Hand Hygiene
What do you do if your hands are visibly soiled?
Wash with soap and water
What is the easiest way to reduce the number of CAUTIs?
Remove indwelling catheters/ avoid using indwelling catheters
What should you do if you identify that the Central Venous Catheter (CVC) or hemodialysis VasCath dressing is non-occlusive?
Change the central line dressing
Who can stage a pressure injury?
Per policy, only wound care nurses
What fall risk assessment tool is used by LHMC?
What infectious disease is spread throughout the hospital due to poor hand hygiene?
C.Diff
What are 2 interventions for reducing foley usage?
1. Scheduled toileting
2. External urinary devices
3. Nurse driven straight cath protocol
4. Provide patient education
5. Double void for retention
What are 3 interventions that can be performed to prevent CLABSI during regular central line maintenance?
1. Hand Hygiene
2. Use alcohol impregnated caps/ scrub caps
3. CHG baths
4. Label IV lines
5. Maintain an Occlusive Dressing
Which pressure injury stage is most common for
MedSurg HAPI Incidence?
DTI (Deep Tissue Injury)
When should a fall risk assessment be completed?
admission, with any change in caregiver (shift change), or any change in status
Name 3 times (per policy) that you must use hand sanitizer during your workday
1. Upon entering a patient's room
2. Upon leaving a patient's room
3. Before any aseptic task
4. Before donning sterile gloves
5. After removing gloves or other PPE
6. After an exposure risk to body fluids (not actual exposure)
7. If moving from a contaminated body site to another body site during patient care, with concurrent change in gloves
8. After contact with potentially contaminated inanimate objects/ furniture in the patient's environment
Name 2 reasons why it is important to follow the LHMC Urine Culture Algorithm for Patients with an Indwelling Urethral (Foley) Catheter
Reduce unnecessary testing
Reduce chance of false-positive CAUTI
Reduce need for foley exchange
Name 3 Indications for a central line
1. Poor peripheral access
2. Medication requiring a central line (certain vesicants, chemo, TPN)
3. Hemodialysis, CRRT
4. Long-term antibiotics without alternative
5. Critical Care
Name 3 interventions for HAPI prevention (PIP bundle)
1. Frequent repositioning
2. Use of air mattresses
3. Reduce friction and shear
4. Moisture management
5. Patient education
Name 2 standard fall prevention strategies for all patients
Orient to surroundings
Educate patient/family of fall risk assessments, injury risk, and interventions for fall prevention
Answer call lights promptly
Use properly fitting size clothing and footwear
Implement purposeful rounding
Maintain safe unit/room/environment. Reduce clutter, use siderails
Why is it important to maintain proper hand hygiene? List 4 Reasons
1. Limit the spread of bacteria
2. Protect patients
3. Protect yourself
4. Prevent hospital acquired infections
Name 3 reasons a patient would not be eligible for the Nurse-Driven Catheter Removal Protocol
• Critical illness (that requires proning, core temp monitoring, or neuromuscular blockade) or other specific clinical indication for hourly urinary output measurement
• Urinary incontinence with Stage 3 or greater pressure injuries/decubitus ulcers, perineal wounds or perineal necrotizing infections
• Acute immobilization (e.g., acute spinal cord injury, unstable hip injury) and external catheters are not feasible
• Acute urinary retention or obstruction relief when ISC is not indicated
• Palliative or comfort care of the terminally ill
• Postoperative monitoring of urinary output per specific surgical pathway/protocol
• Condition requiring chronic indwelling catheter (e.g., neurogenic bladder that cannot be managed via intermittent straight catheterization)
• Recommended/placed by urology (i.e. within 7d post-prostatectomy; significant genitourinary/pelvic trauma, hematuria requiring CBI [continuous bladder irrigation])
When are catheter hubs/ needleless connectors scrubbed with an alcohol pad?
Before each connection of tubing or syringe change
(before each flush, between any disconnection and re-connection!)
When should a two-nurse skin assessment be completed at minimum?
1. On admission (ED, direct admit)
2. On transfer (unit to unit)
3. If patient of the floor for 2+ hours (Dialysis, IR, Cath lab etc.)
Name 3 interventions for moderate or high fall risk patients
Yellow socks
Fall alert sign outside door
Yellow wrist band
Move closer to nurses station and keep door open when not in room
Stay with patient when toileting
Supervise or assist when ambulating, personal hygiene, sitting at bedside, etc.
Activate bed/chair alarms - utilize iBed feature & motion detector zones on the bed
Educate patient to call for assistance before getting up to ambulate
Communicate fall risk
What is the hand hygiene compliance percentage for Burlington Inpatient in calendar year 2025?
76% (Jan-Sept 2025)
How many CAUTIs occurred in MedSurg in the calendar year 2025?
14 (Jan-Sept 2025)
How many CLABSIs occurred in MedSurg in the calendar year 2025?
11 (Jan-Sept 2025)
How many HAPI incidences occurred in MedSurg in the calendar year 2025?
64 (Jan-Sept 2025)
How many Patient Falls occurred in MedSurg in the calendar year 2025?
241 (Jan-Sept 2025)