Jones Memorial Hospital Wellsville, New York

1. Jones Memorial HospitalWellsville, New York What JMH is doing to Reduce HAI’s and Maintain our Patients Safety? IPRO HAI Webinar January 13, 2014

2. Where is Wellsville, NY? * Wellsville, NY Mary Morse

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4. 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

5. Reducing our CAUTI Rate We have and will continue to work hard to decrease these rates.

6. Reducing our CAUTI Rates Current Rates for CAUTI • 2011-0.31% • 2012-0.47% • 2013-0.10% Mary Morse

7. 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

8. EMR Documentation We simplified nursing documentation for foley insertions

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10. Soft Stops for Foley Removal Nurse driven protocol to evaluate and discontinue unnecessary foley catheters

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12. Foley Catheter Discontinuation Algorithm Mary Morse

13. Urinary Retention Algorithm Mary Morse

14. Patient Safety and Infection Prevention ticket Ticket for Non compliance with Urinary Care and Central Line Care Mary Morse

15. Maintaining our CLABSI Rate We have work hard to prevent any CLABSI’s over the last 5 years

16. CLABSI Rate Current Rates • 2009-0% • 2010-0% • 2011-0% • 2012-0% • 2013-0% Mary Morse

17. 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

18. Central Line Insertion/Timeout Checklist Mary Morse

19. EMR Documentation We simplified nursing documentation for central line care

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21. Reducing our C Diff Rates We are working very hard at eradicating Clostridium Difficile

22. 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

23. 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

24. Multi Disciplinary Effort Our Nursing Staff Our Providers Mary Morse

25. Multi Disciplinary Effort Environmental Services Our Pharmacy Staff Mary Morse

26. Hand Hygiene and Personal Protective Equipment Ticket for Non compliance with Hand Hygiene and PPE

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29. Questions Contact: Mary Morse, RN, Infection Control Practitioner Jones Memorial Hospital (585) 596-4021 morsem@jmhny.org Mary Morse