Mortality Complication – Aspiration Pneumonia
We used the Plan-Do-Study-Act (PDCA) process improvement methodology to decrease the prevalence of hospital acquired Aspiration Pneumonia* Review literature* Create a Best Practice presentation for staff on the prevention of Aspiration Pneumonia - Order swallow evaluations in patients with AMS - Follow up, and continue monitoring patients for any changes in their swallowing ability* Review and modify Nursing, PCT orientation & annual mandatories - Suctioning with oral care - Swallow evaluation on extubation - Include mental status and need for swallow evaluation at every assessment
Problem: Hospital acquired Aspiration Pneumonia on and during admission, with a swallow evaluation for patients that are less alert (old age, dementia, coma, post stroke, brain injury, seizures, post-extubation) and have swallowing issues
Measurement: Pareto graphs, bar graphs were used to identify the most common apparent causes
Analysis: Mortality data for JSUMC was obtained from Vizient and analyzed for trends, and reassessed quarterly from Q3 2022 to Q4 2023 We used the Plan-Do-Study-Act (PDCA) process improvement methodology
Implementation: Create a Best Practice presentation for staff on the prevention of Aspiration Pneumonia - Order swallow evaluations in patients with AMS - Follow up, and continue monitoring patients for any changes in their swallowing ability - Suctioning with oral care - Swallow evaluation on extubation
Results/Discussion: A decrease in aspirations in mortality complications was observed- Q3 2022 - 48.14%- Q1 2023 - 31.03%- Q2 2023 - 25.00%- Q3 2023 - 27.27%- Q4 2023 - 33.33%
Speakers
Gauri Joshi, MBBS, DIS, CPHQ, CLSSBB, CPPS
Quality Improvement Specialist - Jerdey Shore University Medical Center
Event Details
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Performance and Process Improvement
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Location Virtual
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Organizer NAHQ Next
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