Case Studies
In the fourth quarter of 2009, Lutheran Medical Center conducted a pilot study on three medical/surgical units and determined that its baseline rate for catheter-associated urinary tract infections was 14.1 per 1,000 catheter days. The national benchmark for medical/surgical units is 4.9. The goal…
Ventilator-associated pneumonia and central line-associated infections data for the third quarter of 2008 showed inconsistent compliance with practice standards. A leadership team was developed to hard-wire effective communication, continuity of care, and ongoing staff and patient education. On…
Catheter-associated urinary tract infection remains the most common health care-acquired infection. To address this, Glens Falls Hospital created an interdisciplinary committee to reduce the CAUTI rate. The hospital focused on removing the Foley catheter as soon as clinically possible, and managing…
Motivated by two years of high central line associated blood stream infection rates in the intensive care unit, Ellis Medicine undertook a reduction initiative. The successful strategies are now being applied toward a goal of eliminating health careacquired infections, and to inculcate a hospital-…
To reduce the incidence and spread of hospitalacquired infections in two critical operational nodes of patient contact, Canton-Potsdam Hospital formed multidisciplinary task forces with oversight from a central 'Safety and Service Excellence' coordinating office. The task forces assessed the…
Beth Israel Medical Center implemented a multifaceted intervention to interrupt transmission and prevent hospital-onset C. difficile infections. This successful program involved senior leadership, interdisciplinary teams, use of evidence-based practices, checklists and timely feedback of data.
In 2008, Albany Medical Center was one of 18 regional referral neonatal intensive care units to adopt central line insertion and maintenance bundles, and in 2009 agreed to use checklists to monitor maintenance-bundle adherence. Its NICU's central line-associated blood stream infection rate…
Falls increased in Thompson Health's inpatient areas in 2009 and 2010, and the number of falls was higher than the benchmark National Database of Nursing Quality Indicators data comparisons of same-size and Magnet-designated facilities. Eighty-seven percent of patients who fell on the 3-West…
In response to an increase in fall-related injuries in its skilled nursing facility, Champlain Valley Physicians Hospital Medical Center conducted a 'Kaizen' process, based on the Lean Six Sigma methodology, to identify the root causes of the falls. Results from the Kaizen were then taken to the…
The fall intervention program identified areas needing improvement including a lack of multidisciplinary attention and the need for better identification of patients at risk. At the time, green wrist bands were the only means of identification. A newly created education program included a 'STOP'…