comprehensive unit based patient safety program deepa jose,rn,ccrn
TRANSCRIPT
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Comprehensive Unit based Patient Safety Program
Deepa Jose,RN,CCRN.
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Unit Based Patient Safety Program
MedStar Franklin Square Medical Center Intensive care unit
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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
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5 steps in CUSP• Educate staff on the science of safety
training.• Staff identify defects.• Executive partnership.• Begin learning from defect.• Implement teamwork tools.
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Is it safe for your patient?What is the best way to do it?
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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
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Members of the team• RNs• Multifunctional techs• Respiratory therapists• Physicians• Physician assistants• PT & OT.• House keeping staff.• Unit secretaries
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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
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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
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CLABSI prevention
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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
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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.
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New central line dressing
• ICU started using Sobra View ultimate dressing for all central lines.
• Apply biopatch at insertion site
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CHG( Chlorhexidine Gluconate) bath
• Daily CHG baths to all ICU patients with central line or Foley catheter.
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ICU/2T team
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CLABSI Data
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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
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CAUTI
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CLABSI
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Falls
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HAPU
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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.