what jmh is doing to reduce hais and maintain our patients safety? ipro hai webinar january 13, 2014
TRANSCRIPT
Jones Memorial Hospital
Wellsville, New York
What JMH is doing to Reduce HAI’s and Maintain our Patients Safety?
IPRO HAI WebinarJanuary 13, 2014
2
Where is Wellsville, NY?
* WELLSVILLE, NY
Mary Morse
3Mary Morse
4
Reducing our CAUTI ratesMaintain our CLABSI ratesReducing our C Diff ratesTickets to staff that are non compliant
Goals for Jones Memorial Hospital
Mary Morse
Reducing our CAUTI Rate
We have and will continue to work hard to decrease these rates.
6
Current Rates for CAUTI2011-0.31%2012-0.47%2013-0.10%
Reducing our CAUTI Rates
Mary Morse
7
Best Practice Measures
Key focus was on education to providers and nursing.
Supporting the Nursing Staff
Bladder Scanner purchased in 2012
Collecting a urinalysis on every admission
Discussed at Morning Huddle and list is post for providers
We developed a Urinary Care Bundle
We simplified documentation in EMR
We looked at where the majority of foleys were being placed
We looked at why foleys were being placed
Soft stop for foley removal
We developed a Urinary Retention Algorithm
Tracking and ensuring compliance
Ticket staff for non compliance with policy/procedures
Mary Morse
EMR Documentation
We simplified nursing documentation for foley insertions
9Mary Morse
Soft Stops for Foley Removal
Nurse driven protocol to evaluate and discontinue unnecessary foley catheters
11Mary Morse
12
Foley Catheter Discontinuation Algorithm
Mary Morse
13
Urinary Retention Algorithm
Mary Morse
14
Patient Safety and Infection Prevention ticketTicket for Non compliance with
Urinary Care and Central Line CareMary Morse
Maintaining our CLABSI Rate
We have work hard to prevent any CLABSI’s over the last 5 years
16
Current Rates
2009-0% 2010-0% 2011-0% 2012-0% 2013-0%
CLABSI Rate
Mary Morse
17
Best Practice Measures
Key focus was on education to providers and nursing Supporting the Nursing Staff
We developed a Central line insertion practices/timeout (CLIP) form
Discussed at Morning Huddle and list is post for providers
Central line Care Bundle
We simplified documentation in EMR
Tracking and ensuring compliance
Ticket staff for non compliance with policy/procedures
Mary Morse
18
Central Line Insertion/Timeout Checklist
Mary Morse
EMR Documentation
We simplified nursing documentation for central line care
20Mary Morse
Reducing our C Diff Rates
We are working very hard at eradicating Clostridium Difficile
22
C Diff Rates
Key focus was on education to providers, nursing, environmental staff
2009 - 2013
Current Rate2009-0.75%2010-0.40%2011-0.24%2012-0.10%2013-0.11%
2009 2010 2011 2012 20130.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
Rate C Diff-HAI/per JMH admission
Mary Morse
23
Best Practice Measures
Interventions This was a multidisciplinary effort
We developed a Antimicrobial Stewardship Program
Our lab changed the way we test and added a cost/dose to our sensitivity report
Our Environmental Services changed cleaning products
Our nursing staff isolated any new admissions with diarrhea and began testing
We purchased a portable sink for outside pts room
Our providers were open minded and listened to best practices
Our Administrative team was supportive
Mary Morse
24
Multi Disciplinary Effort
Our Nursing Staff Our Providers
Mary Morse
25
Environmental Services Our Pharmacy Staff
Mary Morse
Multi Disciplinary Effort
Hand Hygiene and Personal Protective
Equipment
Ticket for Non compliance with Hand Hygiene and PPE
27Mary Morse
28Mary Morse
29
Questions
Mary Morse
Contact:Mary Morse, RN, Infection Control PractitionerJones Memorial Hospital(585) [email protected]