Patient Safety Indicators

Publicly Reported Safety Indicators

The Ontario Ministry of Health and Long Term Care has established a number of safety indicators that all hospitals are required to publicly report. We encourage you to review our results through the tabs above.

Nosocomial Antibiotic Resistant Organism Infection Rates

MRSA and VRE are important nosocomial pathogens which can cause a variety of types of infection in hospitalized patients.  Bacteremias are infections where the bacteria are present in the patient's blood, and represent the most serious type of infection caused by MRSA and VRE.  MRSA and VRE bacteremias provide one measure of patient safety and quality of care and should prompt hospitals to look carefully at infection prevention and control practices. Clostridium difficile is a bacterium that causes diarrhea and other intestinal conditions. See Clostridium difficile tab for additional detail. 

Need more Information? You can also read our questions & answers about these bacteria.

Ministry reporting requirements for VRE & MRSA bacteremia

Our quarterly results by site are as follows.

How do we measure this?

Monthly Clostridium Difficile Rates

Clostridium difficile is a bacterium that causes diarrhea and other intestinal conditions. The use of antibiotics increases the chances of developing C. difficile associated disease (CDAD). The combination of the presence of C. difficile and the number of people receiving antibiotics can lead to outbreaks of CDAD in hospitals. Staphylococcus aureus is a bacterium that is normally found on the skin and the nose.

The following charts represent monthly rates (per 1000 patient days) where patients have developed the above infections. The blue bars represent rates of infection that were acquired during the patient's hospital stay in Sunnybrook - also known as a nosocomial infection.

The green bars represent rates of infections that are acquired in another health care setting or in the community - this is categorized as an 'admitted' infection in the graph. The red line represents the Canadian Nosocomial Infection Surveillance Program (CNISP) hospital acquired (nosocomial) rate used as a benchmark for each organism.

How do we measure this?

Clostridium Difficile - All sites

Chart not available.

	Jul-20	Aug-20	Sep-20	Oct-20	Nov-20	Dec-20	Jan-21	Feb-21	Mar-21	Apr-21	May-21	Jun-21
Nosocomial Cases	4	5	8	12	6	4	6	5	5	7	1	2
Rate/1000 Patient Days – Nosocomial	0.19	0.33	0.53	0.73	0.38	0.24	0.3	0.27	0.24	0.35	0.05	0.09
Rate/1000 Patient Days – Admitted	0	0.2	0.13	0.18	0.25	0.37	0.41	0.16	0.24	0.25	0	0

Clostridium Difficile - Bayview Site

Chart not available.

	Jul-20	Aug-20	Sep-20	Oct-20	Nov-20	Dec-20	Jan-21	Feb-21	Mar-21	Apr-21	May-21	Jun-21
Nosocomial Cases	3	0	8	11	6	4	6	5	5	5	1	2
Rate/1000 Patient Days – Nosocomial	0.2	0.36	0.59	0.75	0.43	0.27	0.39	0.35	0.32	0.34	0.06	0.12
Rate/1000 Patient Days – Admitted	0	0.22	0.15	0.2	0.29	0.41	0.52	0.14	0.26	0.34	0	0

Clostridium Difficile - Holland Centre Site

Chart not available.

	Jul-20	Aug-20	Sep-20	Oct-20	Nov-20	Dec-20	Jan-21	Feb-21	Mar-21	Apr-21	May-21	Jun-21
Nosocomial Cases	0	0	0	0	0	0	0	0	0	0	0	0
Rate/1000 Patient Days – Nosocomial	0	0	0	0	0	0	0	0	0	0	0	0
Rate/1000 Patient Days – Admitted	0	0	0	0	0	0	0	0	0	0	0	0

Clostridium Difficile - St. John's Rehab Site

Chart not available.

	Jul-20	Aug-20	Sep-20	Oct-20	Nov-20	Dec-20	Jan-21	Feb-21	Mar-21	Apr-21	May-21	Jun-21
Nosocomial Cases	0	0	0	1	0	0	0	0	0	2	0	0
Rate/1000 Patient Days – Nosocomial	0	0	0	0	0	0	0	0	0	0.56	0	0
Rate/1000 Patient Days – Admitted	0	0	0	0	0	0	0	0.41	0.3	0	0	0

Central Line Infection (CLI)

Central lines or central venous catheters are inserted into large central veins in the neck, upper chest or groin. They are primarily used to deliver medication and fluid to patients. One of the complications that can result from a central line is that of infection which may result from the central line itself. A central line infection is the presence of bacteria or yeast in the blood of a patient that results when a central line is inserted.

The infection rate below reflects the rate of infections per quarter per 1000 central line days (1,000 central line days represents a comparator by which we can compare the total number of infections). Please note that although reporting is by site, all patients requiring a central line are cared for at the Bayview Sunnybrook site. The table below the graph shows the rate numerically as well as the actual number of incidents occurring in the quarter. The rates have been shown with and without the patients cared for in the Ross Tilley Burn Centre, because the risk of central line infection is not comparable for patients with extensive burns.

How do we measure this?

Central Line Infection (CLI) - Bayview Site

Chart not available.

Without Ross Tilley Burn Centre Patients	Q2 (20/21)	Q3 (20/21)	Q4 (20/21)	Q1 (21/22)
Incidents	0	1	0	1
Days	4432	4425	4457	5702
Rate/1000 central line days	0.18	0.18	0.18	0.18

With Ross Tilley Burn Centre Patients	Q2 (20/21)	Q3 (20/21)	Q4 (20/21)	Q1 (21/22)
Incidents	0	0	0	1
Days	4977	4912	4752	6164
Rate/1000 central line days	0.16	0.16	0.16	0.16

Hand Hygiene

The most common mode of transmission of health care-associated infections (HAIs) in healthcare settings is via the hands of health care workers that have touched colonized or infected patients or contaminated material or equipment. Monitoring hand hygiene practices and the provision of timely feedback are vital to improving hand hygiene compliance and, in turn, reducing HAIs.

How do we measure this?

At Sunnybrook Health Sciences Centre, hand hygiene compliance has been a corporate priority for over a decade. The hand hygiene program initially focused on audits to measure compliance which demonstrated improvements from 2007 to 2015. However, direct observation of hand hygiene compliance tends to overestimate performance. Therefore, Sunnybrook along with other Toronto Academic Health Sciences Network hospitals partnered to validate a more accurate means of measuring hand hygiene compliance between 2015 and 2017.

Since 2017, Sunnybrook uses group electronic hand hygiene monitoring to provide a more accurate estimate of unit-based hand hygiene compliance. This system was implemented on all medical and surgical wards, and then expanded to critical care units in 2019 . This automated system works by counting alcohol and soap-based dispenser activations through a wireless sensor. Unit-level HH adherence is determined every 24 hours by dividing HH events by the expected numbers of hand hygiene opportunities per patient hour (HHO rate) multiplied by the hourly patient census.

What are the results?

References

1. Kovacs-Litman, A et al. Do physicians clean their hands? Insights from a covert observational study. J Hosp Med, 2016; 862-4.
2. Leis JA, Powis JE, McGeer A et al. Introduction of Group Electronic Monitoring of Hand Hygiene on Inpatient Units: A Multicenter Cluster Randomized Quality Improvement Study. Clin Infect Dis
3. Kovacs-Litman A, Muller MP, Powis JE et al. Association Between Hospital Outbreaks and Hand Hygiene: Insights from Electronic Monitoring. Clin Infect Dis
4. Nayyar D et al. Hand hygiene opportunities on Canadian acute-care inpatient units: A multicenter observational study. Infect Control Hosp Epidemiol 2018; 39(11): 1378-80.
5. Han A, Conway LJ, Moore C, et al. Unit-Specific Rates of Hand Hygiene Opportunities in an Acute-Care Hospital. Infect Control Hosp Epidemiol, 2017;38:411-6.
6. Leis JA et al. Validation and Implementation of Group Electronic Hand Hygiene Monitoring across Twenty-four Critical Care Units. Infect Control Hosp Epidemiol, 2021.

Hospital Standardized Mortality Ratio (HSMR)

The Hospital Standardized Mortality Ratio (HSMR) is a measurement that compares a hospital’s mortality rate with the overall national average rate. While this indicator provides a measure of overall mortality, it should be considered alongside other indicators when assessing the quality of care provided.

A ratio that is greater than the annual national average suggests that the hospital’s mortality rate is higher than the average rate. A ratio that is below the annual national average suggests that the hospital’s mortality rate is lower than the average rate.

How do we measure this?

Results 2015-2020

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Legend

 Moving towards the national average
 Better than the national average

HSMR	2015-2016	2016-2017	2017-2018	2018-2019	2019-2020
Indicator results	84	77	73	83	78
National average*	93	91	89	97	95

*Excluding Quebec.

Surgical Safety Checklist Compliance

It has been proven that the use of a surgical checklist helps to reduce the rates of death and major complications after surgery. By using a surgical checklist, the surgical team is able to confirm important information about the patient and to ensure that the necessary steps have been taken prior and will be taken during the procedure to ensure safe patient care.

This indicator refers to the percentage of surgeries in which a three-phase surgical safety checklist was performed.

How do we measure this?

Surgical Site Infection Prevention

Surgical site infections (SSI) are the second leading type of healthcare-associated infection. Timely administration of prophylactic antibiotics is a key infection prevention strategy for hip and knee replacement surgeries. The greatest benefits are seen when antibiotics are administered within 60 minutes prior to skin incision. The following data shows the percentage of times we were able to administer the appropriate antibiotic within the recommended timeframe.

How do we measure this?

Timely Administration Rate of Prophylactic Antibiotics - All Sites

Chart not available.

Hips	Q2 (20/21)	Q3 (20/21)	Q4 (20/21)	Q1 (21/22)
Within time frame	48	41	47	34
Total cases	49	42	48	35
Percentage	97.1	97.1	97.1	97.1

Knees	Q2 (20/21)	Q3 (20/21)	Q4 (20/21)	Q1 (21/22)
Within time frame	248	262	259	97
Total cases	252	267	261	100
Percentage	97	97	97	97

Ventilator Associated Pneumonia (VAP)

Ventilator Associated Pneumonia (VAP) is defined as a Pneumonia occurring in patients in the ICU requiring mechanical ventilation (a machine which delivers artificial respirations). VAP is a complication that can lead to poor health outcomes for patients.

The VAP rate below reflects the rate of infections per quarter per 1000 ventilator days (1,000 ventilator days represents a comparator by which we can compare the total number of infections). Please note that although reporting is by site, all ventilated patients are cared for at the Bayview Sunnybrook site. The table below the graph shows the rate numerically as well as the actual number of incidents occurring in the quarter. The rates have been shown with and without the patients cared for in the Ross Tilley Burn Centre, because burn patients often have smoke inhalation so their risk of VAP is not comparable to other ventilated patients.

How do we measure this?

Ventilator Associated Pneumonia (VAP) - Bayview Site

Chart not available.

Without Ross Tilley Burn Centre Patients	Q2 (20/21)	Q3 (20/21)	Q4 (20/21)	Q1 (21/22)
Incidents	6	4	7	8
Days	3340	3100	3457	4441
Rate/1000 central line days	1.8	1.8	1.8	1.8

With Ross Tilley Burn Centre Patients	Q2 (20/21)	Q3 (20/21)	Q4 (20/21)	Q1 (21/22)
Incidents	6	1	7	9
Days	3651	3379	3575	4698
Rate/1000 central line days	1.92	1.92	1.92	1.92