Comprehensive Unit-based Safety Program Research Articles

Reducing Central Line–Associated Bloodstream Infections in Three ICUs at a Tertiary Care Hospital in the United Arab Emirates

Central line-associated bloodstream infection (CLABSI) is associated with significant morbidity and mortality. A quality improvement project was conducted to decrease CLABSI rates by 50% across all ICUs in a tertiary care hospital (Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates). A multifaceted interventional program was implemented in a drive to reduce CLABSI rates. Stage 1 of the intervention entailed implementation of a central line insertion bundle, an insertion checklist, dedicated central line trolleys, education of all staff involved in insertion and maintenance of central lines, and empowerment of nurses. Stage 2 entailed implementation of a maintenance bundle and a CLABSI prevention policy and inclusion of central line assessment in the daily goals. Stage 3 was implemented in the form of CLABSI champions, spot checks on maintenance techniques, and review of every CLABSI. Stage 4 entailed the implementation of a Comprehensive Unit-based Safety Program (CUSP). Stage 5 consisted of a "back to basics" campaign, which included refocusing on basic evidence-based care bundles, introduction of bundle-compliance verification, and educational sessions and awareness programs. Overall CLABSI rates significantly decreased (p < .0001) from a mean of 2.99 (standard deviation [SD], 1.69) in the preimplementation period (January 2008-June 2011) to 1.47 (SD, 1.01) in the postimplementation period (July 2011-August 2014) across all ICUs. Overall, there were significantly more months with CLABSI-free days in the post-implementation than in the preimplementation period. The combination of evidence-based interventions, standardization of procedures, teamwork, and front-line staff involvement in the decision-making process contributed to decreases in CLABSI rates across three ICUs.

Measurement of implementation components and contextual factors in a two-state healthcare quality initiative to reduce ventilator-associated pneumonia.

To develop and field test an implementation assessment tool for assessing progress of hospital units in implementing improvements for the prevention of ventilator-associated pneumonia (VAP) in a two-state collaborative, including data on actions implemented by participating teams and contextual factors that may influence their efforts. Using the data collected, learn how implementation actions can be improved and analyze effects of implementation progress on outcome measures. We developed the tool as an interview protocol that included quantitative and qualitative items addressing actions on the Comprehensive Unit-based Safety Program (CUSP) and clinical interventions for use in guiding data collection via telephone interviews. We conducted interviews with leaders of improvement teams from units participating in the two-state VAP prevention initiative. We collected data from 43 hospital units as they implemented actions for the VAP initiative and performed descriptive analyzes of the data with comparisons across the 2 states. Early in the VAP prevention initiative, most units had made only moderate progress overall in using many of the CUSP actions known to support their improvement processes. For contextual factors, a relatively small number of barriers were found to have important negative effects on implementation progress (in particular, barriers related to workload and time issues). We modified coaching provided to the unit teams to reinforce training in weak spots that the interviews identified. These assessments provided important new knowledge regarding the implementation science of quality improvement projects, including feedback during implementation, and give a better understanding of which factors most affect implementation.

Implementing Unique Comprehensive Unit-Based Safety Program (CUSP) Initiative

Implementing Unique Comprehensive Unit-Based Safety Program (CUSP) Initiative

Introduction to "preventing healthcare-associated infections: results and lessons learned from AHRQ's HAI program".

Affiliations: 1. Agency for Healthcare Research and Quality, Rockville, Maryland; 2. RAND Corporation, Santa Monica, California; 3. IMPAQ International, LLC, Columbia, Maryland. Received June 9, 2014; accepted June 16, 2014; electronically published September 15, 2014. 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/35S3-0001$15.00. DOI: 10.1086/677817 For over a decade, the Agency for Healthcare Research and Quality (AHRQ) has invested in research and implementation projects to prevent healthcare-associated infections (HAIs) in diverse healthcare settings. AHRQ’s commitment to HAI prevention has been expressed in activities within the agency and through its funding of contracts and grants. In 2011, AHRQ funded IMPAQ International and the RAND Corporation to conduct a synthesis of results of AHRQ-funded HAI projects to identify the major results and lessons learned stemming from AHRQ-funded research, disseminate this information, and identify remaining gaps in the HAI knowledge base. To accomplish these goals, the synthesis draws information from AHRQ-funded project documents (final reports, peerreviewed literature, and HAI-prevention tool kits), in-depth interviews with project leaders, and the AHRQ-published Advances in the Prevention and Control of HAIs, which focuses on methods. In addition, the present volume, “Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ’s HAI Program,” is one of two supplements published in peer-reviewed infection control journals. The American Journal of Infection Control is publishing the other special supplement. Both publications are key information sources for the synthesis project and the field and serve as valuable mechanisms for disseminating the scientific results of the HAI projects. This volume presents 18 manuscripts developed by AHRQfunded HAI project leaders who have agreed to share important scientific findings. The articles examine epidemiological topics such as regional variation in catheter-associated urinary tract infection and urinary catheter use; the spread of multidrug-resistant organisms (MDROs) between nursing homes and acute care hospitals; risk factors and detection of surgical site infections; mortality among patients with healthcare-associated pneumonia; age, gender, racial, and ethnic disparities in HAI rates; and resistance of Staphylococcus aureus to zinc and cadmium. In addition, the studies included herein report results related to HAI-prevention and quality-improvement efforts, such as effectiveness of and cost savings from universal methicillin-resistant Staphylococcus aureus decolonization versus screening and isolation and targeted decolonization; development of a tool to assess the Comprehensive Unit-Based Safety Program to Eliminate Ventilator-Associated Pneumonia implementation progress; effectiveness of antibiotic stewardship programs in acute care hospitals, skilled nursing facilities, pediatric primary care practices, and assisted living; and the use of microbiology data to notify infection preventionists about admission of patients with MDROs. Collectively, the articles presented in this volume contribute substantially to HAIprevention science, and we trust they will be of interest to readers of this journal.

Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections

Central line (CL)-associated bloodstream infections (CLABSI) are an important cause of patient morbidity and mortality. Novel strategies to prevent CLABSI are needed. We described a quasiexperimental study to examine the effect of the presence of a unit-based quality nurse (UQN) dedicated to perform patient safety and infection control activities with a focus on CLABSI prevention in a surgical intensive care unit (SICU). From July 2008 to March 2012, there were 3,257 SICU admissions; CL utilization ratio was 0.74 (18,193 CL-days/24,576 patient-days). The UQN program began in July 2010; the nurse was present for 30% (193/518) of the days of the intervention period of July 2010 to March 2012. The average CLABSI rate was 5.0 per 1,000 CL-days before the intervention and 1.5 after the intervention and decreased by 5.1% (P = .005) for each additional 1% of days of the month that the UQN was present, even after adjusting for CLABSI rates in other adult intensive care units, time, severity of illness, and Comprehensive Unit-based Safety Program participation (5.1%, P = .004). Approximately 11.4 CLABSIs were prevented. The presence of a UQN dedicated to perform infection control activities may be an effective strategy for CLABSI reduction.

Building a Business Case for Colorectal Surgery Quality Improvement

Improving surgical quality is a priority, but building a business case for the efforts could be challenging. Bridging the gap between the clinicians and hospital leaders is the first step to align quality and financial priorities within health care. The aim of this study was to evaluate the financial impact of the surgical comprehensive unit-based safety program on colorectal surgery procedures. This a retrospective cohort study. This study was conducted at a university-based tertiary care hospital. All patients undergoing colectomy or proctectomy between July 2010 and June 2012 were included. A comprehensive unit-based safety program focused on colorectal surgical site infection reduction was implemented. Three surgeons participated in the program in year 1, and 5 surgeons participated in year 2. Patients were categorized as participating or nonparticipating based on the surgeon who performed the procedure. Resource utilization and cost were the main outcome measures. During the 2 years, there were 626 patients who met the selection criteria. Participating surgeons operated on 444 patients (70.9%), and the nonparticipating surgeons operated on 182 patients (29.1%). After adjusting for covariates, the variable direct cost was significantly lower for the participating surgeons in laboratory work by $191 (p = 0.009), operating room utilization by $149 (p = 0.05), and supplies by $615 (p = 0.003). The surgical site infection rates, need for an intensive care unit stay, and length of stay were not significantly different between the 2 groups. The multiple biases related to surgeon self-selection for program participation and surgeon training and clinical skills were not addressed in this study owing to the limitations in sample size and data collection. A comprehensive unit-based safety program implementation, including dedicated frontline providers who focused on the standardization of protocols, was able to reduce the variation in resource utilization and costs in comparison with a control group.

Hypotension: Preventing the Fall

Childbearing Poster Presentation Purpose for the Program The staff in the labor and delivery (L&D) unit at Baylor University Medical Center noticed an increased incidence of hypotension after epidural placement, which required ephedrine for treatment. Data collection began to determine if the perception was accurate and if there were recognizable patterns. Initial surveys that evaluated knowledge regarding hypotension were given to various nurses on each shift. Additionally, 69 retrospective random chart audits were conducted, which evaluated baseline blood pressure before and after epidural placement and evaluated the use of ephedrine to treat hypotension. Our initial data suggested a staff knowledge deficit and a postepidural hypotension rate of 22.67%. Proposed Change The L&D Comprehensive Unit‐Based Safety Program (CUSP) felt this data reflected a quality improvement opportunity. Based on our process modeling flow chart and fishbone diagram, we developed a goal to reduce postepidural hypotension in the obstetric patient population by 5% with the implementation of nursing education and clarification of order sets. Implementation, Outcomes, and Evaluation To correct the knowledge deficit and inconsistent use of order sets, we developed and provided educational in‐services. The in‐services focused on potential exaggerating or precipitating factors and the prevention and corrective measures of postepidural hypotension. We also focused on improving communication between registered nurses (RNs) and anesthesiologists, empowering the RNs to ask more questions regarding procedure type, medications given, timing, and amount of preload versus co‐load. Additionally, our documentation system was revised to facilitate improved documentation of interventions, including intravenous fluid bolus timing and amount. Biweekly random chart audits were performed to evaluate progress and percentage of hypotension. Through standardized education and improved collaboration between RNs and anesthesiologists, Baylor University Medical Center's hypotension rate in the obstetric population decreased from 22.67% to 8%. Implications for Nursing Practice Though literature states that hypotension affects up to 80% of parturient women, we aim to decrease the incidence of maternal/fetal response and promote safe passage with efforts focused on prevention, recognition, and early intervention,

Maintaining and Sustaining the On the CUSP: Stop BSI Model in Hawaii

Hawaii joined the On the CUSP: Stop BSI national effort in the United States in 2009 (CUSP stands for Comprehensive Unit-based Safety Program). In the initial 18-month study evaluation, adult ICUs decreased central line-associated bloodstream infection (CLABSI) rates by 61%. The impact of a series of novel strategies/tools in reducing infections and sustaining the collaborative in ICUs and non-ICUs in Hawaii was assessed. This cohort collaborative consisted of 20 adult ICUs and 18 nonadult ICUs in 16 hospitals. Hawaii developed and implemented six tools between July 2010 and August 2011: a tool to investigate CLABSIs, a video to address cultural barriers, a standardized dressing change kit, a map of the cohort's journey, a 12-strategies leadership dashboard, and a geometric plot of consecutive infection-free days. The primary outcome measure was overall CLABSI rates (mean infections per 1,000 catheter-days). A comparison of baseline data from 28 ICUs with 12-quarter (36-month) postimplementation data indicated that the CLABSI rate decreased across the entire state: overall, 1.57 to 0.29 infections/1,000 catheter-days; adult ICUs, 1.49 to 0.25 infections/1,000 catheter-days; nonadult ICUs, 2.54 to 0.33 infections/1,000 catheter-days, non-ICUs (N= 14), 4.52 to 0.25 infections/1,000 catheter-days, and PICU/NICU (N = 4), 2.05 to 0.53 infections/1,000 catheter-days. Days between CLABSIs in the adult ICUs statewide increased from a median of 5 days in 2009 to 70 days in 2011. Hawaii successfully spread the program beyond adult ICUs and implemented a series of tools for maintenance and sustainment. Use of the tools shaped a culture around the continued belief that CLABSIs can be eradicated, and infections further reduced.

Decreasing Central-Line–Associated Bloodstream Infections in Connecticut Intensive Care Units

Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.

A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*

To determine the causal effects of an intervention proven effective in pre-post studies in reducing central line-associated bloodstream infections in the intensive care unit. We conducted a multicenter, phased, cluster-randomized controlled trial in which hospitals were randomized into two groups. The intervention group started in March 2007 and the control group started in October 2007; the study period ended September 2008. Baseline data for both groups are from 2006. Forty-five intensive care units from 35 hospitals in two Adventist healthcare systems. A multifaceted intervention involving evidence-based practices to prevent central line-associated bloodstream infections and the Comprehensive Unit-based Safety Program to improve safety, teamwork, and communication. We measured central line-associated bloodstream infections per 1,000 central line days and reported quarterly rates. Baseline average central line-associated bloodstream infections per 1,000 central line days was 4.48 and 2.71, for the intervention and control groups (p = .28), respectively. By October to December 2007, the infection rate declined to 1.33 in the intervention group compared to 2.16 in the control group (adjusted incidence rate ratio 0.19; p = .003; 95% confidence interval 0.06-0.57). The intervention group sustained rates <1/1,000 central line days at 19 months (an 81% reduction). The control group also reduced infection rates to <1/1,000 central line days (a 69% reduction) at 12 months. This study demonstrated a causal relationship between the multifaceted intervention and the reduced central line-associated bloodstream infections. Both groups decreased infection rates after implementation and sustained these results over time, replicating the results found in previous, pre-post studies of this multifaceted intervention and providing further evidence that most central line-associated bloodstream infections are preventable.

Hospitals Slash Central Line Infections With Program That Empowers Nurses

IT’S BEEN 31 MONTHS SINCE A PAtient in the intensive care unit has developed a central line–associated bloodstream infection (CLABSI) at the Peterson Regional Medical Center in Kerrville, Tex, said nurse educator Theresa Hickman, RN, during a press briefing in September. Hickman credits this achievement— eliminating infections that were once considered inevitable—to the staff of the 125-bed rural hospital, which implemented the Comprehensive Unitbased Safety Program (CUSP), an initiative being rolled out at hospitals nationwide to curb hospital-acquired infections. Hickman described it as the most powerful quality improvement effort she’s encountered in her 32-year career. What makes it different from many other efforts is that it empowers nurses and other frontline caregivers to identify and fix problems that may compromise patient safety. “We listen to the wisdom of our frontline caregivers,” she said. And she’s not alone in singing the praises of the program. Over the past 4 years, CUSP has been rolled out at 1100 intensive care units across the country, and preliminary data suggest that the effort has cut the rate of CLABSIs nationally by 40%, reducing the rate of infections per 1000 centralline days from 1.9 to 1.1. According to Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), which sponsored the project, the program has prevented 2000 infections, saved 500 lives, and saved $34 million in health costs. “This could be health care’s man-onthe-moon moment,” said Peter Pronovost, MD, senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, who created the program with colleagues at Hopkins and has been testing its effectiveness.

Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections

Surgical site infections (SSI) are a common and costly problem, prolonging hospitalization and increasing readmission. Adherence to well-known infection control process measures has not been associated with substantial reductions in SSI. To date, the global burden of preventable SSI continues to result in patient harm and increased health care costs on a broad scale. We designed a study to evaluate the association between implementation of a surgery-based comprehensive unit-based safety program (CUSP) and postoperative SSI rates. One year of pre- and post-CUSP intervention SSI rates were collected using the high-risk pilot module of the American College of Surgeons National Surgical Quality Improvement Program (July 2009 to July 2011). The CUSP group met monthly and consisted of a multidisciplinary team of front-line providers (eg, surgeons, nurses, operating room technicians, and anesthesiologists) who were directly involved in the care of colorectal surgery patients. Surgical Care Improvement Project process measure compliance was monitored using standard methods from the Centers for Medicare and Medicaid Services. In the 12 months before implementation of the CUSP and interventions, the mean SSI rate was 27.3% (76 of 278 patients). After commencement of interventions, the rate was 18.2% (59 of 324 patients) for the subsequent 12 months--a 33.3% decrease (95% CI, 9-58%; p < 0.05). The interventions included standardization of skin preparation; administration of preoperative chlorhexidine showers; selective elimination of mechanical bowel preparation; warming of patients in the preanesthesia area; adoption of enhanced sterile techniques for skin and fascial closure; addressing previously unrecognized lapses in antibiotic prophylaxis. There was no difference in surgical process measure compliance as measured by the Surgical Care Improvement Project during the same time period. Formation of small groups of front-line providers to address patient harm using local wisdom and existing evidence can improve patient safety. We demonstrate a surgery-based CUSP intervention that might have markedly decreased SSI in a high-risk population.

Reduction of Central Line Associated Bloodstream Infections in the BMT Population

Decrease central line associated bloodstream infections (CLABSI) in the adult blood and marrow transplant/hematology/oncology unit utilizing comprehensive unit based safety program (CUSP). Increased incidence of CLABSI within inpatient BMT unit. CLABSI contributes to prolonged length of stay, increased costs, co-morbidity, and mortality. Elimination of CLABSI and/ or to reduce rate as low as feasible for identified patient population. CLABSI result annually in estimated 84,000-204,000 preventable infections, 10,000-25,000 preventable deaths and $1.7 – 21.4 billion avoidable costs. Multidisciplinary group formed to identify deficits and interventions needed for improvement. Participation began December 2011 in national CUSP and CLABSI reduction program through Kansas Healthcare Collaborative program. Nursing staff, hospital and unit leadership, infection prevention and BMT physician attended the conference. Multidisciplinary team was instrumental in developing strategies to reduce CLABSI rates. Data was collected and reported monthly. Quality improvement opportunities identified and implemented. Monthly CLABSI meetings established. Education and training issues identified and implemented. Deficits were evaluated and action plans initiated. Infection prevention nurses presented all BMT CLABSI for review and roundtable discussion. Investigation tool executed after prompt notification of CLABSI. Letter to staff caring for patient sent for further examination and identification of potential deficits possibly leading to CLABSI. Various education topics were presented to staff, patients and families consistent with enforcing infection prevention practices and proper line maintenance. During fiscal year 2010, BMT/Heme/Onc unit combined had 29 CLBSI identified with 20 among the BMT patient population, resulting in an overall 2.02 CLABSI rate per 1000 patient days. During fiscal year 2011, BMT/Heme/Onc unit combined had 15 CLBSI identified with 9 among the BMT patient population, resulting in a 1.01 CLABSI rate per 1000 patient days. There was a 50 percent reduction in CLABSI from FY10 to FY11. Methods to decrease incidence of CLABSI in BMT patients were identified and successfully implemented through the use best practices and increased awareness developed by a multidisciplinary team to identify all opportunities for improvement.

Michigan Health & Hospital Association Keystone Obstetrics: A Statewide Collaborative for Perinatal Patient Safety in Michigan

Preventable harm to mothers and infants during labor and birth is a significant patient safety and professional liability issue. A Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Obstetric Collaborative Project involved perinatal teams from 15 Michigan hospitals during an 11-month period in 2009. The purpose of the project was to promote safe care practices during labor and birth using the Comprehensive Unit-based Safety Program (CUSP). Consistent with the CUSP model, this project's components included assessing and promoting a culture of safety; interdisciplinary team building; case review; learning from defects through multiple methods of education; team and individual coaching and peer encouragement; administrative support for the establishment of a fundamental safety infrastructure; and ongoing evaluation of care processes and outcomes. Study measures included 32 components of a perinatal patient infrastructure, 6 care processes during labor and birth, and 4 neonatal outcomes. Significant improvements were found in the safety culture (Safety Attitudes Questionnaire), the perinatal patient safety infrastructure components, and all care processes. Although the project was successful, getting buy-in from all members of the clinical team in each hospital for all of the measures was challenging at times. There was initial resistance to some of the measures and their various expected aspects of care. For example, some of the clinicians were initially reluctant to adopt the recommended standardized oxytocin protocol. Peer encouragement and unit-based feedback on progress in minimizing early elective births proved useful in many hospitals. A CUSP in obstetrics can be beneficial in improving the care of mothers and infants during labor and birth.

Eradicating Central Line–Associated Bloodstream Infections Statewide

The authors' goal was to determine if a national intensive care unit (ICU) collaborative to reduce central line-associated bloodstream infections (CLABSIs) would succeed in Hawaii. The intervention period (July 2009 to December 2010) included a comprehensive unit-based safety program; a multifaceted approach to CLABSI prevention; and monitoring of infections. The primary outcome was CLABSI rate. A total of 20 ICUs, representing 16 hospitals and 61 665 catheter days, were analyzed. Median hospital bed size was 159 (interquartile range [IQR] = 71-212) and median ICU bed size was 10 (IQR = 8-12). Median unit catheter days per month were 112 (IQR = 52-197). The overall mean CLABSI rate decreased from 1.5 infections per 1000 catheter days at baseline (January to June 2009) to 0.6 at 16 to 18 months postintervention (October to December 2010). The median rate was zero CLABSIs per 1000 catheter days at baseline and remained zero throughout the study period. Hawaii demonstrated that the national program can be successfully spread, providing further evidence that most CLABSIs are preventable.

Assessing and improving safety climate in a large cohort of intensive care units*

To evaluate the impact of a comprehensive unit-based safety program on safety climate in a large cohort of intensive care units participating in the Keystone intensive care unit project. A prospective cohort collaborative study to improve quality of care and safety culture by implementing and evaluating patient safety interventions in intensive care units predominantly in the state of Michigan. The comprehensive unit-based safety program was the first intervention implemented by every intensive care unit participating in the collaborative. It is specifically designed to improve the various elements of a unit's safety culture, such as teamwork and safety climate. We administered the validated Safety Attitudes Questionnaire at baseline (2004) and after 2 yrs of exposure to the safety program (2006) to assess improvement. The safety climate domain on the survey includes seven items. Post-safety climate scores for intensive care units. To interpret results, a score of <60% was in the "needs improvement" zone and a ≥10-point discrepancy in pre-post scores was needed to describe a difference. Hospital bed size, teaching status, and faith-based status were included in our analyses. Seventy-one intensive care units returned surveys in 2004 and 2006 with 71% and 73% response rates, respectively. Overall mean safety climate scores significantly improved from 42.5% (2004) to 52.2% (2006), t = -6.21, p < .001, with scores higher in faith-based intensive care units and smaller-bed-size hospitals. In 2004, 87% of intensive care units were in the "needs improvement" range and in 2006, 47% were in this range or did not score ≥10 points or higher. Five of seven safety climate items significantly improved from 2004 to 2006. A patient safety program designed to improve teamwork and culture was associated with significant improvements in overall mean safety climate scores in a large cohort of 71 intensive care units. Research linking improved climate scores and clinical outcomes is a critical next step.

Integrating CUSP and TRIP to Improve Patient Safety

Despite increased awareness of the risks to patients within the health care system, there has been little improvement in patient safety, with 1 in 7 patients experiencing an adverse event during hospitalization. Patients are exposed to harm not only through medical errors but also by physicians' failure to adhere to evidence-based best practices, as patients receive recommended therapies only half of the time. Although much research has been devoted to developing new therapies, little time has been spent investigating the science of health care delivery. We developed 2 models for improving health care delivery that have been successfully utilized in the Michigan Keystone Project to eliminate catheter-related bloodstream infections. The first is the Comprehensive Unit-Based Safety Program (CUSP), which is aimed at changing the culture of safety and provides a framework for addressing patient safety issues at a local level. CUSP takes advantage of local wisdom to identify potential patient harms and create individualized solutions. The second is the Translating Evidence Into Practice (TRIP) model, which evaluates best practices at a hospital or hospital system level, and then creates strategies for implementation at a local level. TRIP seeks to identify barriers to implementation of best-practice medicine and standardize care over multiple care units. Components of the 2 programs are not mutually exclusive and both can be used to mitigate potential patient harms.

Effect of the Comprehensive Unit-Based Safety Program (CUSP) on the Compliance With Head of Bed Elevation in the Intensive Care Unit

PURPOSE: Institute of heath care improvement (IHI) recommends to elevate the head end of the patients’ bed between 30 and 45 degrees as an intervention to prevent ventilator associated pneumonia (VAP). In our unit the rate of compliance with the head of bed elevation was 60% in September 2009. This was low in comparison to IHI recommended rate 95%. Design: Prospective, observational study. Our goal was to exceed the 95% recommended compliance.

Integrating patient safety in to the culture of the organisation

Tawam Hospital based in the United Arab Emirates is a Johns Hopkins affiliated hospital; Tawam is currently establishing a culture of safety under the auspices of Johns Hopkins. The Comprehensive...

Impact of the Comprehensive Unit-Based Safety Program (CUSP) on Safety Culture in a Surgical Inpatient Unit

A culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings. CUSP was implemented beginning in February 2008 on an 18-bed surgical floor at an academic medical center to improve patient safety, nurse/physician collaboration, and safety on the unit. This unit admits three to six patients per day from up to eight clinical services. Staff implemented several interventions to reduce safety hazards and improve culture. Surgical patients admitted to one clinical service were cohorted on this unit to increase physician presence. A team-based goals sheet was implemented to improve communication and coordination of daily goals of care. Nurses were included on rounds to form an interdisciplinary team. Five of six culture domain scores demonstrated significant improvements from 2006 and 2007 to 2008. There was a 27% nurse turnover rate in 2006 and a 0% turnover rate in 2007 and 2008. Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety program. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. CUSP is sufficiently structured to provide a strategy for health care organizations to improve culture and learn from mistakes, yet is flexible enough for units to focus on risks that they perceive as most important, given their context. Broad use of this program throughout health systems could arguably produce substantial improvements in patient safety.