Disclosures

Nothing to disclose

No discussion of “off-label” use of medications

Objectives

Be able to list key components of CUSP

Be able to discuss methods to engage staff in CUSP / NCABSI

Be able to describe NCABSI, including goals

CUSP

Comprehensive Unit-based Safety Program

Developed at Johns Hopkins University Science of Safety - Dr. Peter Provonost

First used in Keystone Project in Michigan – reduced CLABSI state-wide

Used in the CLABSI and CAUTI projects from the American Hospital Association

Now a part of NCABSI

Key components of CUSP

Educate the team on the “Science of Safety”

Identify Defects (Staff Safety Assessment)

Engage Senior Executive Leadership

Learn from Defects

Implement Teamwork and Communication Tools

Engaging the Staff

Education of the staff as to the nature of the problem

Empower them to be the drivers of improvement with the CUSP program

Emphasize the patient at all times and relate the reason for the project back to them

Get the informal leaders on board

Frequent discussions about the program and the project

The problem

In the United States 100,000 patients die every year from Healthcare

Associated Infections (HAI) The annual cost is ~ $30 billion Of the 100,000 patient deaths, it is estimated that 30,000

– 60,000 are from Central Line Associated Blood Stream Infections (CLABSI)

However, elimination of CLABSI from the NICU is possible

How does your NICU compare to others?

Vermont Oxford Network for NICU data

Hospital Networks Based on ownership, such as HCA Based on specialty affiliations, such as CWISH (Council

of Women’s and Infant’s Specialty Hospitals) Based on physician groups, such as Pediatrix

“Every system is designed to achieve the results it gets”

Unit-Based

One of the keys of the CUSP program is that it is meant to be driven by those at the bedside What is the next source of harm (or in NCABSI –

infection) for our patients? What can be done to prevent that harm (or infection)?

It is NOT a program that is handed down from the board or administration or nursing leadership

Executive leadership is critical to ensure that staff is safe to express opinions and contribute to discussion

Safe systems

Are standardized (Science vs. Art) Checklists, such as those in aviation Humans are NOT infallible

Are designed to find out when things go wrong and to learn from those events

Rely on diverse and independent input Allow people to contribute in a “psychologically safe”

way

Emphasize the patient

The patient should be at the heart of all

The NCABSI project has a video that all teams should watch, called the “Gabby” video. In the video, a father relates the story of his daughter, Gabby, who was born at 25 weeks and weighed 614 grams. Gabby was slowly but steadily improving, but then became ill and died from a CLABSI.

Relate similar stories from your own NICU

Engaging the physicians

A physician champion is critical Respected Knowledgeable Willing to discuss the issues with other physicians

Have frequent discussions with the physician champion regarding progress and comparison to benchmarks

Other enticements with NCABSI ABP maintenance of certification credit

NCABSI

Neonatal Catheter Associated Blood Stream Infections

8 state collaborative ~ 100 NICUs ~ 7500 lines ~ 60000 line days

Supported by American Hospital Association (AHA) with funding from Agency for Healthcare Research and Quality (AHRQ)

NCABSI goals

Reduce catheter related infections in participating NICUS by 75% over the course of the year long study

Utilize CUSP to change local NICU culture so that changes made become part of the norm

Lay the groundwork for individual CQI projects by developing a group of people familiar with the methodology

Lay a foundation for future multi-state collaborative projects

Each NICU creates a team

Project leader

Physician champion

Nurse manager champion

Executive champion

Infection control representative

Data entry contact

Other team members

Review the Action Plan

Each center reviews the action plan

Determine if there are significant differences between the action plan and the current practices in your NICU Is there a reason for this difference? Is the difference clinically significant? Do we desire to change our current plan to be more

consistent with the NCABSI project action plan?

Implement those changes you desire using a series of Plan-Do-Study-Act (PDSA) cycles

Data collection

Patients with central lines are enrolled through the NCABSI website NCABSI

All data is collected through the website

Enter an insertion checklist form for each line placed

Enter a daily maintenance form

When the line is removed or a patient is discharged, enter that information on the website

Training videos are under “Data” in the “Resources” section of the website

NHSN data

National Healthcare Safety Network (NHSN) is an internet based surveillance system from the CDC

Most hospitals report NHSN data already Infection control / prevention are generally familiar with

the format and the requirements

This data will be entered through the NCABSI website as baseline for the 3-6 months prior to the project and monthly during the project

PDSA cycles

Look at your maintenance failures for potential system changes

Learning from defects (from CUSP) helps you identify how to address system failures

Make small changes – PDSA cycles should be rapid

Pilot changes on a limited basis

“A Primer on Quality Improvement Methodology in Neonatology”. Ellsbury, Ursprung. Clinics in Perinatology, 2010 Mar; 37(1): 87-99.

Pearls

Submit data on at least a weekly basis

Hold team meetings often – at least monthly to review progress and develop new rapid cycle changes to evaluate

Develop PDSA cycles with an end that is different from the project as a whole