Author(s): Gauri Joshi, MBBS, DIS, CPHQ, CLSSBB, CPPS
Quality Improvement Specialist
Jerdey Shore University Medical Center

Gauri Joshi is a foreign medical graduate, she completed her medical school in India & a residency in Ophthalmology in Lyon France. In the USA she has been working in Quality, Performance Improvement, Patient Safety, Regulatory Compliance since eighteen years. She has been a member of the National Association for Healthcare Quality (NAHQ) since 2018 and has published articles in Pediatric ophthalmology and ocular trauma, Bulletin of the French Society of Ophthalmology, and Ophthalmologie.

Competency Domain: Performance & Process Improvement

Description: 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 extubating - 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-extubating) 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 extubating 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%

Evaluation: Complete Poster Evaluation