On The Cusp Journey Sentara Care Plex Hospital

On The Cusp Journey: Sentara Care. Plex Hospital Gail J. Rudder RN, CRNI Infection Preventionist November 10 th, 2011 11/10/2011 1

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 2

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 11/10/2011 3

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

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 5

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 11/10/2011 6

Sentara Care. Plex 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 11/10/2011 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 & Transitions o Greatest Opportunity: Handoffs & Transitions (29%) - Engage Unit-Based Safety Coaches - Conduct Culture Debriefing/Focus Groups 8

What we Did; What We Found Out • Safety Video o Preventing Errors through Safety Habits - > 80% ICU staff viewed o Sentara-specific “Prevention of Blood-Stream Infections” video made available on PLMS (educational intranet) • Top 10 BSI Prevention Tips o 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 improvement o Reduction of device days 11/10/2011 9

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. 11/10/2011 10

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-thehub campaign, PPE 11/10/2011 11

Where We Are Today • • • 11/10/2011 Hand hygiene increased 3 rd Quarter 2011: 89% (all disciplines) 3 rd 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 3 rd Qtr 2010: 0. 53; - DUR 3 rd Qtr 2011: 0. 46 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? ? 11/10/2011 14

11/10/2011 15