what jmh is doing to reduce hais and maintain our patients safety? ipro hai webinar january 13, 2014

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

Mary Morse

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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) 596-4021morsem@jmhny.org