1. What JMH is doing to Reduce HAIs and Maintain our Patients Safety? IPRO HAI Webinar January 13, 2014

2. Where is Wellsville, NY? * W ELLSVILLE, NY Mary Morse2

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4. Reducing our CAUTI rates Maintain our CLABSI rates Reducing our C Diff rates Tickets to staff that are non compliant Mary Morse4

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

6. Current Rates for CAUTI 2011-0.31% 2012-0.47% 2013-0.10% Mary Morse6

7. 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 Mary Morse7

8. We simplified nursing documentation for foley insertions

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10. Nurse driven protocol to evaluate and discontinue unnecessary foley catheters

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14. Ticket for Non compliance with Urinary Care and Central Line Care Mary Morse14

15. We have work hard to prevent any CLABSIs over the last 5 years

16. Current Rates 2009-0% 2010-0% 2011-0% 2012-0% 2013-0% Mary Morse16

17. 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 Mary Morse17

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19. We simplified nursing documentation for central line care

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21. We are working very hard at eradicating Clostridium Difficile

22. Key focus was on education to providers, nursing, environmental staff 2009 - 2013 Current Rate 2009-0.75% 2010-0.40% 2011-0.24% 2012-0.10% 2013-0.11% Mary Morse22

23. 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 Mary Morse23

24. Our Nursing StaffOur Providers Mary Morse24

25. Environmental ServicesOur Pharmacy Staff Mary Morse25

26. Ticket for Non compliance with Hand Hygiene and PPE

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