Beyond the checklist: CUSP slashes infection rates 40%

"Too often quality is something that is done to you. Now this is something we do. It's a change in mindset."
- Peter Pronovost, MD

By Gary Evans, Executive Editor

Peter Provonost, MDThe successful use of checklists to prevent central line associated bloodstream infections (CLABSIs) has been highly publicized, in part because of the sheer novelty of using a simple solution to solve a highly complex problem. The media, legislators and the medical community have become much enamored of the "checklist revolution," but it turns out that this highly effective little tool is only the spear point of a much larger culture change: the Comprehensive Unit-based Safety Program (CUSP).

The rest of the story is now being told, and all signs are that CUSP will be increasingly implemented in hospitals as various federal health care agencies continue to collaborate in an aggressive effort to reduce health care associated infections (HAIs) and other preventable patient harms.

"CUSP is an approach that helps clinical teams provide safer care. It combines clinical best practices with an understanding of the science of safety and improved patient safety culture," Carolyn M. Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ), said at a Sept. 10 press conference announcing new CLABSI reduction data in Bethesda, MD. "Until recently these infections were thought to be an unfortunate consequence of care. Our work to fight CLABSIs with CUSP demonstrates definitively that they are not. These infections can be prevented. These results changed our idea of what's possible."

Carolyn M. Clancy, MDIndeed, the CUSP approach may be used to prevent a variety of other infections and even non-infectious events like medication errors. But it is CLABSI prevention that has really verified the power of the tool, with the most recent data showing hospitals across the country cut infection rates by 40%. A nationwide CUSP program partially funded by AHRQ in partnership with the American Hospital Association involved hospital teams at more than 1100 adult intensive care units (ICUs) in 44 states. The unpublished findings indicate that hospitals participating in the project reduced the rate of CLABSIs nationally from 1.903 infections per 1,000 central line days to 1.137 infections per 1,000 line days over a four-year period — an overall reduction of 40%.

"Forty percent isn't just a number," Clancy said. "It means that more than 500 lives were saved and more than 2,000 fewer people suffered an infection."

The Centers for Disease Control and Prevention estimates that 41,000 bloodstream infections strike hospital patients with central lines each year. Of these patients, one in four die from infections caused by such pathogens as Staphylococcus, Enterococcus, Candida and a variety of gram negatives. In addition to reducing infections and saving lives, the CUSP project also saved some $34 million in health care costs.

To help infection preventionists and other clinicians adopt the program, AHRQ has created a comprehensive website with a wealth of tools. The CUSP tool kit breaks the program down into modules, one of which is engaging senior leadership. Infection preventionists are cited as key players in this role, as a toolkit IP checklist calls upon them to "Meet with the CEO and hospital project leader to learn about the initiative and understand the infection prevention roles." (See IP checklist, below)

Infection Prevention Checklist


Checklist items

Leader Responsible

Date Started

1. Meet with the CEO and hospital project leader to learn about the initiative and understand the infection prevention (IP) roles.

2. Introduce the project to all IP staff members and explain their role.

3. Require all current and new IP staff to receive Science of Safety training.

4. Assign an IP to each team.

5. Require the IP to contribute actively to monthly team meetings.

6. Participate in project calls and face-to-face meetings.

7. Work with unit teams to investigate each incident and report the findings across the institution.

8. Shadow the nurses.

9. Arrange for nurses to shadow IPs.

10. Identify and mitigate barriers to achieving the project goals.

11. Ask clinicians what is difficult in achieving the project goals.

12. Collaborate to remove barriers to achieving the project goals.

1. Collaborate with clinical and administrative leaders to develop a coordinated plan for reduction throughout the organization.

2. Ensure that all IP staff are skilled in the use of CDC definitions and surveillance methods.

3. Maintain an active infection surveillance program using CDC criteria.

4. Monitor hand hygiene no less than quarterly and report performance to all employees and the board.

5. Ensure the accuracy and efficacy of staff education on strategies to prevent (e.g., electronic learning systems that document required education).

6. Provide monthly unit-level data to project leads for posting and transparent tracking.

7. Send senior hospital leaders unit-specific weekly reports on the number of people infected with , the weeks without , and quarterly rates of .

8. Lead efforts to assess the utility and necessity of infection-related technologies, including special dressings and catheters.

9. Enter data into the program's central database to ensure accuracy, focused analysis, and data integrity.

Source: Agency for Healthcare Research and Quality (AHRQ):

Empowering frontline care givers

Theresa Hickman, RNThough AHRQ and the AHA provided resources to collect and analyze the data in the CLABSI collaborative, each individual hospital funded its own CUSP prevention effort. Project cost efforts were not provided, but the benefit of reduced infections and energized unit teams would seem to be more than enough to justify upfront costs. Consider the testimony of frontline care givers and clinicians, who shared their CUSP results at the press conference with a fervor not typically seen in discussing an infection control intervention.

"In my 32 years as a nurse CUSP is the most powerful program I've ever seen," said Theresa Hickman, RN, nurse educator of Peterson Regional Medical Center in Kerrville, TX, a 125-bed rural, not-for-profit hospital.

The entire hospital has not had a CLABSI in 31 months, she said, crediting the success in large part to the fact that 90% of the central lines inserted at the facility are placed by nurse-led IV access teams.

"Historically, frontline care givers, especially nurses, have not been included in safety programs," Hickman said. "CUSP turns that model on its head and it empowers the frontline care giver to make a difference. In our hospital we empower the frontline care giver to fix any issue that can cause a patient harm. Failure is not an option — every minute that a defect goes unresolved a patient is in danger. "

The most culture-changing aspect of the program may be the realization among staff that infections are no longer viewed as an unfortunate tradeoff for providing care to sick patients.

Michael Tooke, MD"I really want to emphasize the profound impact that is at the heart of the success of CUSP, and that is the shift in our thinking. It was actually possible to eliminate something we had come to view as inevitable," said Michael Tooke, MD, chief medical officer at Memorial Hospital in Easton, MD. "It meant that we didn't have to accept the harm we were causing our patients. It meant that eliminating them was possible. And frankly, if that was the case, it meant that the only acceptable target was zero."

Under the two-hospital system's "Target Zero" CUSP program — as of the date of the press conference — it had been 810 days since the last CLABSI in the ICU at Memorial and 1,025 days at affiliated Dorchester Shore Health, he said.

"In February of 2010 we experienced the last ventilator associated pneumonia in either one of our ICUs," Tooke said. "We're our community's only health care system. Our patients are our neighbors, our friends, our coworkers and often even our own families. Target Zero struck a very personal chord."

Sustaining the gain

Infection preventionists are all too familiar with the wildly successful program that inevitably loses energy and fades back to baseline levels. How is the gain sustained under CUSP?

"Success is a rocket fuel," Tooke said. "I can't emphasize how important it is to get the results back in the hands of the unit. When you have success — when you go for an entire month [with no infections] or 100 days, six months — some have gone a year. People own that and they are proud of it. They realize they are taking care of patients. Feeding back those results is crucial. It gets people's attention and then you can use that success to go on to another issue and say, 'Look it worked here, let's try it here.' It sustains itself, it really does."

Indeed, health care workers actually become "protective" of their infection rates, particularly if they have reached zero levels, Hickman said. "Not too long ago one of the charge nurses on the floor called me and said, 'We have a CLABSI.' She was distraught. It turned out we did not, but they become very proud of this and have [the attitude] 'Not in their hospital.'"

The success-breeds-success attitude extends to comparisons and competition between facilities because "when hospitals see other hospitals succeeding it goes viral," Clancy said.

With so many national efforts underway to prevent HAIs, there were several questions at the press conference trying to clarify which larger program this latest CUSP initiative falls under. The multiple-agency effort called the Partnership for Patients is the answer, but just that the question had to be asked shows how far infection prevention has come from the days when IPs labored in obscurity and HAIs were not on the national radar. Major players throughout health care are now on board, including the AHA, which wants to expand the CUSP initiative.

"We now have 1,100 or so hospitals and 1,700 to 1,800 units, but we know that there are thousands more hospitals and tens of thousands more units," said Richard J. Umbdenstock, AHA president and CEO. "We want to see this spread."

It's not about the list

CUSP is the brainchild of Peter Pronovost, MD, PhD, senior vice president for patient safety and quality at Johns Hopkins Medicine. The first broad-scale application of CUSP was in Michigan ICUs, which significantly reduced CLABSIs using the program Pronovost developed at Johns Hopkins.1 Several different types of checklist are included in the CUSP toolkit, but the Pronovost's original checklist included these key elements:

  • Hand hygiene
  • Full-barrier precautions during catheter insertion
  • Skin cleansing with chlorhexidine
  • Avoiding the femoral insertion site
  • Removal of unnecessary catheters.

"When we first published our Michigan results [in 2006] the media often translated that story as if it was only a checklist." he said. "We did CUSP in Michigan – that's why it worked. This work builds upon that. These are brand new data that we are presenting today that haven't been published, and the results are really astonishing."

Pronovost described the program as three legs of a stool. "It's a checklist for best practices," he said. "It's CUSP — which is really the culture change and teamwork programs — and then it is measuring and feeding back infection rates. All three of those are important. The checklist could change if you are working on UTIs or VAPs, but CUSP endures. It is the lifeblood of this program."

Tooke concurred, saying "This is not just about the checklist. We made our checklist mandatory and saw our rates drop, but they didn't go to zero because it is an entire process. You have to look at how the line is maintained, [know] how long the line has been in and make sure that you assess a patient every day to [consider] pulling it out. All of these things are factors. You don't just do the checklist and then you are done."

The CUSP culture change goes beyond infection control issues, creating an environment that encourages the identification of any number of problems, Hickman added.

"One of the defects that was identified in our ICU was that a nurse made a drug error because we draw medications out of very small amps. The print is very small," she said. "We found that this was a common problem — the nurses were having trouble reading. So we bought a whole bunch of magnifying glasses and we didn't have that defect happen anymore. CUSP is very broad [and could be applied] to fix anything that could cause harm to a patient."

Likewise, the approach is not necessarily limited to a specific unit type or particular health care setting, Pronovost said. "CUSP applies anywhere. We are using it in outpatient and inpatient [areas]. In part it started in the ICU because I'm an ICU doc and I used the ICU as the learning laboratory. We tested, changed it, and improved it in real time while we were caring for patients. But it really applies throughout heath care."

The CUSP approach is somewhat radical in that it empowers health care worker teams and breaks down the traditional hierarchy of power in the hospital.

"One of our problems was verifying that a physician washed his hands," Hickman says. "So [we agreed] if the nurse did not see the physician washing his hands prior to the procedure, then it was considered that he didn't wash."

This aspect of the program may sound a bit daunting and nursing empowerment is a legitimate concern for some CUSP teams. The CUSP tool kit suggests using role-playing exercises during training sessions to allow nurses to practice speaking up and help them to gain confidence. It also advises distribution of pocket cards with information on the targeted improvement areas — such as unit infection rates — as a way to add impetus to speak-up situations.

Pronovost ran head-on into this briar patch when he first began the program at Johns Hopkins years ago, but he knew that giving team members equal footing and full voice would be critical to protect patients. "The nurses rolled their eyes and said, "My job isn't to police the docs. If I do, I'm going to get my head bit off," he said. "And the docs said, "You can't have a nurse question me in public. It makes it look like I don't know things." To which I said, "Welcome to the human race. We all don't know things."

Things that go bump in the night

Another way to look at CUSP is in terms of "common harms" and "local harms," Provonost said.

"Common harms are the ones in the news that the Partnership for Patients is focusing on – urinary tract infections, bloodstream infections, pneumonias," he said. "All of those could absolutely be supported by this. The checklist or the evidence-based practices will vary, but how you implement them, how you get staff engaged, absolutely applies."

However, each health care facility also faces its share of local problems, and the safety culture built through CUSP can be used to address those as they occur.

"We need to build capacity for those frontline clinicians to address all of those things that could go 'bump in the night,'" he said. "That is what this program does. Really, the power of it is coupling those two – the ability to address these major types of harm across the U.S., but also building that capacity and the skills in front-line clinicians to solve [local problems]."

Now a widely acknowledged leader in the national patient safety movement, Pronovost recalled a time when he had only a cursory knowledge of such infection prevention strategies and safety programs.

"A snowy night Feb. 22, 2001, ironically my birthday," he said. "An adorable 18-month old girl who looked hauntingly like my daughter was taken off life support and died in her mother's arms at Johns Hopkins. She died from a cascade of errors that started with a central line associated bloodstream infection."

The child's mother asked essentially how could her daughter have been saved — how could such infections be prevented in the future? Pronovost took up the plea as a call to action that continues.

"At the time our rates of infections — like most hospitals in the country — were sky-high, and I was one of the doctors putting in these catheters and harming patients," he said. "No clinician wants to harm patients, but we were. So we set out to change this. We developed a checklist of best practices and an intervention called CUSP to change the culture and engage frontline clinicians, and use performance measures so we can be accountable for our results. It worked."


  1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006; 355:2,725-2,732.