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On The Cusp Journey: Sentara CarePlex Hospital

Gail J. Rudder RN, CRNI

Infection Preventionist

November 10th, 2011

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Understanding CUSP

• National Program to Improve Patient Safety and eliminate CLABSI

• PROJECT GOALS: To reduce the mean CLABSI rate to less than 1 per 1,000 catheter days; to improve safety culture by 50%

• Comprehensive Unit-based Safety Program• An intervention to learn from MISTAKES and

IMPROVE safety CULTURE

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Understanding CUSP

• Six elements of CUSP

- Evaluate the safety culture (Hospital

Survey On Patient Safety)

- Educate staff on the science of safety

- Identify defects in care

- Engage and partner with executive

- Learn from one defect per month

- Re-measure culture annually

Five Interventions for CLABSI Reduction

• Educate staff on evidence-based practices to reduce CLABSI

• Empower nurses to ensure compliance with best practice

• Provide feedback on infection rates at the unit level

• Assess progress monthly

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Hitting the Road and Getting Started

• Enrolled February 2010; initiated April 2010 • Kick-off meeting with Dr. Pronovost in Richmond• Identified the Team – initially ICU and IP&C • Reviewed Program Goals• Weekly immersion calls to review the components

of CUSP and its objectives.• Developed the meeting schedule• Pre-Implementation Check List

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Data Requirements• First Meeting: Assigned staff surveys –

Technology & Exposure; HSOPS; assigned deadlines for completion

• CLABSI Rate• Team Checkup Tool; Learning from Defects• Staff safety assessment• How will the next patient be harmed?• Assigned reporting and other action items to

team members

Sentara CarePlex CUSP Activities

• Expanded the team to include Administration, Critical Care Physicians, IV Therapy, ESD, Pharmacy and Respiratory Therapy

• 60% Critical Care Staff completed baseline assessment for HSOPS

• Staff assigned to watch 2 safety videos

- Preventing Errors through Safety Habits

- Sentara-specific “Science of Safety” CUSP video• Monthly team meetings and data submission via

MHA Care Counts

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What we Did; What we Found Out

• Monthly Team meetings and data submission

- Last CLABSI at SCH: April 2010 (4 as of April)

- Top barriers: Time & Buy-In• HSOPS baseline results obtained

o 61% staff completed the survey – Goal of 60%o Lowest scoring areas

- Overall perception of Patient Safety, Teamwork

Across Units, Non-punitive Response to Error, and

Handoffs & Transitionso Greatest Opportunity: Handoffs & Transitions (29%)

- Engage Unit-Based Safety Coaches

- Conduct Culture Debriefing/Focus Groups

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What we Did; What We Found Out

• Safety Videoo Preventing Errors through Safety Habits - > 80% ICU staff

viewedo Sentara-specific “Prevention of Blood-Stream Infections” video

made available on PLMS (educational intranet)

• Top 10 BSI Prevention Tipso Selection, Insertion & Maintenance (May/June 2010)o Develop new CVL Procedure to educate staff on process

aligned with best practice – focus on maximal sterile barriers for patient and staff inserting line

o Hand Hygiene - Opportunity for improvemento Reduction of device days

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• Nurse Empowerment – 20% of nursing staff felt empowered to stop procedure

• Physician engagement – low or no physician support/presence at unit level due to time constraints

• Daily Goals revised to focus on being concise and goal oriented in time specific terms.

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What we Did; What We Found Out

Recommendations and Focus

• All new staff view the Safety Video during GHO

• Sentara CUSP video • Staff education on CVL insertion procedure –

mass education for physician and nursing staff

• ? necessity and removal of device• Back to basics – Hand hygiene, scrub-the-

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Where We Are Today

• Hand hygiene increased• 3rd Quarter 2011: 89% (all disciplines)• 3rd Quarter 2010: 86% (all disciplines)• Compliance to MSB: 100%• Device dwell time decreased but still over

goal of 0.29 per 100 patient days

- DUR 3rd Qtr 2010: 0.53;

- DUR 3rd Qtr 2011: 0.46

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Where We Are Today:CLABSI

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“A thought which does not result in action is nothing much, and an action

which does not proceed from a thought is nothing at all ”

………….George Bernanos

QUESTIONS??

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