Comprehensive Unit based Patient Safety Program

Deepa Jose,RN,CCRN.

Unit Based Patient Safety Program

MedStar Franklin Square Medical Center Intensive care unit

What is CUSP?

The Comprehensive Unit-Based Safety Program (CUSP) was designed to improve safety culture and learn from mistakes (two components of a safety scorecard) by integrating safety practices into the daily work of a unit or clinical area

5 steps in CUSP• Educate staff on the science of safety

training.• Staff identify defects.• Executive partnership.• Begin learning from defect.• Implement teamwork tools.

Is it safe for your patient?What is the best way to do it?

ICU Top Ten quality Initi ati ves 1. Preventing Falls2. Preventing Pressure Ulcers3. Improve Patient Satisfaction -Hourly Rounding & Prompt Call

Bell Response4. Prevent CAUTIs – REMOVE FOLEY ASAP!5. Preventing CLABSI – Remove Central Lines ASAP6. Preventing MRSA & VRE Transmission7. Preventing Ventilator Associated Pneumonias – Q4 hour

mouth care8. Enhancing Communication – Bedside Reporting, Include

Patient in Plan of care, and teach about meds & 9. Improving Hand Hygiene & Isolation compliance10. Family Meetings by Day 5 for ALL Patients – Palliative Care

Members of the team• RNs• Multifunctional techs• Respiratory therapists• Physicians• Physician assistants• PT & OT.• House keeping staff.• Unit secretaries

Purpose of the Team• Create a multidisciplinary team to identify defects in

the delivery of care • Identify barriers contributing to defects in the

delivery of safe and efficient care • Develop strategies to remove barriers and prevent

defects in the future • Create a “Culture of Safety” through improved peer

to peer accountability and interdisciplinary relations • Minimize variability in practice to standardize the

delivery of care • Identify and share best practices

Preventing central line infections• Use Procedure Cart for ALL Central Line

insertions• Complete Central Line Checklist for ALL line

insertions• Use Maximum Barrier Precautions for Central

Line Insertions• Pause for a Cause• Proper Hand Hygiene Before & After Procedure

CLABSI prevention

Hand Washing Campaign

• Hand hygiene posters in each room

• Hand sanitizer wipes on patient meal trays

• Associates starts wearing the sign

Key Focus of ICU CUSP program

Unit activities• Monthly patient safety meeting.• Leadership safety rounds.• Publish data of CLABSI and CAUTI.• Staff education about new initiatives and

the outcomes of new program.

New central line dressing

• ICU started using Sobra View ultimate dressing for all central lines.

• Apply biopatch at insertion site

CHG( Chlorhexidine Gluconate) bath

• Daily CHG baths to all ICU patients with central line or Foley catheter.

ICU/2T team

CLABSI Data

July

Aug

Sept

Oct

Nov

Dec

Jan

Feb

Mar

April

May

June

VAP Infection Rate*

000000000000CAUTI Infection Rate*

0.51.52.5

ICU DEVICE-ASSOCIATED GRAPHFY 2012

CAUTI

CLABSI

Falls

HAPU

Future Goals

• Expand the program to all inpatient units.

• Get more involved with the Maryland state STOP HAI program.

• Ongoing staff education and training.• Ongoing program evaluation and

accurate data collection.