Date of Graduation

Summer 8-7-2018

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions



Problem: From October 2016 to September 2017, the 5th floor medical surgical telemetry unit has had 9 incidences of hospital-acquired pneumonia (HAP). Among the facility, this is the floor with the highest HAP incidences.

Context: HAP is associated with $40,000 to $65,000 to each patient care cost; an additional 7-9 days of stay in the hospital, increases the chances of discharging a patient to a skilled nursing facility instead of home, and has an attributable mortality rate (Quinn, et al., 2014).

Interventions: Daily oral brushing self-audits are given to patient care technicians (PCT) for both day and evening shifts. For patient mobility, scorecards that have the progressive mobility levels are placed in certain rooms in one of the unit’s wings.

Measures: Oral brushing and mobility care are to be done with patients daily to assist in HAP prevention. The region provides daily scores of oral brushing percentage and average progressive mobility score. The project’s balancing measures are workplace safety and falls.

Results: The average percentage of oral brushing increased from 38% to 61% on 5 East while the oral brushing percentage increased from 45% to 65% on 5 West. The baseline average mobility points for the month of May 2018 was 4.1. It is now at 4.32 since last July 7, 2018.

Conclusion: There are signs of positive improvement on oral brushing percentage and average mobility scores on the unit. Noted suggestive evidence of the need to modify interventions to maximize benefits and sustainability of the results. These can include verification of oral brushing documentation, placing mobility scorecards in every room instead of a number of rooms, daily huddles of data from previous day and job aids for float and new staff.

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