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On the CUSP

Safety program makes its way cross-country

Monday April 18, 2011
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Committed to patient safety, critical care nurses are teaming up to create safer, more collaborative ICUs by implementing the Comprehensive Unit-based Safety Program. CUSP combines communication improvement initiatives and teamwork tools that can help enhance patient care and amplify safety practices. The program is making its way across the country, fueled by positive testimonials and impressive results.


Emily McGee-Pasola, RN, left, and Pat Posa, RN, review the “Huddle Board” on which they track progress for St. Joseph Mercy’s various safety initiatives.
(Photo courtesy of St. Joseph Mercy)
“The program has helped us tremendously,” says Sandra Simmons, RN, MSN, MHA, nursing director of the adult ICUs at HealthPark Medical Center, part of Lee Memorial Health System in Fort Myers, Fla. “We were doing a lot of technical things to help prevent infections, but what we were missing was a culture of safety. [CUSP] helped us to change our culture.”


Nancy Eisenhuth, RN
Simmons credits a multidisciplinary approach, engaging the front-line staff and reinforcing positive accomplishments with achieving a zero infection rate for more than a year. HealthPark has used CUSP to address multiple ICU patient safety issues.

“It’s more than about [infection] rates, it’s about doing the best practices consistently,” says Anne Van Waes, RN, director of infection control at Anne Arundel Medical Center in Annapolis, Md., which joined the project in August 2010.

CUSP, developed by Johns Hopkins Quality and Safety Research Group in Baltimore and deployed to hospitals throughout the U.S. with federal support, is designed to improve clinicians’ communication, awareness of safety and ability to learn from errors, and to help implement teamwork tools, says Christine A. Goeschel, RN, ScD, MPA, MPS, assistant professor at the Johns Hopkins University School of Medicine and director of strategic development and research initiatives at the Quality and Safety Research Group. ICUs merge CUSP with a series of interventions to translate clinical evidence into practice, often outlined as checklists, to decrease specific safety problems, such as central line-associated bloodstream infections or ventilator-associated pneumonia.


Sandra Simmons, RN
“When CUSP is combined with specific evidence-based improvement steps, CUSP can improve anything,” Goeschel says. “CUSP is a framework for any change you want to make where there is a gap between clinical evidence and current practice in your organization.”

Goeschel began the Michigan Health and Hospital Association Keystone ICU project in 2003 to reduce medical errors and improve patient safety. Seventy-five hospitals, with 120 ICUs, participate and collectively have achieved remarkable outcomes using CUSP, including an 8% decrease in hospital mortality.

From March 2004 until March 2010, more than 1,830 lives were saved, more than 140,700 excess hospital days were avoided and more than $300 million in healthcare dollars were saved as a result of CUSP initiatives, according to the 2010 MHA Keystone Center Annual Report. The VAP rate has decreased by 70% to less than 1.5 cases per 1,000 ventilator days in 2010. The CLABSI rate declined from 2.5 cases per 1,000 central line days in 2004 to 0.86 in 2009, according to the report.

“CUSP is the acronym for the cultural improvement work,” says Sam Watson, executive director of the MHA Keystone Center for Patient Safety and Quality. “It’s the cultural improvement that creates the sustainability of this work.”

Bundles

CLABSI

Appropriate use of hand hygiene
Use chlorhexidine for skin preparation
Full-barrier precautions during central venous catheter insertion
Avoid the femoral site when possible
Maintain a sterile field while inserting the line
Ask daily whether catheters can be removed

VAP

Elevate the head of the bed
Daily interruption of sedation infusions
Prophylaxis for peptic ulcer disease and deep venous thrombosis
Daily oral care with chlorhexidine

Source: Institute for Healthcare Improvement



Anne Van Waes, RN
CUSP Principles

Participants in a CUSP project initially learn about the science of safety, survey the unit for defects that could pose a risk to patients, come up with solutions to minimize hazards and strive to improve teamwork and communication. They analyze errors and discover system problems. “CUSP provides tools for learning to take place with executives, front-line caregivers, unit managers, docs, all at the table together,” Goeschel says.

Fostering that team approach takes work. St. Joseph Mercy Hospital in Ann Arbor, Mich., joined the MHA Keystone ICU project in 2004, at first focusing on CLABSI and then VAP. The health system has decreased CLABSI from 7.6 per 1,000 catheter days in 2004 to 0.88 in 2010, and it has saved nearly 300 lives. “Culture was a gradual change, and we are still working on it,” says Pat Posa, RN, BSN, MSA, system performance improvement leader for critical care at St. Joseph Mercy Health System.

“Putting in the checklist is not the answer. It’s the whole process of knowing each person is valuable and defects are not OK.”

Emily McGee-Pasola, RN, a clinical nurse leader at St. Joseph Mercy, says initially nurses often felt uneasy communicating with physicians as equal team members. “It’s difficult to implement change and ask staff nurses to do more, but when you have a team of people, you can show staff how doing what we ask them to do can positively impact the patient,” McGee-Pasola says.

St. Joseph Mercy’s CUSP team continues to set new goals and is now tackling sepsis, early mobility, appropriate sedation, delirium and other safety issues common in the ICU.

Success Spreads Across the Country

The Agency for Healthcare Research and Quality initially helped the Keystone Center and Johns Hopkins export the “On the CUSP: Stop BSIs” initiative to 10 states in 2008 by awarding the Health Research and Educational Trust a three-year, nearly $3 million grant. One year later, the federal agency provided nearly $7 million in funding to allow all states to take part. About 1,100 hospitals in 45 states and the District of Columbia are participating. An interim report released April 5 by AHRQ shows a 35% reduction in CLABSI in adult ICUs among 350 hospitals participating in the national project.

CLABSI rates dropped from an average of 1.8 infections to 1.17 infections per 1,000 central line days.

The shock trauma ICU at Crozer-Chester Medical Center in Upland, Pa., started working on CUSP in 2009, and has cut its CLABSI rate in half to 1.3 per 1,000 line days and dropped its VAP rate to 0.4 per 1,000 ventilator days. When an infection occurs, the CUSP team digs in to learn why it happened.

“The CUSP program, identifying defects was huge,” says Nancy Eisenhuth, RN, MSN, CEN, CCRN, NE-BC, clinical director of the shock trauma ICU and step down unit at CCMC. “Doing it with staff and getting their input was a wonderful thing. Nurses are more engaged, and that’s how you see the change.”

Nurses, physicians and other team members conduct focused rounding each morning in the shock trauma ICU to determine the plan of the day and the greatest safety risks for patients. The unit has applied CUSP concepts to new safety initiatives, such as preventing sepsis.

Memorial Regional Hospital South in Hollywood, Fla., launched its CUSP program two years ago and has seen infection rates decline and found a gradual improvement in staff members’ perceptions of the culture. For instance, in the past nurses typically accepted that critically ill patients with a central line would get an infection, but now they know they can prevent those complications, says Mary Guaracino, RN, CNO at Memorial South. “It was creating a team approach — not something pushed from administration, but brought up from the bedside caretaker,” Guaracino says. “Critical care nurses have always been an advocate, and the CUSP project fulfills that goal.”

The state hospital associations have created virtual learning communities. Participating hospitals take part in “immersion calls” learning from experts and sharing information. Eisenhuth says she found the calls helpful with brainstorming solutions. Van Waes agrees, saying her team has found the group teleconference sessions and listening to other ICUs’ successes great motivators.

On the CUSP continues to grow. As more hospitals join the initiative, nurses enjoy an opportunity to participate in new ways to enhance safety. “This is hard work,” Goeschel says. “But it’s hopeful and energizing to realize we have the potential to improve outcomes in a pretty dramatic way.”

To learn more about “On the CUSP: Stop HAI,” visit OntheCuspStopHAI.org.


Debra Ansombe Wood, RN, is a freelance writer.