1. VP for Patient Safety and Quality
On the CUSP: Stop CAUTI
Data…Data…Data
April 19, 2011
Sam Watson
VP for Patient Safety and Quality
MHA Keystone Center
Good afternoon and thank you Kimberly for the opportunity to update the Missouri teams on the national CAUTI project. This project is still in development, with plans to launch this fall.
My name is Marchelle Djordjevic, I am a program manager at HRET- the research affiliate of the American Hospital Association. My primary responsibility is overall national project management for the CUSP projects. I have several years project management experience working in healthcare research and quality where most recently I was the program manager at the American College of Surgeons for the ACS NSQIP. I started with HRET at the beginning of this year.
I work closely with Deb Bohr, who is also a Program Manager for the CUSP projects at HRET. Deb manages state recruitment and is here to help address any questions you may have about state and hospital recruitment.

2. CAUTI Content Call Schedule
CUSP/CAUTI Content Call #1 – CUSP
Moderator – Sam Watson; Speaker – Sean Berenholtz
03/07/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866)
60 Min.
CUSP/CAUTI Content Call #2 - The Science of Safety
Moderator – Sam Watson;  Speaker – Sean Berenholtz
03/22/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866)
60 Min.
CUSP/CAUTI Content Call #3 - Care and Removal Intervention
Moderator – Sam Watson;  Speaker – Mohamad Fakih
04/05/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866)
60 Min.
CUSP/CAUTI Content Call #4 - Data Collection
Moderator – Sam Watson;  Speaker – Sam Watson
04/19/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866)
60 Min.
CUSP/CAUTI Content Call #5 - The View from the Bedside
Moderator – Sam Watson;  Speaker – Russ Olmsted
05/03/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866)
60 Min.
CUSP/CAUTI Content Call #6 - Implementation in a Community Hospital
Moderator – Sam Watson;  Speaker – Mary Jo Skiba
05/17/11
2 ET/1 CT/12 MT/11 PT
Attendee: (866)
60 Min.

3. What Participation Requires Data Submission
Intervention
Measure
Frequency
CUSP
HSOPS
Baseline and post intervention
Team Check-up Tool
Quarterly
Care and Removal
Process Prevalence & Appropriateness
Daily then Weekly within Protocol
Outcome
Monthly within Protocol
- UTI Rate / Device Days
- UTI Rate / Patient Days
Insertion
TBD

4. Prevalence and Appropriateness (PROCESS)
Cohort 2 
Prevalence and Appropriateness (PROCESS)
Cohort 2 CAUTI Rates (OUTCOME) S M T W F
BASELINE PERIOD
No Data Collected
JUN 2011
Baseline Data Collected 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
JUL 2011 31
AUG 2011
IMPLEMENTATION
Intervention Data Collected
SEPT 2011
SUSTAINABILITY PERIOD 1
OCT 2011

5. SUSTAINABILITY PERIOD 2
No Data Collected
NOV 2011 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
DEC 2011 31
Post-Intervention Data Collected
JAN 2012

6. Data Collection Schedule
MEASURE
DATA COLLECTION SCHEDULE
DATES
CAUTI Rates (Outcome)
Number of Symptomatic CAUTI’s attributable to your unit for that month
Number of urinary catheter days per month (number of patients with urinary catheter device is collected daily at the same time each day and the total is summed for the month)
Number of patient days per month
Collect monthly for 5 months beginning in June and quarterly thereafter (June-August will be considered baseline)
2011:
June 1-30
July 1-31
August 1-31
September 1-30
October 1-31
2012:
January 1-31
April 1-30
Prevalence & Appropriateness (Process)
Assess each patient on the unit for the presence of a urinary catheter
Record the reason for the catheter
Baseline: Mon-Fri for 3 weeks
Baseline: August 1-5, 8-12, 15-19, 2011
Prospective: Mon-Fri for 2 weeks, 1 day per week for 6 weeks then one week per quarter thereafter
Prospective: September 5-9, 12-16, 20 & 27
October 4, 11, 18, 25
January 9-13
April 9-13
July 9-13
October 15-19

7. Data Collection Prevalence and appropriateness data (Process Measure)
Collected in Care Counts
Team Check Up Tool
CAUTI data (Outcome Measure)
NHSN Import
Direct entry into Care Counts

8. Prevalence and Appropriateness Data

9. Prevalence and Appropriateness Data

10. Prevalence and Appropriateness Data

11. CAUTI Outcomes Data

12. CAUTI Outcome Data

13. Feedback
Data collection timeline correlates closely with project interventions
Feedback to teams/unit staff must be given in real-time to evaluate progress and modify processes as necessary 
Reports will be available in Care Counts
Can be generated at the unit level and at a higher aggregate level

14. Important Dates Cohort 2 Data Entry Training Webinar:
May 2, 5, 9, & 12 at 2pm Eastern Time
Cohort 2 Hospital Survey on Patient Safety (HSOPS) Training Webinar:
May 16, 19, 23, 26 at 2pm Eastern Time

15. Ongoing Resources for Data
MHA Resources for data questions:
---Nicole Smith (for Care Counts issues)
Although our focus today is on eliminating Central Line Blood Stream Infections or CLABSI, you may have noticed our brand new logo, “On the CUSP: Stop HAI. Since launching the CLABSI elimination effort, we have received funding to focus on another hospital acquired infection (which happens to be CAUTI). We wanted a more inclusive logo to go with our brand new website being launched this week— Please do not hesitate to contact your State Lead, Elizabeth Cobb, or Deborah Bohr at the Health Research & Educational Trust, who is in charge of recruitment for this effort.
I want to thank you for listening to me today. I’d be happy to answer any questions.

16. Your Feedback is Important

17. Questions