Reduce Hospital-Acquired Conditions


• Surgical Site Infections – Partnering with Infection Control and the Spine Steering Committee to decrease spine and craniotomy surgical site infection rates. 

• Pulmonary Embolism/Deep Venous Thrombosis (PE/DVT) – Partnering with a Nursing Council to reduce PE/DVT rates and improve patient compliance with wearing Sequential Compression Devices (SCDs) during hospitalization. Perioperative PE/DVT Prevention Poster

• Hand Hygiene – Partnering with Infection Control and the Medical Director of the Co-management Hospitalist Service to maintain hand hygiene compliance rates > 85% in all patient care areas in the hospital.

• Medication Reconciliation Pilot – Partnering with Department of Clinical Pharmacy to decrease in-hospital medication prescribing and administration errors by ensuring an accurate, up-to-date medication list immediately prior to surgery. 

• Mannitol Infusion Pilot – Partnering with nursing, pharmacy, and the Department of Neurology to decrease mannitol extravasation rates by standardizing a protocol for mannitol infusion. Mannitol Administration Trial Poster

• Falls, Hospital Acquired Pressure Ulcers (HAPUs), Catheter Associate Urinary Tract Infections (CA-UTIs) – Partnering with Nursing to continue to decrease falls, HAPU, and CA-UTI rates.