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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. 

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?

VRE & MRSA Bacteremia - Bayview Site

VREMRSA
Cases*RateCases*Rate
Q4 2020/2110.0200

*New nosocomial

VRE & MRSA Bacteremia - Holland Centre Site

VREMRSA
Cases*RateCases*Rate
Q4 2020/210000

*New nosocomial

VRE & MRSA Bacteremia - St. John's Rehab Site

VREMRSA
Cases*RateCases*Rate
Q4 2020/210000

*New nosocomial

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.

May-20Jun-20Jul-20Aug-20Sep-20Oct-20Nov-20Dec-20Jan-21Feb-21Mar-21Apr-21
Nosocomial Cases6445812646557
Blue Rate/1000 Patient Days – Nosocomial0.350.220.190.330.530.730.380.240.30.270.240.35
Green Rate/1000 Patient Days – Admitted0000.20.130.180.250.370.410.160.240.25

Clostridium Difficile - Bayview Site

Chart not available.

May-20Jun-20Jul-20Aug-20Sep-20Oct-20Nov-20Dec-20Jan-21Feb-21Mar-21Apr-21
Nosocomial Cases6430811646555
Blue Rate/1000 Patient Days – Nosocomial0.50.310.20.360.590.750.430.270.390.350.320.34
Green Rate/1000 Patient Days – Admitted0000.220.150.20.290.410.520.140.260.34

Clostridium Difficile - Holland Centre Site

Chart not available.

May-20Jun-20Jul-20Aug-20Sep-20Oct-20Nov-20Dec-20Jan-21Feb-21Mar-21Apr-21
Nosocomial Cases000000000000
Blue Rate/1000 Patient Days – Nosocomial000000000000
Green Rate/1000 Patient Days – Admitted000000000000

Clostridium Difficile - St. John's Rehab Site

Chart not available.

May-20Jun-20Jul-20Aug-20Sep-20Oct-20Nov-20Dec-20Jan-21Feb-21Mar-21Apr-21
Nosocomial Cases000001000002
Blue Rate/1000 Patient Days – Nosocomial000000000000.56
Green Rate/1000 Patient Days – Admitted0000000000.410.30

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.

Blue Without Ross Tilley Burn Centre PatientsQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Incidents0010
Days4481443244254457
Rate/1000 central line days0000

Green With Ross Tilley Burn Centre PatientsQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Incidents0000
Days5027497749124752
Rate/1000 central line days0000

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?

Hand hygiene adherence on medical and surgical units measured using group electronic monitoring

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2017 (baseline) 2018 2019 2020
HH events 1481656 2538007 4300286 4881085
HH opportunities 3083260 4150308 6800365 6821236

Hand hygiene adherence in critical care units measured using group electronic monitoring

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2019 (baseline) 2020
HH events 216554 1855134
HH opportunities 684750 3650690

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


Yellow Moving towards the national average
Green 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 Checklist - Bayview Site

Chart not available.

Surgical Site Checklist - Bayview SiteQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Percentage100100100100

Surgical Site Checklist - Holland Centre Site

Chart not available.

Surgical Site Checklist - Holland Centre SiteQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Percentage100100100100

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.

Blue HipsQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Within time frame21484147
Total cases21494248
Percentage97.997.997.997.9

Green KneesQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Within time frame28248262259
Total cases28252267261
Percentage99.299.299.299.2

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.

Blue Without Ross Tilley Burn Centre PatientsQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Incidents4647
Days3323334031003457
Rate/1000 central line days2.022.022.022.02

Green With Ross Tilley Burn Centre PatientsQ1 (20/21)Q2 (20/21)Q3 (20/21)Q4 (20/21)
Incidents5617
Days3582365133793575
Rate/1000 central line days1.961.961.961.96