CUSP and the NCABSI project

1. CUSP and the NCABSI project NICU Affinity Group Emory Midtown Hospital May 9, 2012

2. Disclosures • Nothing to disclose • No discussion of “off-label” use of medications

3. Objectives • Be able to list key components of CUSP • Be able to discuss methods to engage staff in CUSP / NCABSI • Be able to describe NCABSI, including goals

4. CUSP • Comprehensive Unit-based Safety Program • Developed at Johns Hopkins University • Science of Safety - Dr. Peter Provonost • First used in Keystone Project in Michigan – reduced CLABSI state-wide • Used in the CLABSI and CAUTI projects from the American Hospital Association • Now a part of NCABSI

5. Key components of CUSP • Educate the team on the “Science of Safety” • Identify Defects (Staff Safety Assessment) • Engage Senior Executive Leadership • Learn from Defects • Implement Teamwork and Communication Tools

6. Engaging the Staff • Education of the staff as to the nature of the problem • Empower them to be the drivers of improvement with the CUSP program • Emphasize the patient at all times and relate the reason for the project back to them • Get the informal leaders on board • Frequent discussions about the program and the project

7. The problem • In the United States • 100,000 patients die every year from Healthcare Associated Infections (HAI) • The annual cost is ~ $30 billion • Of the 100,000 patient deaths, it is estimated that 30,000 – 60,000 are from Central Line Associated Blood Stream Infections (CLABSI) • However, elimination of CLABSI from the NICU is possible

8. How does your NICU compare to others? • Vermont Oxford Network for NICU data • Hospital Networks • Based on ownership, such as HCA • Based on specialty affiliations, such as CWISH (Council of Women’s and Infant’s Specialty Hospitals) • Based on physician groups, such as Pediatrix • “Every system is designed to achieve the results it gets”

9. Unit-Based • One of the keys of the CUSP program is that it is meant to be driven by those at the bedside • What is the next source of harm (or in NCABSI – infection) for our patients? • What can be done to prevent that harm (or infection)? • It is NOT a program that is handed down from the board or administration or nursing leadership • Executive leadership is critical to ensure that staff is safe to express opinions and contribute to discussion

10. Safe systems • Are standardized (Science vs. Art) • Checklists, such as those in aviation • Humans are NOT infallible • Are designed to find out when things go wrong and to learn from those events • Rely on diverse and independent input • Allow people to contribute in a “psychologically safe” way

11. Emphasize the patient • The patient should be at the heart of all • The NCABSI project has a video that all teams should watch, called the “Gabby” video. In the video, a father relates the story of his daughter, Gabby, who was born at 25 weeks and weighed 614 grams. Gabby was slowly but steadily improving, but then became ill and died from a CLABSI. • Relate similar stories from your own NICU

12. Engaging the physicians • A physician champion is critical • Respected • Knowledgeable • Willing to discuss the issues with other physicians • Have frequent discussions with the physician champion regarding progress and comparison to benchmarks • Other enticements with NCABSI • ABP maintenance of certification credit

13. NCABSI • Neonatal Catheter Associated Blood Stream Infections • 8 state collaborative • ~ 100 NICUs • ~ 7500 lines • ~ 60000 line days • Supported by American Hospital Association (AHA) with funding from Agency for Healthcare Research and Quality (AHRQ)

14. NCABSI goals • Reduce catheter related infections in participating NICUS by 75% over the course of the year long study • Utilize CUSP to change local NICU culture so that changes made become part of the norm • Lay the groundwork for individual CQI projects by developing a group of people familiar with the methodology • Lay a foundation for future multi-state collaborative projects

15. Each NICU creates a team • Project leader • Physician champion • Nurse manager champion • Executive champion • Infection control representative • Data entry contact • Other team members

16. Review the Action Plan • Each center reviews the action plan • Determine if there are significant differences between the action plan and the current practices in your NICU • Is there a reason for this difference? • Is the difference clinically significant? • Do we desire to change our current plan to be more consistent with the NCABSI project action plan? • Implement those changes you desire using a series of Plan-Do-Study-Act (PDSA) cycles

17. Data collection • Patients with central lines are enrolled through the NCABSI website • NCABSI • All data is collected through the website • Enter an insertion checklist form for each line placed • Enter a daily maintenance form • When the line is removed or a patient is discharged, enter that information on the website • Training videos are under “Data” in the “Resources” section of the website

18. NHSN data • National Healthcare Safety Network (NHSN) is an internet based surveillance system from the CDC • Most hospitals report NHSN data already • Infection control / prevention are generally familiar with the format and the requirements • This data will be entered through the NCABSI website as baseline for the 3-6 months prior to the project and monthly during the project

19. PDSA cycles • Look at your maintenance failures for potential system changes • Learning from defects (from CUSP) helps you identify how to address system failures • Make small changes – PDSA cycles should be rapid • Pilot changes on a limited basis • “A Primer on Quality Improvement Methodology in Neonatology”. Ellsbury, Ursprung. Clinics in Perinatology, 2010 Mar; 37(1): 87-99.

20. Pearls • Submit data on at least a weekly basis • Hold team meetings often – at least monthly to review progress and develop new rapid cycle changes to evaluate • Develop PDSA cycles with an end that is different from the project as a whole