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11/10/2011 1
On The Cusp Journey: Sentara CarePlex Hospital
Gail J. Rudder RN, CRNI
Infection Preventionist
November 10th, 2011
11/10/2011 2
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
11/10/2011 3
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
11/10/2011 4
11/10/2011 5
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
11/10/2011 6
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
11/10/2011 7
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
11/10/2011 8
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
11/10/2011 9
• 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.
11/10/2011 10
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-
hub campaign, PPE 11/10/2011 11
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
11/10/2011 12
Where We Are Today:CLABSI
11/10/2011 13
“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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