WCH strives to complete speech therapy, physical therapy, and occupational therapy evaluations on 100% of stroke patients that are admitted to the hospital. By completing these evaluations, we reduce the risk of aspiration pneumonia as well as falls in these patients.

For 2024, we are at 99% compliance with speech therapy, physical therapy, and occupational therapy evaluations which has resulted in zero (0) occurrences of aspiration pneumonia in our stroke patient population.

Below is a summary of two practices that have changed recently for the care of patients having procedures with sedation (medication that makes a patient sleep and not remember anything when they wake up).

1. Research and guidelines state the best way to safely monitor a patient during a procedure with sedation is to monitor the carbon dioxide they breathe out through end-tidal CO2 monitoring (or EtCO2). A review of our procedural sedation practices showed this was not happening all the time. As a hospital, we want to provide the best and safest care possible to our patients, therefore we obtained needed equipment and supplies to do the EtCO2 monitoring, trained all staff and doctors involved, and started the new process in 2022. Unit leaders review charts to ensure we are following the correct process. In January through October of 2024, we maintain a 99% compliance rate with best practices for monitoring patients safely during procedural sedation.
2. Research and guidelines state doing a Mallampati Classification before a procedure with sedation is the best and safest practice. The Mallampati Classification is where the doctor looks into a patient’s mouth to see how open their airway (mouth and throat) is, to be prepared in case of emergency. The space is scored 1-4. Patients with a higher score may have a higher risk for airway problems. This allows the doctor to make sure they have the appropriate supplies and people during the procedure to complete it safely and prevent bad events. Training is being done and the doctors’ notes are being edited to allow recording of this score. This score will become standard before procedures with sedation in mid-December of 2024. Chart reviews will be performed to make sure the score is being done as expected.

The goal of infection prevention is to reduce the possibility of acquiring a secondary infection while hospitalized. These are called Healthcare-Associated Infections or HAIs. Hand hygiene is a critical part of preventing the spread of infection in healthcare settings and is the number one way to prevent the spread of germs.

We work hard to reduce risks for our patients by focusing on education on best practices (when and how to use the hand sanitizer versus soap and water) and we increased our number of observations in the reporting period to ensure we have accurate measurements. Hand hygiene education and use of tools to show effectiveness of the technique have been pivotal in increasing a safer environment for our patients.