Hospital-Acquired Complications Information Kit Fact sheets to support safety and quality in Australian health services 2018 Published by the Australian Commission on Safety and Quality in Health Care Level 5, 255 Elizabeth Street, Sydney NSW 2000 Phone: (02) 9126 3600 Fax: (02) 9126 3613 Email: Hospital-Acquired Complications Information Kit Fact sheets to support safety and quality in Australian health services 2018 Contents Foreword 2 Overview 5 Introduction 7 About hospital-acquired complications (HACs) 8 Resources to support adoption of the HACs list 16 Fact sheets 17 1 Pressure injury 19 2 Falls resulting in fracture or intracranial injury 29 3 Healthcare-associated infections 39 4 Surgical complications requiring return to theatre 75 6 Respiratory complications 89 7 Venous thromboembolism 105 8 Renal failure 115 9 Gastrointestinal bleeding 125 10 Medication complications 133 11 Delirium 155 12 Persistent incontinence 165 13 Malnutrition 175 14 Cardiac complications 185 15 Third and fourth degree perineal laceration during delivery 195 16 Neonatal birth trauma 203 Appendices & references 211 Appendix 1: List of HACs and related diagnoses 212 Appendix 2: Development of the HACs list 214 References for Introduction 216 1 Foreword I am pleased to present this Australia has one of the best health systems in the world, and it is supported by dedicated clinicians information kit to support health who work hard to ensure that their patients receive services use the hospital acquired safe and high-quality care. However things can go wrong, and ongoing work is needed to reduce the complications (HACs) list to impact of adverse events on Australian patients and improve the safety and quality of their families. Australian health services. The purpose of this information kit is to provide frontline clinicians, safety and quality professionals, managers and executives, members of governing bodies and others with tools to minimise the occurrence of hospital-acquired complications (HACs) in their health service. The kit also provides insights for patients and carers as to the activities health services are undertaking to ensure safety and quality. The release of this information kit draws upon consultation with clinicians from across Australia, as well as the latest evidence and clinical guidelines. It brings together information about important safety and quality topics in a way that can be used by frontline clinicians to improve their practice, and by managers and executives to improve the safety and quality of health services. 2 The information kit provides strategies related to 16 HACs. The fact sheets outline steps clinicians, managers, governing bodies and others can put in place to reduce the occurrence of HACs. The kit also highlights the importance of ongoing monitoring of these HACs; which can provide an indication of the success of a service, or signify safety and quality issues that require improvement. Given the need to continue work to reduce HACs, I am pleased this kit is now available for use across the health system. Professor Villis Marshall AC Chair Australian Commission on Safety and Quality in Health Care 3 4 Overview This information kit includes a suite of resources for clinicians, managers and executives, governing bodies and others, to put in place strategies that reduce the occurrence of hospital-acquired complications (HACs). The kit includes three elements: • The introduction defines the 16 HACs, explains their development, why they are important, and how monitoring and responding to HACs can help provide the best care for patients. • Detailed fact sheets for clinicians, managers, safety and quality professionals, managers and executives and governing bodies. These include an overview of the governance structures and quality improvement processes needed to minimise the occurrence of a HAC. They also outline key steps to develop and deliver a comprehensive care plan for the patient. • Fact sheet “lift outs”, that can be found inserted within the front of the kit. These short documents are designed for frontline clinicians. They are provided loose to enable you to share these with relevant clinicians as a quick reference guide. All of these elements are available from the website of the Australian Commission on Safety and Quality in Health Care (Commission) (www.safetyandquality.gov.au ). 5 6