Jones Memorial Hospital Wellsville, New York What JMH is doing to Reduce HAI’s and Maintain our Patients Safety? IPRO HAI Webinar January 13, 2014
Mar 31, 2015
Jones Memorial Hospital
Wellsville, New York
What JMH is doing to Reduce HAI’s and Maintain our Patients Safety?
IPRO HAI WebinarJanuary 13, 2014
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Where is Wellsville, NY?
* WELLSVILLE, NY
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Reducing our CAUTI ratesMaintain our CLABSI ratesReducing our C Diff ratesTickets to staff that are non compliant
Goals for Jones Memorial Hospital
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Reducing our CAUTI Rate
We have and will continue to work hard to decrease these rates.
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Current Rates for CAUTI2011-0.31%2012-0.47%2013-0.10%
Reducing our CAUTI Rates
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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
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EMR Documentation
We simplified nursing documentation for foley insertions
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Soft Stops for Foley Removal
Nurse driven protocol to evaluate and discontinue unnecessary foley catheters
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Foley Catheter Discontinuation Algorithm
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Urinary Retention Algorithm
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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
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Current Rates
2009-0% 2010-0% 2011-0% 2012-0% 2013-0%
CLABSI Rate
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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
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Central Line Insertion/Timeout Checklist
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EMR Documentation
We simplified nursing documentation for central line care
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Reducing our C Diff Rates
We are working very hard at eradicating Clostridium Difficile
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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
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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
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Multi Disciplinary Effort
Our Nursing Staff Our Providers
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Environmental Services Our Pharmacy Staff
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Multi Disciplinary Effort
Hand Hygiene and Personal Protective
Equipment
Ticket for Non compliance with Hand Hygiene and PPE
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Questions
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Contact:Mary Morse, RN, Infection Control PractitionerJones Memorial Hospital(585) [email protected]