Transcript Jones Memorial Hospital

What JMH is doing to Reduce HAI’s and
Maintain our Patients Safety?
IPRO HAI Webinar
January 13, 2014
Where is Wellsville, NY?
* WELLSVILLE, NY
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 Reducing
our CAUTI rates
 Maintain our CLABSI rates
 Reducing our C Diff rates
 Tickets to staff that are non
compliant
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We have and will continue to work hard to
decrease these rates.
Current Rates for CAUTI
 2011-0.31%
 2012-0.47%
 2013-0.10%
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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
Key focus was on education
to providers and nursing.
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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
Supporting the Nursing Staff
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We simplified nursing documentation for
foley insertions
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Nurse driven protocol to evaluate and
discontinue unnecessary foley catheters
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Patient Safety and Infection Prevention ticket
Ticket for Non compliance with
Urinary Care and Central Line Care
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We have work hard to prevent any CLABSI’s
over the last 5 years
Current Rates
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2009-0%
2010-0%
2011-0%
2012-0%
2013-0%
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We developed a Central
line insertion
practices/timeout
(CLIP) form
Discussed at Morning
Huddle and list is post
for providers
Central line Care
Bundle
Key focus was on education
to providers and nursing
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We simplified
documentation in EMR
Tracking and ensuring
compliance
Ticket staff for non
compliance with
policy/procedures
Supporting the Nursing Staff
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We simplified nursing documentation for
central line care
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We are working very hard at eradicating
Clostridium Difficile
Current Rate
2009-0.75%
2010-0.40%
2011-0.24%
2012-0.10%
2013-0.11%
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0.80%
0.70%
0.60%
0.50%
Rate C Diff-
0.40%
HAI/per JMH
admission
0.30%
0.20%
0.10%
Key focus was on education to
providers, nursing,
environmental staff
0.00%
2009 2010 2011 2012 2013
2009 - 2013
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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
Interventions
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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
This was a
multidisciplinary effort
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Our Nursing Staff
Our Providers
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Environmental Services
Our Pharmacy Staff
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Ticket for Non compliance with Hand Hygiene
and PPE
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Contact:
Mary Morse, RN, Infection Control
Practitioner
Jones Memorial Hospital
(585) 596-4021
[email protected]
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