The Agency for Healthcare Research and Quality announced in October 2009 that
a program called the Comprehensive Unit-based Safety Program (CUSP), which
successfully reduced central line-associated blood stream infections in intensive
care units, will expand to all 50 States and additional hospitals in States
already participating in the CUSP, extend to other settings in addition to
intensive care units, and broaden its focus to address other types of healthcare-associated infections. This fact sheet provides an overview of projects
that AHRQ has supported since 2001 that involve CUSP, which is based on a system
that the Johns Hopkins University Quality and Safety Research Group developed.
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Acronyms
Ending Healthcare-Associated Infections
Background on the Comprehensive Unit-based Safety Program
AHRQ Projects Using the Comprehensive Unit-based Safety
Program
For More Information
Acronyms
AHRQ—Agency for Healthcare Research
and Quality
BSI—blood stream
infection
CAUTI—catheter-associated urinary tractinfection
CDC—Centers for Disease
Control and Prevention
CLABSI—central line-associated blood stream infection
CUSP—Comprehensive Unit-based Safety
Program
HAI—Healthcare-associated
infection
ICU—intensive
care unit |
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Ending Healthcare-Associated Infections
Healthcare-associated infections (HAIs) are the most common complication
of hospital care, resulting in 1.7 million infections and 99,000 deaths each
year. The added financial burden attributable to HAIs is estimated to be
between $28 billion to $33 billion each year. To address this growing problem,
the Agency for Healthcare Research and Quality (AHRQ) has funded numerous
projects that target HAI prevention.
This fact sheet provides an overview of many projects that AHRQ has supported
since 2001 that have led to the successful reduction of central line-associated
blood stream infections (CLABSIs) in hospital intensive care units (ICUs).
Often referred to as a central venous catheter, a central line is a tube placed
in a large vein in a patient's neck, chest, or groin to administer medication
or fluids or to collect blood samples. According to the Centers for Disease
Control and Prevention (CDC), each year, an estimated 250,000 cases of CLABSI
occur in U.S. hospitals, and an estimated 30,000 to 62,000 infected patients
die.
The AHRQ-funded projects involve the implementation of a Comprehensive Unit-based
Safety Program (CUSP), which is based on an Intensive Care Unit Safety Reporting
System developed by the Johns Hopkins University Quality and Safety Research
Group, Baltimore, MD.
In October 2009, AHRQ announced that the CUSP will expand to all 50 States
and additional hospitals in States already participating in the program, extend
to other settings in addition to ICUs, and broaden the focus to address other
types of infections, such as catheter-associated urinary tractinfections (CAUTIs).
Information on the infection reduction program and brief descriptions of AHRQ's
projects that use the CUSP is below.
Background on the Comprehensive Unit-based Safety Program
The CUSP integrates communication, teamwork, and leadership to create and
support a "harm-free" patient care culture. It provides a
structured strategic framework for safety improvement, yet it is flexible enough
to tap into staff wisdom and encourage them to fix hazards that they perceive
pose the greatest risks. CUSP is implemented at the unit level and provides
a scalable program that can be implemented throughout an organization. The
program draws from frontline providers who have the most knowledge about safety
hazards and the means to lessen the severity of those hazards, and provides
a mechanism to help defend against hazards.
CUSP is comprised of five steps, and the program is a continuous process designed
to incorporate an ongoing evidence-based patient safety infrastructure into
an existing unit. Each step of CUSP builds on previous work to equip
frontline providers with the tools, metrics, and framework to tackle the challenge
of quality improvement. The steps are briefly described below:
- Step 1. Staff are educated on the science of safety.
- Step 2. Staff complete an assessment of patient safety culture.
- Step 3. A senior hospital executive partners with the unit to improve communications and educate leadership.
- Step 4. Staff learn from unit defects.
- Step 5. Staff use tools, including checklists, to improve teamwork, communication, and other systems of work.
AHRQ Projects Using the Comprehensive Unit-based Safety Program
The Keystone Project
As a result of applying the CUSP in more than 100 ICUs in Michigan and using
the program's simple five-step checklist that was designed to prevent
certain hospital infections, this project reduced the rate of blood stream
infections from intravenous lines by two-thirds within 3 months. Known as
the "Keystone Project," the initiative also helped the average
ICU decrease its infection rate from 4 percent to 0. Over 18 months, the
program saved more than 1,500 lives and nearly $200 million.
The project, a partnership between the Johns Hopkins University School of Medicine
and the Michigan Health & Hospital Association Keystone Center and its
member hospitals, resulted in a large and sustained reduction in rates of catheter-related
blood stream infections (BSIs). The study targeted clinicians' use of five
evidence-based procedures recommended by the CDC: hand hygiene, using full-barrier
precautions during the insertion of central venous catheters, cleaning the
skin with chlorhexidine, avoiding the femoral site when possible, and removing
unnecessary catheters. Findings of the study were published in the December
28, 2006, issue of the New England Journal of Medicine.
CUSP Expands to 100 Hospital ICUs
This project continues the Keystone Project's work by helping States apply
and beta test the CUSP as a strategy for reducing CLABSIs in 100 hospital
ICUs from 10 States over a 3-year period. Specifically, new partners or existing
statewide cooperatives of stakeholders, including State hospital associations,
quality improvement organizations, public health agencies, and health care
purchasers, will work to help reduce these infections in ICUs. Participating
hospitals will implement a checklist to ensure compliance with safety practices,
educate staff on evidence-based practices to reduce BSIs, educate staff on
team training, provide feedback on infection rates to hospitals and hospital
units, and implement monthly team meetings to assess progress.
Thus far,
State hospital associations and patient safety groups from more than two
dozen States have been selected to participate in the project. Participation
is based on capability and the availability of infrastructure to implement
the safety protocols being tested in the project in addition to providing
broad geographic representation.
CUSP Expanding on a National Scale
In fiscal year 2009, AHRQ awarded $8 million to expand the project above and
implement CUSPs nationally.
- Since the initial implementation of the CUSP-CLABSI initiative in 10 States,
additional hospitals in those States have expressed interest in participating
in the program. This project will increase the number of participating hospitals.
Total funding: $1,000,000
- As a result of additional funding from AHRQ and a private foundation, participation
of Keystone Project's CUSP-CLABSI initiative is now open to all 50
States, Puerto Rico, and the District of Columbia. Total funding: $3,000,000
- The project also has expanded the CUSP-CLABSI initiative beyond the ICU
to general medical and surgical hospital units in 10 States. Total
funding: $2,000,000
- The success of the CUSP in reducing CLABSIs has increased pressure to apply
the program to other HAIs, including CAUTIs. For a demonstration of the CUSP
concept as applied to CAUTIs, investigators will adapt CUSP materials to
CAUTI and then use them in 10 hospitals in each of 10 States, for a total
of 100 hospitals. Total funding: $1,000,000
- CUSP also is being used to examine the comparative effectiveness of standard
recommended practices with antibiotic catheter locks and antiseptic catheter
locks for preventing BSIs in hemodialysis patients. Secondary evaluations
will include screening assessments for changes in antimicrobial resistance
and evaluating the development of toxicities related to the use of catheter
locks. Total funding: $1,000,000
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For More Information
For more information, visit the following pages on AHRQ's Web site:
AHRQ Publication Number: 09(10)-P013-2
Current as of October 2010
Internet Citation:
Ending Healthcare-Associated Infections. October 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/haicusp.htm