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Patient Safety Indicators

Community of peoplePublicly 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.

Ministry Reporting Requirements for VRE & MRSA Bacteremia:

Our quarterly results for the period Q3 2018/2019 by site are as follows:

VRE MRSA
Campus Cases* Rate Cases* Rate
Bayview 0 0.00 1 0.02
Holland Centre 0 0.00 0 0.00
St. John's Rehab 0 0.00 0 0.00


*New nosocomial

Need more information?

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

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.

Mar-18Apr-18May-18Jun-18Jul-18Aug-18Sep-18Oct-18Nov-18Dec-18Jan-19Fen-19
Nosocomial Cases826615967585
Blue Rate/1000 Patient Days – Nosocomial0.350.090.260.270.040.220.410.260.320.230.370.25
Green Rate/1000 Patient Days – Admitted0.260.140.220.140.040.270.180.30.230.090.090.1

Clostridium Difficile - Bayview Site

Chart not available.

Mar-18Apr-18May-18Jun-18Jul-18Aug-18Sep-18Oct-18Nov-18Dec-18Jan-19Feb-19
Nosocomial Cases725615967585
Blue Rate/1000 Patient Days – Nosocomial0.440.130.320.40.060.320.590.380.490.330.520.36
Green Rate/1000 Patient Days – Admitted0.380.20.320.20.060.390.260.380.330.130.130.14

Clostridium Difficile - Holland Centre Site

Chart not available.

Mar-18Apr-18May-18Jun-18Jul-18Aug-18Sep-18Oct-18Nov-18Dec-18Jan-19Feb-19
Nosocomial Cases000000000000
Blue Rate/1000 Patient Days – Nosocomial000000000000
Green Rate/1000 Patient Days – Admitted000000000000

Clostridium Difficile - St. John's Rehab Site

Chart not available.

Mar-18Apr-18May-18Jun-18Jul-18Aug-18Sep-18Oct-18Nov-18Dec-18Jan-19Feb-19
Nosocomial Cases001000000000
Blue Rate/1000 Patient Days – Nosocomial000.19000000000
Green Rate/1000 Patient Days – Admitted0.460.460000000000

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

 
Blue Without Ross Tilley Burn Centre Patients Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Incidents 2 2 4 0
Days 4315 4264 4054 3971
Rate/1000 central line days 0.46 0.47 0.99 0.00

Green With Ross Tilley Burn Centre Patients Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Incidents 2 2 4 0
Days 4760 4761 4468 4341
Rate/1000 central line days 0.42 0.42 0.90 0.00

Hand Hygiene

The single most common transmission of health care-associated infections (HAIs) in a health care setting is via hands of health care workers who 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 compliance and, in turn, reducing HAIs.

Consistent with the Ministry of Health's reporting requirements, the following graph show Sunnybrook's compliance rates with respect to proper hand hygiene compliance:

  • Before initial patient/patient environment contact
  • After patient/patient environment contact

How do we measure this?

Hand Hygiene Compliance - All Sites - January 2018 to March 2018

 
Blue Moment 1 Bayview Holland Centre St. John's Rehab
% Compliance 72.52 70.09 86.78

Green Moment 4 Bayview Holland Centre St. John's Rehab
% Compliance 88.58 89.60 90.06

Blue Moment 1 The % compliance for before initial patient/patient environment contact by combined categories of health care provider (HCP). Note: # times hand hygiene performed before initial pat/pat env contact divided by # observed hand hygiene indications for before initial pat/pat env contact.
Green Moment 4 The % compliance for after patient/patient environment contact by combined categories of HCP.
Note: # times hand hygiene performed after pat/pat env contact divided by # observed hand hygiene indications for after pat/pat env contact. Multiply by 100.

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 2012-2017


Yellow Moving towards the national average
Green Better than the national average

HSMR 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
Indicator results 92 86 84 77 73
National average* 95 94 93 91 91

*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 Checklist Compliance

 
Blue Bayview Site Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Percentage 99.9 100.0 100.0 100.0

Green Holland Site Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Percentage 100.0 100.0 100.0 100.0

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

 
Blue Hips Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Within time frame 67 50 65 87
Total cases 58 50 65 87
Percentage 98.53 100.0 100.0 100.0

Green Knees Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Within time frame 271 253 268 296
Total cases 274 262 270 304
Percentage 98.9 96.6 99.3 97.4

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

 
Blue Without Ross Tilley Burn Centre Patients Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Incidents 8 8 10 13
Days 3602 3275 3175 2902
Rate/1000 ventilator days 2.22 2.44 3.15 4.48

Green With Ross Tilley Burn Centre Patients Q4 (17/18) Q1 (18/19) Q2 (18/19) Q3 (18/19)
Incidents 10 9 12 14
Days 3895 3572 3358 3026
Rate/1000 ventilator days 2.57 2.52 3.57 4.63