Tel Aviv Sourasky Medical Center Uses AHRQ's Comprehensive Unit-Based Safety Program

The AHRQ-funded Comprehensive Unit-based Safety Program (CUSP)—a process that helps nurses and doctors provide safer care for patients in their hospital unit—was influential in the launch of a program in 2009 to prevent catheter-related bloodstream infections in Israel's Tel Aviv Sourasky Medical Center.

Gabi Barbash, M.D., M.P.H., Director of the Tel Aviv Sourasky Medical Center, says, "The implementation of CUSP at the medical center demonstrated a near elimination of catheter-related bloodstream infections over an 18-month period and a significant improvement in the safety culture in participating intensive care units (ICUs)."

The concept of CUSP was developed by Peter Pronovost, M.D., Ph.D., at Johns Hopkins University, with funding from AHRQ, as a way to help doctors and nurses in ICUs prevent infections. In most cases, these infections can be prevented through careful attention to a bundle of evidence-based safety practices, including catheter insertion technique and hygiene procedures, combined with improvements in safety culture, teamwork, and communication. CUSP was first tested in Michigan hospitals and then expanded to other States nationwide.

Barbash learned about CUSP through an article in the New England Journal of Medicine about central line infections. He encountered Pronovost's findings, and within four months had implemented the program in Tel Aviv Sourasky's ICUs, surgical and medical wards, and operating rooms.

Approximately 2,700 nurses and doctors were involved in the effort. Led by the pediatric ICU head nurse, Nurit Azar, RN, M.P.A., in collaboration with the epidemiology team, the components of the Israeli program included:

• A dedicated kit containing all the necessary equipment for insertion of a central catheter, prepared in collaboration with staff from the department of sterilization.
• A checklist, based on the CUSP checklist, to assure standardization of the procedure.
• Nurse and physician education, through project presentation in staff meetings and a mandatory online examination.
• Marketing tools to increase awareness of and compliance with the program, such as an internal promotional campaign, an article published in the hospital's magazine, posters displayed throughout the wards, and a slogan.
• Management and followup of adherence with the new guidelines.

A "care bundle" to reduce the rate of catheter-related bloodstream infections was implemented that included hand washing, use of maximal barrier precautions (covering the patient from head to toe with a sterile drape), cleaning the skin with chlorhexidine, and avoiding the femoral vein for central venous access in adult patients.

A computer program was used to track pertinent information and provide daily reports to department chairs and head nurses so that central venous lines were removed as soon as it was safe to do so. The program also issues reminders to replace lines inserted under suboptimal or nonsterile conditions, such as during resuscitation.

Barbash says, "The implementation of the CUSP program required behavioral and cultural changes among our health care providers. Initially, adherence was suboptimal. For example, dedicated kits were not used and registering the procedure in the computer was not always done."

To increase compliance and ensure success, they performed random inspections of patients with central lines. This information was then compared with reports in the hospital information system database and real-time feedback was provided on any deviations.

A significant improvement in program compliance was demonstrated between January 2010 and June 2011, when all information in the system database agreed with the patient charts. During this time, the rate of catheter-related infections per 1,000 central venous catheter days dropped from 26.1 to 12.4.

Tel Aviv Sourasky Medical Center manages approximately 103,000 new hospital admissions, 32,000 surgical procedures, 1 million outpatient clinic visits, and 200,000 emergency room visits per year. It is one of Israel's largest and most progressive full-service health care treatment and research institutions.

Barbash concludes, "We are convinced that understanding the care bundle strategy is a first step in overcoming potential barriers to the improvement of patients' safety."