiotic exposure. This project aimed to address this quality gap and improve beta-lactam adequacy using the DMAIC Lean Six Sigma quality improvement framework.
METHODS: A multidisciplinary steering committee was formed and completed a stakeholder analysis to define the gap in practice. An Ishikawa cause and effect (Fishbone) diagram was used to identify the root causes and an impact/effort grid facilitated prioritization of interventions. An intervention which included bundled education with the use of therapeutic drug monitoring (TDM; i.e., drug level testing) was projected to have the highest impact relative to the amount of effort and selected to address beta-lactam inadequacy in the critically ill.
RESULTS: The education and TDM intervention were deployed through a Plan, Do, Study, Act (PDSA) cycle. In the three months after \'go-live,\' 54 episodes of beta-lactam TDM occurred in 41 unique ICU patients. The primary quality metric of beta-lactam adequacy was achieved in 94% of individuals after the intervention. 94% of clinicians gauged the education provided as sufficient. The primary counterbalance of antimicrobial days of therapy, a core antimicrobial stewardship metric, was unchanged over time (favorable result; p=0.73).
CONCLUSIONS: Application of the DMAIC Lean Six Sigma quality improvement framework effectively improved beta-lactam adequacy in critically ill patients. The approach taken in this quality improvement project is widely generalizable to other drugs, drug classes, or settings to increase the adequacy of drug exposure.
METHODS: A multidisciplinary steering committee was formed and completed a stakeholder analysis to define the gap in practice. An Ishikawa cause and effect (Fishbone) diagram was used to identify the root causes and an impact/effort grid facilitated prioritization of interventions. An intervention which included bundled education with the use of therapeutic drug monitoring (TDM; i.e., drug level testing) was projected to have the highest impact relative to the amount of effort and selected to address beta-lactam inadequacy in the critically ill.
RESULTS: The education and TDM intervention were deployed through a Plan, Do, Study, Act (PDSA) cycle. In the three months after \'go-live,\' 54 episodes of beta-lactam TDM occurred in 41 unique ICU patients. The primary quality metric of beta-lactam adequacy was achieved in 94% of individuals after the intervention. 94% of clinicians gauged the education provided as sufficient. The primary counterbalance of antimicrobial days of therapy, a core antimicrobial stewardship metric, was unchanged over time (favorable result; p=0.73).
CONCLUSIONS: Application of the DMAIC Lean Six Sigma quality improvement framework effectively improved beta-lactam adequacy in critically ill patients. The approach taken in this quality improvement project is widely generalizable to other drugs, drug classes, or settings to increase the adequacy of drug exposure.
摘要：
背景：β-内酰胺抗生素由于其有利的有效性和安全性而被广泛用于重症监护病房。给予败血症患者的β-内酰胺必须在感染识别后尽快（早期），治疗可疑生物体（适当），并以根除感染的剂量（足够）。>90％的患者发生早期和适当的抗生素递送。但不到一半的脓毒症患者获得足够的抗生素暴露。该项目旨在解决这一质量差距，并使用DMAIC精益六西格玛质量改进框架提高β-内酰胺的充足性。
方法：成立了一个多学科指导委员会，并完成了利益相关者分析，以确定实践中的差距。使用Ishikawa因果图（鱼骨图）来确定根本原因，并且影响/努力网格促进了干预措施的优先次序。一种干预措施，包括捆绑教育和使用治疗药物监测(TDM；即，药物水平测试）预计相对于工作量的影响最大，并选择解决危重患者中β-内酰胺不足的问题。
结果：教育和TDM干预是通过计划进行部署的，Do,Study,行动（PDSA）循环。在\'上线后的三个月里，41例ICU患者发生了54例β-内酰胺TDM发作。干预后，94％的个体达到了β-内酰胺充足性的主要质量指标。94%的临床医生认为所提供的教育足够。抗菌治疗天数的主要平衡，一个核心的抗菌管理指标，随着时间的推移没有变化(良好的结果；p=0.73)。
结论：DMAIC精益六西格玛质量改进框架的应用有效地改善了危重患者的β-内酰胺充足性。本质量改进项目采取的方法可广泛推广到其他药物，药物类，或设置以增加药物暴露的充分性。
方法：成立了一个多学科指导委员会，并完成了利益相关者分析，以确定实践中的差距。使用Ishikawa因果图（鱼骨图）来确定根本原因，并且影响/努力网格促进了干预措施的优先次序。一种干预措施，包括捆绑教育和使用治疗药物监测(TDM；即，药物水平测试）预计相对于工作量的影响最大，并选择解决危重患者中β-内酰胺不足的问题。
结果：教育和TDM干预是通过计划进行部署的，Do,Study,行动（PDSA）循环。在\'上线后的三个月里，41例ICU患者发生了54例β-内酰胺TDM发作。干预后，94％的个体达到了β-内酰胺充足性的主要质量指标。94%的临床医生认为所提供的教育足够。抗菌治疗天数的主要平衡，一个核心的抗菌管理指标，随着时间的推移没有变化(良好的结果；p=0.73)。
结论：DMAIC精益六西格玛质量改进框架的应用有效地改善了危重患者的β-内酰胺充足性。本质量改进项目采取的方法可广泛推广到其他药物，药物类，或设置以增加药物暴露的充分性。
