Jones memorial hospital wellsville new york
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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. Where is Wellsville, NY?. * Wellsville, NY. Goals for Jones Memorial Hospital. Reducing our CAUTI rates Maintain our CLABSI rates

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Jones Memorial Hospital Wellsville, New York

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Jones memorial hospital wellsville new york

Jones Memorial HospitalWellsville, New York

What JMH is doing to Reduce HAI’s and Maintain our Patients Safety?

IPRO HAI Webinar

January 13, 2014


Jones memorial hospital wellsville new york

Where is Wellsville, NY?

* Wellsville, NY

Mary Morse


Jones memorial hospital wellsville new york

Mary Morse


Goals for jones memorial hospital

Goals for Jones Memorial Hospital

  • Reducing our CAUTI rates

  • Maintain our CLABSI rates

  • Reducing our C Diff rates

  • Tickets to staff that are non compliant

Mary Morse


Reducing our cauti rate

Reducing our CAUTI Rate

We have and will continue to work hard to decrease these rates.


Reducing our cauti rates

Reducing our CAUTI Rates

Current Rates for CAUTI

  • 2011-0.31%

  • 2012-0.47%

  • 2013-0.10%

Mary Morse


Best practice measures

Best Practice Measures

  • 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

Key focus was on education to providers and nursing.

Supporting the Nursing Staff

Mary Morse


Emr documentation

EMR Documentation

We simplified nursing documentation for foley insertions


Jones memorial hospital wellsville new york

Mary Morse


Soft stops for foley removal

Soft Stops for Foley Removal

Nurse driven protocol to evaluate and discontinue unnecessary foley catheters


Jones memorial hospital wellsville new york

Mary Morse


Foley catheter discontinuation algorithm

Foley Catheter Discontinuation Algorithm

Mary Morse


Urinary retention algorithm

Urinary Retention Algorithm

Mary Morse


Patient safety and infection prevention ticket

Patient Safety and Infection Prevention ticket

Ticket for Non compliance with Urinary Care and Central Line Care

Mary Morse


Maintaining our clabsi rate

Maintaining our CLABSI Rate

We have work hard to prevent any CLABSI’s over the last 5 years


Clabsi rate

CLABSI Rate

Current Rates

  • 2009-0%

  • 2010-0%

  • 2011-0%

  • 2012-0%

  • 2013-0%

Mary Morse


Best practice measures1

Best Practice Measures

  • 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

Key focus was on education to providers and nursing

Supporting the Nursing Staff

Mary Morse


Central line insertion timeout checklist

Central Line Insertion/Timeout Checklist

Mary Morse


Emr documentation1

EMR Documentation

We simplified nursing documentation for central line care


Jones memorial hospital wellsville new york

Mary Morse


Reducing our c diff rates

Reducing our C Diff Rates

We are working very hard at eradicating

Clostridium Difficile


C diff rates

C Diff Rates

  • Current Rate

    2009-0.75%

    2010-0.40%

    2011-0.24%

    2012-0.10%

    2013-0.11%

Key focus was on education to providers, nursing,

environmental staff

2009 - 2013

Mary Morse


Best practice measures2

Best Practice Measures

  • 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

Interventions

This was a multidisciplinary effort

Mary Morse


Multi disciplinary effort

Multi Disciplinary Effort

Our Nursing Staff

Our Providers

Mary Morse


Multi disciplinary effort1

Multi Disciplinary Effort

Environmental Services

Our Pharmacy Staff

Mary Morse


Hand hygiene and personal protective equipment

Hand Hygiene and Personal Protective Equipment

Ticket for Non compliance with Hand Hygiene and PPE


Jones memorial hospital wellsville new york

Mary Morse


Jones memorial hospital wellsville new york

Mary Morse


Questions

Questions

Contact:

Mary Morse, RN, Infection Control Practitioner

Jones Memorial Hospital

(585) 596-4021

[email protected]

Mary Morse


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