On the CUSP: Stop CAUTI

Oregon CAUTI Data Review

Oregon CAUTI Meeting February 27, 2014

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National Project Goals

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The Project Goals:

1. reduce mean CAUTI rates in participating clinical units by 25 percent; and

2. improve safety culture as evidenced by improved teamwork and communication by employing CUSP methodology.

Context: Oregon and the National Collaborative

• Oregon is enrolled in Cohort 4 (started July 2012)

• Eleven other states/sponsors enrolled units for the first time in Cohort 4: AK, CO, IN, LA, MA, MI, MS, NV, OK, PR, UHC

• To date:

– 7 Cohorts

– 42 states

– 962 hospitals

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Oregon: Enrollment

# HOSPITALS # UNITS % ICU’s

OR 12 24 25%

4

• Blue Mountain Hospital – M/S

• Mid-Columbia Medical Center – ICU

• St. Charles Medical Center (12 units)

• Coquille Valley Hospital – M/S

• Pioneer Memorial Hospital Prineville– ICU & M/S

• St. Charles Redmond – Family Birthing Center & ICU

• Harney District Hospital - M/S

• Samaritan Albany General Hospital – M/S

• Wallowa Memorial Hospital – Housewide

• Kaiser Sunnyside Medical Center – MSIUC, MSPCU

• Southern Coos Hospital and Health Center – M/S

• Willamette Valley Medical Center - ICU

Participating Hospitals:

Oregon: Data Learning Objectives

To understand your progress toward:

• Reducing the rate of catheter associated urinary tract infections (CAUTI’s) AND

• Implementing the Comprehensive Unit-based Safety Program (CUSP)

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OR Outcome Data Submission

(as of 2/11/14)

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100% 100% 100% 100% 100% 100% 100% 100% 96%

0%

20%

40%

60%

80%

100%

OR Outcome Data Submission

C4 n=24 units

OR CAUTI RATES By Catheter Days 42% drop since baseline

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2.96

4.99

2.51

4.19

2.52

1.73

2.47 2.26 2.33 2.55

2.00

2.08

0.00

1.00

2.00

3.00

4.00

5.00

6.00

Baseline(Jul-Sept 12)

Implem(Oct-Nov 12)

13-Feb 13-May 13-Aug 13-Nov

CAUTI rate by Catheter Days

C4 n= 24 units Ntl Compare

OR CAUTI RATES By Patient Days 54% drop since baseline

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9.03

14.90

7.88

12.48

6.51

4.17

7.57 6.87 6.94

7.35

5.70

5.77

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Baseline(Jul-Sept 12)

Implem(Oct-Nov 12)

13-Feb 13-May 13-Aug 13-Nov

CAUTI rate by Patient Days

C4 n= 24 units Ntl Compare

OR Catheter Prevalence (Catheter days/Pt. Days)

20% drop since baseline

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30% 30%

31% 30%

26% 24%

31% 30%

30% 29%

29% 28%

0%

20%

40%

60%

80%

100%

Baseline(Jul-Sept 12)

Implem(Oct-Nov 12)

13-Feb 13-May 13-Aug 13-Nov

Catheter Prevalence

C4 n= 24 units Ntl Compare

Oregon: Data Learning Objectives

To understand your progress toward:

• Reducing the rate of catheter associated urinary tract infections (CAUTI’s) AND

• Implementing the Comprehensive Unit-based Safety Program (CUSP)

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OR Team Checkup Tool Submission

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75%

0% 0%

13%

63%

0%

20%

40%

60%

80%

100%

OR TCT Submission

C4 n= 24 units

OR CUSP Activities

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83%

17%

72%

0%

33% 33%

93%

73% 73%

0%

20%

40%

60%

80%

100%

Sr. Exec Rounds Identified Safety Defect Learned from Defect

% of unit TCT’s reporting this activity

Q3 2012 n= 18 Q2 2013 n=3 Q3 2013 n=15

Oregon: Take Home Points

• CAUTI Rate : Excellent improvement!

-- By cath days: down by 42% from baseline

-- By patient days: down by 54% from baseline

• Catheter Prevalence: Excellent improvement!

-- Down by 20% from baseline

-- Currently below national comparative data

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Oregon Take Home Points: CUSP Activities

Team Check up Tool: opportunity not fully realized through CUSP/CAUTI work

--CUSP tools still available

--Important to partner CAUTI reduction strategies with teamwork and communication improvements surrounding the unit’s patient safety culture

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Oregon Take Home Points

The work continues to follow the catheter recommendations for EVERY patient, EVERY

time, to help reduce the risk of CAUTI’s.

Thank you for all that you do to make care safer for our patients.

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