Infection Prevention Quality Plans

QI Showcase - April 13, 2011

Barbara Dumont, RN, CPHRMSt. John’s Lutheran Hospital

Libby, Montana

Challenge How could we raise awareness hospitalwide

to improve our safety culture and infection prevention practices?

Our Quality Committee decided to choose Infection Prevention as our global goal and all departments were expected to address this in their quality plans for FY2011.

Quality Plans Each clinical and

non-clinical department met the challenge and developed infection prevention goals.

Hand Hygiene

World Health

Organization’s

“5 Moments of

Hand Hygiene”

surveillance

Hand Rub

Hand rub and

sanitizer use

surveillance

Pig PenDietary posted the

Pig Pen picture and

pointed to it when

staff did not do a 20

second hand wash

– they used a timer

Flu Vaccine:Seasonal influenza

vaccine compliance

to include either

receiving the

vaccine or signing

the declination

form

Personal Protective Equipment Staff received education

on PPE or reviewed where to find PPE and when to use it.

Staff were observed for using PPE properly.

Plant ops monitored their staff wearing gowns when entering the surgery area.

Central IV Lines Our CL policy had

been revised the previous year, which included changing from alcohol prep to ChloraPrep.

New hub caps were purchased that have 70% isopropyl alcohol (IPA) in them to decrease infection at the hub.

Equipment Sanitizing Imaging sanitized

exam rooms MM developed a policy

to decontaminate devices prior to inspection, service or repair

Use of blood pressure cuff disposable covers

Environmental Cleaning EVS monitored

cleaning using a marker pen and blacklight.

Office staff sanitized doorknobs when someone entered who had a cold.

Education

Infection prevention

education is included

in our annual

employee safety

education through

Healthstream online.

Outcomes Hand Hygiene goals 90-100% Overall = 89%

compliance (ranged from 68%-100%)

Flu Vaccine: 87% compliance with

staff receiving vaccine. 100% overall with either receiving vaccine or signing declination form.

Outcomes continued…. Personal protective

equipment

Thresholds 85-100% Central IV line infection

rate

Threshold < 5% Equipment sanitizing

Thresholds 90-100%

97% compliance

2.94%

91% compliance

Outcomes continued…. 2010: IP staff

education using an all day safety training format

Threshold 100% 2011: IP Healthstream

online education

Threshold 100% by June 30, 2011

Attendance 100%

Currently at 68% completion rate with 2 ½ months to go

FY 2012 Hospitalwide Quality Goal

Each department will develop a unit specific LEAN or similar type project

Sample of topics chosen so far:1. EVS: Patient discharge process2. Pharmacy/Nursing: Medication reconciliation3. Dietary: Wasted meals of discharged

patients

Questions?

Thank you!