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Patient Safety Reporting

More information about the hospital’s Hand-Hygiene and other Patient Safety Indicators.


PATIENT SAFETY REPORTS

Ontario Hospitals are now required to publicly report their rates of hospital acquired c-difficile rates, MRSA rates, VRE rates, Surgical Safety Checklist and the Hospital’s Standardized Mortality Ratio (HSMR).  It is our pleasure to dedicate this section of the LDMH Web-Site to providing those reports and Central Line Infections and Hand-Hygiene Compliance Rate updates every month.  Patient Safety is a major corporate priority for LDMH and we are pleased to share the results of our work with our community.  We take pride in providing high quality, safe patient care and want to ensure you have the utmost confidence in us. 

For more information about these Patient Safety Indicators click on the links below:

HAND HYGIENE COMPLIANCE RATE

Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients and health care providers.  Effective hand hygiene practices in hospitals play a key role in improving patient and provider safety, and in preventing the spread of health care-associated infections. To be clear, health care providers are washing their hands. What the provincial audit tool does is help ensure that they are washing them the right way at the right times.

 
2008-2009
2009-2010
2010-2011
2011-2012
 2012-2013
 2013-2014
2014-2015 
2015-2016
2016-2017
2017-
2018
% Compliance BEFORE Initial Patient / Patient Environment  Contact 
33%
72%

95%

90%
 97%
91% 
 95%
94%
 99% 97%
% Compliance AFTER Initial Patient / Patient Environment Contact
48%
92%
87%
93%
 93%
 95%
95% 
97%
 99% 97%

For more information about these Patient Safety Indicators click on the links below:

Hand-Washing Instructions

Proper Water Free Hand-washing Instructions

Frequently Asked Questions

Hand-Washing FAQs

 

C-Difficile

What is C-difficile?

C-difficile is one of the many types of bacteria that can be found in feces and has been known as a cause of health care associated diarrhea for about 30 years.

 2010-2011

 Q1

 Q2

 Q3

Q4 

Number of new c-difficile cases 

Less than 5 

 Less than 5

 0

Less than 5 

C-difficile rate 

 0.75

0.2 

 0

 0.18

2011-2012

Q1

Q2

Q3

Q4

Number of new c-difficile cases

Less than 5

0

Less than 5 

0

C-difficile rate

0.2

0
 0.21  0
2012-2013

 Q1

Q2 
Q3 Q4
Number of new c- difficile cases

Less than 5 

Less than 5 
 Less than 5 Less than 5 
C-difficile rate

0.39 

0.19 
 0.56  .36
2013-2014

 Q1

 Q2
Q3 Q4
Number of new c-difficile cases

Less than 5 

Less than 5 
Less than 5   Greater than 5
C-difficile rate

0.36 

0.69 
 0.90  1.22
2014-2015

 Q1

Q2 
Q3 Q4
Number of new c-difficile cases

 Less than 5

 Less than 5
 0  8
C-difficile rate

0.22

 0.41
0  1.59 
 2015-2016

Q1 

 Q2 Q3  Q4 
Number of new c-difficile cases

 0

 0 Less than 5   0
 C-difficile rate  0 0  0.20  0
2016-2017 Q1 Q2 Q3 Q4
Number of new c-difficile cases 0  Less than 5  Less than 5 0
C-difficile rate 0  0.23  0.23  0
2017-2018  Q1  Q2 Q3   Q4
 Number of new c-difficile cases  Less than 5  0  Less than 5  0
 C-difficile rate  0.64 0 0.44 
2018-2019 Q1 Q2 Q3 Q4
Number of new c-difficile cases  Less than 5    
C-difficile rate  0.45  0    

For more information about these Patient Safety Indicators click on the links below:

MRSA Bacteremia

What is Methicillin-resistant Staphylococcus aureus (MRSA)?

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant to certain or all types of the beta-lactam classes of antibiotics such as penicillins, penicillinase-resistant penicillins (e.g. cloxacillin) and cephalosporins. MRSA are strains of S. aureus that have an MIC to oxacillin of ≥ 4 mcg/ml. or contain the mecA gene coding for penicillin binding protein 2a (PBP 2a).

2010-2011

Q1

Q2

Q3

Q4

Number of new MRSA cases
0
0
0

Less than 5

MRSA rate
0
0
0
0.18
2011-2012

Q1

Q2

Q3

Q4

Number of new MRSA cases
Less than 5
0
 0  0
MRSA rate
0.2
0
 0  0
 2012-2013
 Q1
 Q2
Q3  Q4 
Number of new MRSA cases
Less than 5 
Less than 5 
Less than 5 
 MRSA rate
 0.59
0.19 
0.19 
 2013-2014
 Q1
Q2 
Q3  Q4 
Number of new MRSA cases
 Less than 5
Less than 5   Less than 5
MRSA rate
 0.17
 0.18  0.20
 2014-2015
 Q1
Q2 
Q3  Q4 
Number of new MRSA cases
Less than 5 
 0
 0  0
MRSA rate
 0.22
 0
 0  0 
2015-2016
Q1
Q2
Q3 Q4
Number of new MRSA cases  0  0  Less than 5  0
 MRSA rate  0  0  0.20 0
2016-2017 Q1 Q2 Q3 Q4
Number of new MRSA cases 0  0  0
MRSA rate 0 0
2017-2018 Q1 Q2 Q3 Q4
 Number of new MRSA cases  0 0  0
MRSA rate   0  0
2018-2019 Q1 Q2 Q3 Q4
Number of new MRSA cases  0  0    
MRSA rate  0    

VRE Bacteremia

What is Vancomycin-resistant Enterococci (VRE)?

Enterococci are bacteria that are normally present in the human intestines and in the female genital tract and are often found in the environment. These bacteria can sometimes cause infections. Vancomycin is an antibiotic that is often used to treat infections caused by enterococci. In some instances, enterococci have become resistant to this drug and thus are called vancomycin-resistant enterococci (VRE). VRE have a minimal inhibitory concentration (MIC) to vancomycin of ≥ 32 mcg/ml. They contain the resistance genes VAN-A or VAN-B.

2010-2011

Q1

Q2

Q3

Q4

Number of new VRE cases
0
0
0
0
VRE rate
0
0
0
0
2011-2012

Q1

Q2

Q3

Q4

Number of new VRE cases
0
0
 0  0
VRE rate
0
0
 0  0
 2012-2013
 Q1
Q2 
Q3 Q4
Number of new VRE cases
 0
 0
 VRE rate
 0
 0
 2013-2014
 Q1
 Q2
Q3 Q4
Number of new VRE cases
 0
0  0
 VRE rate
 0
 0
 0  0
 2014-2015
 Q1
 Q2
Q3 Q4
Number of new VRE cases
 0
 Less than 5  0 
 VRE rate
 0
 0
 0.19  0
2015-2016
Q1
Q2
Q3 Q4
Number of new VRE cases 0  0  0 0
 VRE rate 0  0  0  0
2016-2017 Q1 Q2 Q3 Q4
Number of new VRE cases 0 Less than 5  0  0
VRE rate 0  0.23  0  0
2017-2018 Q1 Q2 Q3 Q4
Number of new VRE cases  0 0  0  0
VRE rate  0  0
2018-2019 Q1 Q2 Q3 Q4
Number of new VRE cases  0    
VRE rate  0  0    

 

For more information about these Patient Safety Indicators click on the links below:

HSMR

What is the Hospital Standardized Mortality Ratio (HSMR)?

The HSMR is an important new measure that can help support efforts to improve patient safety and quality of care in Canadian hospitals. The HSMR compares the actual number of deaths in a hospital with the average Canadian experience, after adjusting for several factors that may affect in-hospital mortality rates, such as the age, sex, diagnoses and admission status of patients. The ratio provides a starting point to assess mortality rates and identify areas for improvement, which may help to reduce hospital deaths from adverse events.

2010-2011
Q1
Q2
Q3
Q4
YE
HSMR
82
109
98
102
96
2011-2012
Q1
Q2
Q3
Q4
YE
HSMR
85
91
 109   135  109
 2012-2013
 Q1
 Q2
 Q3  Q4  YE
 HSMR
105 
 105
72   100  95
 2013-2014
 Q1
 Q2
Q3 Q4   YE
HSMR 
 105
 81
84   105  95
 2014-2015
 Q1
Q2 
 Q3 Q4  YE 
HSMR
 90
 88
 97 80   89
2015- 2016  Q1  Q2  Q3  Q4  YE
HSMR  87  105 110   126 107
2016- 2017 Q1 Q2 Q3 Q4 YE
HSMR 90 75   79  95  85
2017- 2018 Q1 Q2 Q3 Q4 YE
 HSMR  67  73  77    
2018- 2019 Q1 Q2 Q3 Q4 YE
HSMR  79        

For more information about these Patient Safety Indicators click on the links below:

What is a Central-Line Associated Blood Stream Infection (CLI-BSI)?

When a patient requires long-term access to medication or fluids through an IV, a central line is put in place. A central line blood stream infection can occur when bacteria and/or fungi enters the blood stream, causing a patient to become sick. The bacteria can come from a variety of places (e.g., skin, wounds, environment, etc.), though it most often comes from the patient’s skin.

 

Hospitals follow best practices on how to prevent bacteria from entering into a central line. Patients in the ICU often require a central line since they are seriously ill, and will require a lot of medication, for a long period of time.

2010-2011

Q1

Q2

Q3

Q4

Number of new CLI cases
0
0
0
0
CLI rate
0
0
0
0
2011-2012

Q1

Q2

Q3

Q4

Number of new CLI cases
0
0
 0  0
CLI rate
0
0
 0  0
 2012-2013
Q1 
 Q2
Q3  Q4 
 Number of new CLI cases
0
 0  0
CLI rate
 0
 0
 2013-2014
Q1 
 Q2
 Q3 Q4 
Number of new CLI cases
 0
 0
CLI rate
0
 0
 2014-2015
 Q1
 Q2
Q3  Q4 
 Number of new CLI cases
 0
0
 0  0
CLI rate
0
 0
 0  0
2015-2016  Q1  Q2  Q3 Q4 
Number of new CLI cases  0  0  0  0
CLI rate  0  0 0 0
2016-2017 Q1 Q2 Q3 Q4
Number of new CLI cases 0  0 0 0
CLI rate 0  0  0  0
2017-2018 Q1 Q2 Q3 Q4
Number of new CLI cases  0 0  0  0
CLI rate  0  0  0
2018-2019 Q1 Q2 Q3 Q4
Number of new CLI cases  0    
CLI rate    

For more information about these Patient Safety Indicators click on the links below:

What is a Ventilator Associated Pneumonia (VAP)?

For our public reporting purposes, ventilator associated pneumonia (VAP) is defined as a pneumonia (lung infection) occurring in patients in an intensive care unit (ICU), requiring, external mechanical breathing support (a ventilator) intermittently or continuously, through a breathing tube for more than 48 hours.

2010-2011

Q1

Q2

Q3

Q4

Number of new VAP cases
1
0
0
0
VAP rate
30.1
0
0
0
2011-2012

Q1

Q2

Q3

Q4

Number of new VAP cases
0
0
 0  0
VAP rate
0
0
 0  0
 2012-2013
Q1 
 Q2
Q3  Q4 
Number of new VAP cases
0
0
 0  0
VAP rate
0
 0
0 0
 2013-2014
 Q1
 Q2
Q3  Q4 
Number of new VAP cases
 0
 0
 0
VAP rate
 0
 2014-2015
Q1 
Q2 
Q3   Q4
Number of new VAP cases
0
0
 0  0
VAP rate
 0
 0
0  0
2015-2016  Q1  Q2 Q3  Q4 
Number of new VAP cases  0  0 0
VAP rate  0  0  0  0
2016-2017 Q1 Q2 Q3 Q4
Number of new VAP cases 0  0  0
VAP rate 0  0  0  0
2017-2018 Q1 Q2 Q3 Q4
Number of new VAP cases  0
VAP rate  0  0  0
2018-2019 Q1 Q2 Q3 Q4
Number of new VAP cases  0    
VAP rate  0    

 

What is the Surgical Safety Checklist?

The SSCL compliance indicator refers to the percentage of surgeries in which a surgical safety checklist was performed. The SSCL is considered performed when the designated checklist coordinator confirms that surgical team members have implemented and/or addressed all of the necessary tasks and items in each of the three phases, ‘briefing’, ‘time out’ and ‘debriefing’, of the checklist, based upon the Canadian Patient Safety Institute SSCL.

The percent compliance is calculated as follows:                                 

# of times all three phases of the surgical safety checklist were performed x 100
                                        Total surgeries

2010-2011

Q1

Q2

Q3

Q4

Rate of compliance
99%
80.15%
72.87%
87.26%
2011-2012

Q1

Q2

Q3

Q4

Rate of compliance
95.42%
96.33%
98.42%
97%
 2012-2013
 Q1
 Q2
Q3 
Q4 
Rate of compliance
 97.11%
 95.76%
 97.95%
98.97% 
 2013-2014
 Q1
 Q2
Q3 
Q4 
Rate of compliance
99.23% 
 98.59%
100% 
99.41% 
 2014-2015
 Q1
 Q2
 Q3
Q4 
Rate of compliance
 100%
 100%
 99.7%
 99.7%
2015-2016
Q1
Q2
Q3
Q4
Rate of compliance  99.67%  100%  100%  99.3%
2016-2017 Q1 Q2 Q3 Q4
Rate of compliance 99.33% 99.26%  98.72%  99.79%
2017-2018 Q1 Q2 Q3 Q4
Rate of compliance  99.30%  99.00% 100%   100%
2018-2019 Q1 Q2 Q3 Q4
Rate of compliance  100%

 100%

   

HOW ARE THE RATES CALCULATED?

Hand Hygiene Rate

 Ontario hospitals are posting their hand hygiene compliance rates as percentages for time periods identified by the Ministry of Health and Long-Term Care, using the following formula:

    # of times hand hygiene performed         x 100

    # of observed hand hygiene indications  

 

These percentages also reflect:

 

   (i) hand hygiene before initial patient/patient environment contact by combined health care

        provider type (e.g., nurses, allied health professionals, physicians, etc.)

 

  (ii) hand hygiene after patient/patient environment contact by combined health care provider

       type (e.g., nurses, allied health professionals, physicians, etc.)

 

Hospitals are to collect at least 200 observations for every 100 in patient beds.

 

To ensure statistically valid data for smaller hospitals, or hospitals with fewer in-patient beds a minimum of 50 observed opportunities for hand hygiene will need to be collected.

 

The goal of public reporting hand hygiene compliance is to achieve an overall assessment of whether compliance rates are improving. It is normal for rates to vary from hospital to hospital.

C-difficile Rate

The c-difficile rate is calculated as follows:

 

Number of new cases X 1000

    Number of Patient Days

MRSA Rate

The method of calculation of the MRSA infection rate for the reporting period (on a quarterly basis) is:

 

Number of nosocomial patients with laboratory identification of MRSA bacteraemia x 1000

          Total number of patient days

 VRE Rate

The method of calculation of the VRE infection rate for the reporting period (on a quarterly basis) is:

 

Number of nosocomial patients with laboratory identification of VRE bacteraemia x 1000

           Total number of patient days

HSMR Rate

The method to calculate the hospital’s HSMR is:

 

                                                          Observed Deaths       x 100

                                                          Predicted Deaths

Central-Line Infection Rate (CLI)

All hospitals with ICUs required to report into the Critical Care Information System (CCIS) – a centralized data collection system where hospitals report a variety of critical care information – must publicly report the CLI indicator data. These hospitals are considered “eligible” for CLI-BSI reporting. 

 

These Ontario hospitals are posting their quarterly CLI rate and case count for those infections acquired in their facility, using the following formula:

              total # of ICU related BSIs after 48 hours of central line placement   x 1000

              total # of central line days for ICU patients 18 years and older

Ventilator Associated Pneumonia (VAP) Rate

Ontario hospitals with ICUs are posting their quarterly VAP rate and case count for those infections acquired in their facility, using the following formula:


         Total # of ICU cases of VAP after 48 hours of mechanical ventilation___  X 1000

         Total # of ventilator days for ICU patients 18 years and older

IMPORTANT NOTE: In smaller hospitals, such as ESHC, rates will vary greatly, from month to month, because a change in even one case in a small facility will cause the rate to go up or down considerably.

 

To find out more about patient safety you may visit the Ministry web site at www.ontario.ca/patientsafety


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