1. Comprehensive Unit based Patient Safety Program DeepaJose,RN,CCRN.

2. Unit Based Patient Safety Program MedStar Franklin Square Medical Center Intensive care unit

3. 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. 5 steps in CUSP • Educate staff on the science of safety training. • Staff identify defects. • Executive partnership. • Begin learning from defect. • Implement teamwork tools.

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

7. ICU Top Ten quality Initiatives • Preventing Falls • Preventing Pressure Ulcers • Improve Patient Satisfaction -Hourly Rounding & Prompt Call Bell Response • Prevent CAUTIs – REMOVE FOLEY ASAP! • Preventing CLABSI – Remove Central Lines ASAP • Preventing MRSA & VRE Transmission • Preventing Ventilator Associated Pneumonias – Q4 hour mouth care • Enhancing Communication – Bedside Reporting, Include Patient inPlan of care, and teach about meds & • Improving Hand Hygiene & Isolation compliance • Family Meetings by Day 5 for ALL Patients – Palliative Care

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

9. 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

10. 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 Preventing central line infections

11. CLABSI prevention

12. Key Focus of ICU CUSP program Hand Washing Campaign • Hand hygiene posters in each room • Hand sanitizer wipes on patient meal trays • Associates starts wearing the sign

13. 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.

14. New central line dressing • ICU started using Sobra View ultimate dressing for all central lines. • Apply biopatch at insertion site

15. CHG( Chlorhexidine Gluconate) bath • Daily CHG baths to all ICU patients with central line or Foley catheter.

16. ICU/2T team

17. CLABSI Data

19. CAUTI

20. CLABSI

21. Falls

22. HAPU

23. 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.