On The Cusp Journey: Sentara CarePlex Hospital

1. On The Cusp Journey: Sentara CarePlex Hospital Gail J. Rudder RN, CRNI Infection Preventionist November 10th, 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

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

4. 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

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

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

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 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

13. Where We Are Today:CLABSI

14. “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??