Additional Hospital Acquired Condition (HAC) Resources
The Hospital Acquired Conditions (HACs) included in this section are HACs on which SPS has previously focused improvement efforts resulting in bundles that are proven to reduce harm when implemented reliably. During the current goal period, SPS continues to provide access to tools/resources and learning events to support the continued improvement work in the HACs below.
Adverse Drug Events (ADE)
As of Spring 2011, ADE has seen a 65.1% decrease in outcomes since 2011.
Using analysis of the data obtained from the ADE Pioneer Cohort and available evidence from the medical literature synthesized by medication safety experts, the ADE team has developed a list of medication delivery system interventions that when implemented reliably, and carried out in the context of a comprehensive, integrated medication safety program committed to continuous learning and improvement are highly likely to result in decreased harm to hospitalized children. Reflecting the number and complexity of these system-wide interventions combined with the dependence of some interventions on capital investments which will happen at different times among member hospitals, the ADE reduction strategies are best understood as a Roadmap rather than a traditional “bundle.”
The ISMP Medication Safety Self Assessment® for Perioperative Settings (endorsed by SPS) offers hospitals, freestanding ambulatory centers, and other facilities that perform outpatient medical and/or surgical procedures a unique opportunity to:
Heighten awareness of best practices associated with safe medication systems in the perioperative and procedural setting
Assist your interdisciplinary team with proactively identifying and prioritizing facility-specific gaps in perioperative and procedural medication systems to avoid patient harm
Create a baseline of your efforts to evaluate perioperative medication safety and measure your progress over time
Help analyze the current state of medication safety in perioperative and procedural settings and create a baseline measure of national efforts
You can learn more by clicking here.
Catheter-Associated Urinary Tract Infections (CAUTI)
CAUTI (catheter–associated urinary tract infections) is the sixth largest contributor to harm caused across the SPS network. In 2011, approximately 19 children were harmed each month as a result of CAUTI across the Phase I SPS hospitals (n=33), and, in 2013, Phase II hospitals (n=55) joined the network so the number of children harmed per month increased to 38.
SPS developed a team of subject matter experts and improvement scientists to release the first recommended bundle to prevent CAUTI in children to the network. This bundle summarizes evidence based practices and high reliability concepts to reduce harm caused by CAUTI.
From 2011 to the spring of 2022, the network strategy has been successful with a 47.3% reduction CAUTI. Using data obtained from the SPS network as well as external evidence in the medical literature, the CAUTI team has identified those bundle elements within the first recommended CAUTI bundle that when reliably implemented are highly likely to result in decreased harm to hospitalized children.
Falls
Falls is the ninth largest contributor to harm caused across the SPS network. In 2011, approximately 20 children were harmed each month as a result of Falls across the Phase I SPS hospitals (n=33), and, in 2013, Phase II hospitals (n=55) joined the network and the number of children harmed per month decrease to 12.
SPS developed a team of subject matter experts and improvement scientists to release the first recommended bundle to prevent Falls in children to the network. This bundle summarizes evidence based practices and high reliability concepts to reduce harm caused by Falls.
From 2011 to the spring of 2022, the network strategy has been successful with a 81% reduction Falls. Using data obtained from the SPS network as well as external evidence in the medical literature, the Falls team has identified those bundle elements within the first recommended Falls bundle that when reliably implemented are highly likely to result in decreased harm to hospitalized children.
Non-CVC Venous Thromboembolism
SPS developed a team of subject matter experts and improvement scientists to release the first recommended bundle to prevent VTE in children to the network. This bundle summarizes evidence based practices and high reliability concepts to reduce harm caused by VTE. Participating hospitals created methods for screening patients at risk and developed systems for event detection. This raised situational awareness and created scaffolding upon which to build a risk reduction strategy. In 2016, the VTE operational definition was revised based on feedback received from engaged stakeholders and content specific experts. The revised 2016 SPS VTE operational definition works toward recording all events of harm from hospital-acquired venous thromboembolism classified as either central venous catheter (CVC) related or non-CVC related, and correlating metrics were established. No network changes have been detected in Non-CVC VTE and remains in common cause variation.
Peripheral IV Infiltrations & Extravasations (PIVIE)
While intravenous catheter placement and management is commonly regarded as a routine clinical practice, potential complications from a peripheral IV infiltrate range from trivial irritation and discomfort to serious harm, such as permanent skin and soft tissue loss, impaired limb function, compartment syndrome, distal vascular compromise, and even loss of fingers or other parts of a limb.
The SPS PIVIE team formed in 2015 to test various factors thought likely to reduce incidents of peripheral IV infiltrations and extravasations, and in 2019, published a bundle to the network with interventions statistically correlated to a 17.5% reduction in the cohort’s serious PIVIE rate. In spreading the PIVIE bundle across the network since 2019, SPS has learned a great deal regarding the paucity of national standards around the clinical assessment of PIVIEs and how to best account for this challenge in the network’s operational definition. As a response, SPS has simplified its measurement approach to refocus attention on network improvement through bundle implementation.
Pressure Injuries (PI)
PI (pressure injuries) is the fourth largest contributor to harm across the SPS network. The PI team formed in May 2012 to develop strategies consistent with high reliability concepts to reduce harm caused by PI. Using data obtained from the SPS network as well as external evidence in the medical literature, the PI team identified those bundle elements that, when reliably implemented, are highly likely to result in decreased harm to hospitalized children, and in 2014 released the first PI prevention bundle to the network. In 2019, subject matter experts convened to revise the PI bundle, incorporating new evidence, clarifying language, and aligning with external organizations. Since then, SPS PI leadership team has facilitated workgroups to enhance reliability to the refreshed PI bundle and engage SPS subject matter experts’ recommendation for active surveillance. PI leadership has also sponsored small-scale exploration of tailored improvement to address leading causes of PIs based on network data, including device-associated PIs.
The network strategy in reducing the Serious PI rate (Stage 3, 4, Unstageable) rate has been successful, showing a 37% decrease in PI across the network in August 2018. The network has been challenged to sustain these results, seeing a shift up of 16% in September 2018, for a net reduction of 27% since initiating the work. We estimate that as of mid-2022, 462 serious harm PIs have been prevented across the network.
Surgical Site Infections (SSI)
SSI (surgical site infection) is the fourth largest contributor to harm caused across the SPS network. In 2011, approximately 33 children were harmed each month as a result of SSI across the Phase I SPS hospitals (n=33). The SSI team formed in May 2012 to develop strategies consistent with high reliability concepts to reduce harm caused by SSI, and released the first recommended bundle to the network. In 2013, Phase II hospitals (n=55) joined the network and the number of children harmed per month increased to 46. The network strategy has been successful with a 19% SSI reduction across the network as of May 2014. Using data obtained from the SPS network as well as external evidence in the medical literature, the SSI team has identified those bundle elements within the first recommended SSI bundle that when reliably implemented are highly likely to result in decreased harm to hospitalized children.
Additional Operational Definitions & Bundles
SPS has sunset active improvement work for a few Hospital Acquired Conditions. However, before concluding work, an operational definition and bundle had been created and shared. Please note, the following documents are not updated.