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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??


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