Additional Hospital-Acquired Condition (HAC) Resources
Learn more about SPS’ continued improvement work on the Hospital-Acquired Conditions (HACs) below.
Adverse Drug Events (ADE)
Medication safety and the reduction of harm to children due to adverse drug events remains an important focus in the SPS portfolio. Since the start of our network, children’s hospitals have significantly reduced and sustained adverse drug event rates. Click here to view the most recent ADE chart. SPS aligns our operational definition for Adverse Drug Events to the current version of the National Coordinating Council for Medication Error Reporting and Prevention’s Index for Categorizing Medication Errors.
Using analysis of SPS data and available evidence from the medical literature, a group of pediatric medication safety experts 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.” Please note that references can be accessed via the operational definition document and the roadmap.
Catheter-Associated Urinary Tract Infections (CAUTI)
The reduction of Catheter-Associated Urinary Tract Infections (CAUTI) remains an important focus in the SPS portfolio. Since the start of our network, children’s hospitals have significantly reduced and sustained CAUTI rates. Click here to view the most recent CAUTI chart. SPS aligns our operational definition for catheter-associated urinary tract infections to the current version of the National Healthcare Safety Network (NHSN) Manual.
Using data obtained from SPS Network hospitals, pediatric clinical subject matter expertise, as well as external evidence in the medical literature, SPS has identified prevention bundle elements that, when reliably implemented, are highly likely to result in decreased harm to hospitalized children.
The SPS CAUTI Prevention Bundle is intended to provide clinicians with an evidence-based framework to standardize the prevention of CAUTI in pediatric patients. Please note that references can be accessed via the operational definition document and the bundle.
Falls
The reduction of falls with moderate or greater harm to the patient remains an important focus in the SPS portfolio. Since the start of our network, children’s hospitals have significantly reduced and sustained falls with moderate or greater harm rates. Click here to view the most recent falls chart. SPS aligns our operational definition to the current version of the National Database of Nursing Quality Indicators (NDNQI).
Using data obtained from SPS Network hospitals, pediatric clinical subject matter expertise, as well as external evidence in the medical literature, SPS has identified prevention bundle elements that, when reliably implemented, are highly likely to result in decreased harm to hospitalized children.
The SPS Falls Prevention Bundle is intended to provide clinicians with an evidence-based framework to standardize the prevention of falls in pediatric patients. Please note that references can be accessed via the operational definition document and the bundle.
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 the 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 it remains in common cause variation.
Hospital-Acquired Delirium
Hospital-acquired pediatric delirium is a state of acute brain dysfunction characterized by fluctuating mental status, inattention, and/or disorganized thinking that occurs because of the underlying illness coupled with iatrogenic effects of treatment and the abnormal hospital environment. Even though this is a major documented cause of morbidity and mortality in children admitted to the hospital, pediatric delirium remains under-recognized in many pediatric hospitalizations.
SPS is developing a collaborative effort that can support the implementation of evidence-based practices to prevent and identify pediatric delirium to minimize harm. Besides a validated pediatric delirium screening tool for routine early diagnosis, examples of evidence-based interventions associated with decreased rates include sedation practice changes, early mobility, adjustments to care routines, lighting and sleep times, and parental presence.
For more information on pediatric hospital-acquired delirium, reach out to SPS.
Peripheral IV Infiltrations & Extravasations (PIVIE)
While intravenous catheter placement and management are commonly regarded as routine clinical practices, potential complications from a peripheral IV infiltrate (PIVIE) 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.
Network HAC data confirms SPS’ opportunity to reduce the frequency of serious harm PIVIEs in pediatric patients. Click here to view the most recent Serious Harm PIVIE chart. The SPS PIVIE Prevention Bundle was launched to the Network in 2019 after its initial cohort realized significant improvement in its serious PIVIE rate as a result of testing a standardized hourly assessment of the patient’s peripheral IV site. Since then, SPS has learned a great deal regarding the paucity of national standards around the clinical assessment of PIVIEs and simplified its measurement approach to focus attention on Network improvement through bundle implementation.
Pressure Injuries (PI)
Pressure Injuries (PI) continue to be a contributor of harm across the SPS Network. Publishing the first version of its PI Prevention Bundle in 2014, the Network has achieved notable improvement in reducing serious harm from Stage 3, 4 and unstageable pressure injuries. Click here to view the most recent serious harm pressure injury chart. SPS remains dedicated to sustaining improvement gains across the Network in reducing serious harm from PIs, recognizing the importance of continued application of the PI evidence-based bundle elements, thorough active surveillance, and opportunities for innovation.
Surgical Site Infections (SSI)
Surgical Site Infections (SSI) can cause harm to hospitalized pediatric patients. Since the beginning of Children’s Hospitals’ Solutions for Patient Safety, the Network has achieved a significant overall reduction in the SSI rate.
Using data obtained from SPS Network hospitals, as well as external evidence in medical literature, SPS has identified prevention bundle elements that, when reliably implemented, are highly likely to result in decreased harm to hospitalized children.
The SPS SSI Prevention Bundle is intended to provide clinicians with an evidence-based framework to standardize the prevention of SSI in pediatric patients. Please note that references can be accessed via the operational definition document and the bundle.
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.