1. 11/10/20111 On The Cusp Journey: Sentara CarePlex Hospital Gail J. Rudder RN, CRNI Infection Preventionist November 10 th, 2011

2. 11/10/20112 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. 11/10/20113 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 11/10/20114

5. 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. 11/10/20116 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 11/10/20117

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 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 11/10/20118

9. 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 11/10/20119

10. 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. 11/10/201110 What we Did; What We Found Out

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 11/10/201111

12. Where We Are Today 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 11/10/201112

13. Where We Are Today: CLABSI 11/10/201113

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 Bernanos QUESTIONS?? 11/10/201114

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