A comprehensive unit-based safety program reduced central line–associated bloodstream infections by 40% in 1,100 intensive care units between 2008 and 2012. Some of the ICUs have remained free of these infections for more than two years—a statistic once thought unattainable by many clinicians.

“With these results, health care is taking a giant step forward,” said Peter Pronovost, MD, PhD, the senior vice president for patient safety and quality at Johns Hopkins Medicine, in Baltimore, who created the comprehensive unit-based safety program (CUSP). After initial evaluation of the program at Johns Hopkins in 2001, CUSP was investigated at 100 centers in Michigan between 2003 and 2005, and then promoted nationwide by the Agency for Healthcare Research and Quality (AHRQ).

AHRQ Director Carolyn Clancy, MD, stressed the significance of the national CUSP findings. “Forty percent is not just a number,” she said. “It means 500 lives were saved and more than 2,000 fewer patients suffered an infection. It also means we avoided an estimated $34 million in costs.”

Toolkit for Quality Improvement

At the core of CUSP is a toolkit, developed by clinicians for clinicians, that provides doctors, nurses and pharmacists with the means for understanding safety problems and how to address them. “The toolkit essentially is a multipronged quality improvement program and, very importantly, it is customizable and self-paced,” Dr. Clancy said. “It includes instructor guides, presentation materials, implementation tools such as checklists, and videos that demonstrate desired behaviors.” The kit is available at www.ahrq.gov/​cusptoolkit.

The main checklist is based on infection prevention guidelines from the Centers for Disease Control and Prevention. These guidelines are extensive and the checklist distills them into a form that clinicians can easily use. The checklist describes measures such as using a dedicated line cart, removing unnecessary lines, performing hand hygiene, avoiding the femoral site in adult patients, using skin antisepsis with 0.5% chlorhexidine and empowering staff to stop nonemergent procedures that are violating guidelines. Institutions can modify the checklist to meet their local needs.

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Michael Tooke, MD

The CUSP strategy is based on four Es: engage (understand how the project can improve outcomes), educate, execute and evaluate. “This all starts with measurement. You really have to be aware that you have a problem in the first place,” said Michael Tooke, MD, the chief medical officer at Shore Health, a two-hospital system on the eastern shore of Maryland and an affiliate of the University of Maryland Medical System. The two hospitals—Memorial Hospital in Easton and Dorchester General Hospital in Cambridge—have participated in the national CUSP project and, at press time, had not had a central line–associated bloodstream infection (CLABSI) in more than two years.

Dr. Tooke noted that CUSP is much more than a checklist. “We put the checklist in place and we saw our [infection] rates drop, but they didn’t go to zero because [CUSP] is an entire process.” He added that they had to look at how a line is maintained and how different products were influencing safety, among other things.

The tools in CUSP are numerous. The Staff Safety Assessment Tool gathers information from front-line health care providers, asking how a provider thinks the next patient in their unit will be harmed and what they think can be done to prevent this harm. The Learn From Your Defect Tool helps rigorously analyze the various components and conditions that contribute to an adverse event. It asks questions about possible contributing factors related to patients, tasks, providers, team, training and education, information technology, local environment and institutional environment.

What goes wrong in one ICU may be totally different from what goes wrong in another, Dr. Pronovost noted. “We know there are a lot of local problems. You need to build capacity for those front-line clinicians to address all those things that could go bump in the night, and that is what this program does.”

Pharmacists Part of the Multidisciplinary CUSP Initiative

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Susan Siford, PharmD, MBA

Pharmacists have played a part in many of the CLABSI CUSP efforts. Susan Siford, PharmD, MBA, who works with Dr. Tooke and is the director of pharmacy services for Shore Health, said her pharmacists are involved on several levels. They serve on the multidisciplinary committee that created their CUSP, perform literature reviews to make sure best practices are being used and serve on the committee that evaluates CUSP monthly. Pharmacists evaluate patient charts on a daily basis, identifying medications that can be converted from IV to oral formulation, which allows for the removal of unnecessary central lines. Shikha Polega, PharmD, a clinical specialist in the surgical ICU at St. Joseph Mercy Hospital, Ann Arbor, Mich., said that her pharmacy department was involved in performing a literature assessment for their CUSP and that a pharmacist sits on the program’s evaluation committee.

According to Dr. Siford, the reason CUSP has been so successful is that a multidisciplinary team is involved in developing each institution’s program and implementing it. “Everyone was involved and it made a huge difference,” said Dr. Siford. “It was really working collaboratively as a team that made [our CUSP] so successful.”

Lindsay Ryder, PharmD, BCPS, a specialty practice pharmacist in the medical ICU at Ohio State University Wexner Medical Center, in Columbus, was not part of the national CUSP project, but her hospital has implemented a similar multidisciplinary initiative involving a checklist to slash CLABSIs. She agreed that involving health care workers at all levels—nurses, doctors, pharmacists, etc.—is key to slashing infection rates. “We all feel a sense of accountability. It is not just one group’s job or one person’s job. The biggest reason for our success is involving all members of the team,” said Dr. Ryder. She also agreed that the biggest role that pharmacy can play in a CLABSI reduction initiative is decreasing the number of medications that are administered through a central line.

Core Elements of the CUSP Program

  • Identify five simple steps known to prevent bloodstream infections—such as hand-washing before line insertion and avoiding line placement in the groin area—and incorporate them into a checklist similar to those used by aviation crews.
  • Develop central-line insertion “bundles” that contain all supplies and sterile material needed for the procedure. This simplifies the procedure and ensures that all items are readily available.
  • Encourage nurses to speak up, and even stop the procedure, if providers deviate from the guidelines.
  • Train staff in the science of safety.
  • Foster the development of a workplace culture of safety in which caregivers feel welcome to bring up concerns—such as when physicians attempt to insert a line without first washing hands—and their ideas for how to prevent harm.
  • Continually measure infection rates and give feedback on results to staff and managers.

Getting involved, however, is the first step for pharmacists at institutions that are starting CUSP programs. “[Pharmacists should] get in early and make sure they are part of the multidisciplinary team that drives the care,” Dr. Siford stressed.

A Growing Movement Focused On Multiple Safety Targets

In addition to CUSPs focused on CLABSIs, many hospitals have rolled out CUSPs focused on different targets. Easton Memorial Hospital and Dorchester General Hospital have rolled out programs aimed at prevention of ventilator-associated pneumonia (VAP) as well as prevention of central line–associated urinary tract infections. St. Joseph Mercy Hospital has rolled out several other CUSPs: VAP prevention, tight glucose control, sepsis prevention and delirium management.

“CUSP has changed the entire culture of how we implement guidelines, how we assess evidence-based medicine,” Dr. Polega said. “Because we have changed the culture of safety, people are not scared to speak up. We have created an environment and multidisciplinary rounds, so that they do speak up.”

Theresa Hickman, RN, a nurse educator at Peterson Regional Medical Center, in Kerrville, Texas, which is nearing a three-year CLABSI-free mark, said that in her 32 years as a nurse, she has never seen a program as effective as CUSP. One of the defects identified at her 125-bed rural center with the CUSP Learn From Your Defect Tool was a drug error caused by an older nurse who could not read the small print on a drug vial. “We found out that it was a common problem: The nurses were having trouble reading,” Ms. Hickman said. “So we bought a whole bunch of magnifying glasses and we didn’t have that defect happen anymore.”

Those involved in the CUSP movement are confident that it will continue to spread to additional hospitals. “There is no better rocket fuel than success,” said Dr. Clancy. “When hospitals see others succeeding, it goes viral.”



Drs. Pronovost, Clancy, Tooke, Siford, Polega and Ryder, and Ms. Hickman reported no relevant financial conflicts of interest.