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On The Cusp Journey: Sentara CarePlex Hospital. Gail J. Rudder RN, CRNI Infection Preventionist November 10 th , 2011. Understanding CUSP. National Program to Improve Patient Safety and eliminate CLABSI

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on the cusp journey sentara careplex hospital

On The Cusp Journey: Sentara CarePlex Hospital

Gail J. Rudder RN, CRNI

Infection Preventionist

November 10th, 2011

understanding cusp
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
understanding cusp1
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
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

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
data requirements
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
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
what we did what we found out
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
    • 61% staff completed the survey – Goal of 60%
    • Lowest scoring areas

- Overall perception of Patient Safety, Teamwork

Across Units, Non-punitive Response to Error, and

Handoffs & Transitions

    • Greatest Opportunity: Handoffs & Transitions (29%)

- Engage Unit-Based Safety Coaches

- Conduct Culture Debriefing/Focus Groups

what we did what we found out1
What we Did; What We Found Out
  • Safety Video
      • Preventing Errors through Safety Habits - > 80% ICU staff viewed
      • Sentara-specific “Prevention of Blood-Stream Infections” video made available on PLMS (educational intranet)
  • Top 10 BSI Prevention Tips
      • Selection, Insertion & Maintenance (May/June 2010)
      • Develop new CVL Procedure to educate staff on process aligned with best practice – focus on maximal sterile barriers for patient and staff inserting line
      • Hand Hygiene - Opportunity for improvement
      • Reduction of device days
what we did what we found out2
What we Did; What We Found Out
  • 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.
recommendations and focus
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
where we are today
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 3rdQtr 2010: 0.53;

- DUR 3rdQtr 2011: 0.46


“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 BernanosQUESTIONS??