AHRQ Safety Program for Long-term Care: HAIs/CAUTI Data Office Hours Getting to Know the Comprehensive Data System (CDS) September 29, 2015

2 Presenters Sue Collier, RN, MSN, FABC Clinical Content Development Lead HRET/AHA AJ Rolle, MPH Program Manager HRET/AHA

The goals of today’s Data Office Hours are to: Review the Outcome Data collected for the LTC Program Introduce the HRET’s Comprehensive Data System (CDS) Highlight the features and tools available in CDS Answer any questions you have about the LTC Program surveys, data collection or reporting 3 Goals

4 Outcome Data Measures

Number of Residents in the Facility Each Day Necessary to calculate the CAUTI infection rate 5

Number of Residents With An Indwelling Urinary Catheter Each Day Necessary to calculate the catheter use rate at your facility 6

Number of CAUTIs Each Month Necessary to calculate the CAUTI infection rate 7

Number of Urine Cultures Collected Each Month Too many urine cultures can lead to false-positive CAUTI identification. Fewer urine cultures lead to reporting fewer CAUTIs and reducing antibiotic overuse. 8

Reporting Case Study ResidentSituation Total number of resident days Total number of urinary catheter days Total Number of CAUTIs Total Urine Cultures Collected Paige Turner Hospitalized for 7 days with pneumonia. After returning from the hospital she had in and out catheterization every 6 hours for 4 days. 9 ? Assume a 30 day month and that you only have the information provided

Reporting Case Study ResidentSituation Total number of resident days Total number of urinary catheter days Total Number of CAUTIs Total Urine Cultures Collected Rose Bush Has a indwelling urinary catheter to help with urinary retention. She developed a fever around the 2nd of the month. She was in the ER for 2 hours. The ER called the next day with her urine culture results, they confirmed a CAUTI. She was prescribed antibiotics. Her fever went down, but did not go away. On the 8th her fever spiked and she developed costovertebral pain. A CAUTI was again confirmed. 10 ? Assume a 30 day month and that you only have the information provided

Reporting Case Study ResidentSituation Total number of resident days Total number of urinary catheter days Total Number of CAUTIs Total Urine Cultures Collected Bill Board Had hip replacement surgery on the 15th of the month and was in the hospital for 3 days. He came back with a urinary catheter. On the 22nd the urologist removed the catheter. The following day Bill developed a fever of 101°F and his voided urine culture had 10,000 colonies of E. coli. Bill was prescribed antibiotics 11 ? Assume a 30 day month and that you only have the information provided

Reporting Case Study ResidentSituationTotal number of resident days Total number of urinary catheter days Total Number of CAUTIs Total Urine Cultures Collected Paige TurnerHospitalized for 7 days with pneumonia. After returning from the hospital she had in and out catheterization every 6 hours for 4 days. Rose BushHas a indwelling urinary catheter to help with urinary retention. She developed a fever around the 2nd of the month. She was in the ER for 2 hours. The ER called the next day with her urine culture results, they confirmed a CAUTI. She was prescribed antibiotics. Her fever went down, but did not go away. On the 8th her fever spiked and she developed costovertebral pain. A CAUTI was again confirmed. Bill BoardHad hip replacement surgery on the 15th of the month and was in the hospital for 3 days. He came back with a urinary catheter. On the 22nd the urologist removed the catheter. The following day Bill developed a fever of 101°F and his voided urine culture had 10,000 colonies of E. coli. Bill was prescribed antibiotics 12 ? If this facility only had these three residents what totals would be reported into CDS 80 Resident Days 34 Catheter Days 1 CAUTI 2 Urine Cultures

Data Collection Tool 13 Have you used the Data Collection Tool helpful?

14 HRET Comprehensive Data System (CDS)

Data Collected via CDS Data Collected FrequencyReports Outcome Measures*Monthly (by the 15 th of the following month of which data is collected) Weekly on Fridays (CDS run charts/reports) 1 st week of each month for month prior (cohort and org lead aggregate reports) Team Communication Guide (OPTIONAL for Cohort 4) Quarterly (by the 15 th of the following quarter of which data is collected) Learning Sessions 2 & 3 if requested *If you are submitting CAUTI events to NHSN, your data can be transferred to CDS directly by conferring rights to an HRET group 15 WHO:Facility WHEN:Monthly / quarterly as per above schedule WHERE:CDS – login credentials will be provided via Organizational LeadCDS HOW:Data coordinator collects data at facility and submits to CDS

16 CDS Login Enter your Login ID and Password, then click “Login” If you have forgotten your password, click “forgot your password” to have your password ed to you. Important messages about the system appear in red at the bottom of the page.

17 Initial User Set-up

18 Outcome Measures Data Entry The facility and project always appears on the top left Data entry status for each measure Additional details about each measure

19 Outcome Measures Data Entry

20 Outcome Measures Data Entry Top of pop-up window always displays the measure and timeframe Data becomes available for reporting once you click submit

21 Outcome Measures Data Entry

22 CDS – Reports/Run Charts

23 Team Communication Guide Data Entry

24 Team Communication Guide Example Question Formats

25 CDS User’s Guide If you have technical questions please contact HRET Data Support at

Time for Questions 26 ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Stay Updated with Useful Resources 1. AHRQ Safety Program for Long-term Care: HAIs/CAUTI Project Website AHRQ Safety Program for Long-term Care: HAIs/CAUTI Project Website Login information Username: ltcsafety Password: ltcsafety 2.TeamSTEPPS ® for Long-term CareTeamSTEPPS ® for Long-term Care 27 3.Long-term Care Safety ToolkitLong-term Care Safety Toolkit 4.Outcome Data Definitions FlyerOutcome Data Definitions Flyer 5.Team Communication GuideTeam Communication Guide 6.LTC Program Data Collection ToolLTC Program Data Collection Tool 7.AHRQ Nursing Home Survey on Patient Safety Culture and Administration MaterialsAHRQ Nursing Home Survey on Patient Safety CultureAdministration Materials 8.AHRQ's Nursing Home Survey on Patient Safety Culture Comparative DatabaseAHRQ's Nursing Home Survey on Patient Safety Culture Comparative Database

Your Feedback is Important Please take a moment to complete the evaluation for today’s event. Evaluate Event Now 28