Infection Control

Patient Safety Indicator Reports

We are committed to providing the best and safest care to our patients. One way we do this is by conducting targeted surveillance and reporting our infection rates. Most infections in hospital settings happen through the spread of microorganism such as bacteria or viruses. These microorganisms are found in the community, at home, in schools and in workplaces.

We support the provincial government’s strategy to publicly report five patient safety indicators. We believe it will enhance patient safety and strengthen the public’s confidence in our hospital.

It is important to understand that the reporting of these rates is not the overall solution to reducing the rates of infections in hospitals. These rates are tools that will provide hospitals with good information to assist us in understanding where patient safety issues exist and to help us take actions to improve.

Our rates are below, where you will also find some frequently asked questions on each indicator. You can also access these rates on the patient safety pages of the Health Quality Ontario website. It is important to note that not all hospitals will report all rates, due to the nature of patients and/or the cases it treats.

• Clostridium difficile infections (CDI)
• Hand Hygiene Compliance
• Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections
• Surgical Safety Checklist (SSCL)
• Vancomycin-resistant Enterococci (VRE) bloodstream infections

Clostridium Difficile Infections (CDI)

We publicly report our rate of CDI on a monthly basis via our website.

CDI (commonly referred to as C. difficile or C. diff) is a bacteria (germ) which can be found in people’s bowels, and may not cause any symptoms. In some people, these germs can cause a toxin that damages the lining of the bowel causing loose, watery bowel movements (diarrhea). If a person has diarrhea due to CDI, doctors will prescribe a type of antibiotic that kills it.

Current CDI annual data reporting:

CDI	Apr 2023	May 2023	Jun 2023	Jul 2023	Aug 2023	Sep 2023	Oct 2023	Nov 2023	Dec 2023	Jan 2024	Feb 2024	Mar 2024
# of new cases	0	0	0	0	0	0	0	0	0	0	0	0
Rate/1000 pt. days	0	0	0	0	0	0	0	0	0	0	0	0

Hand Hygiene

A number of practices have been put in place to help prevent and control infections, including a comprehensive hand hygiene program.

The provincial government’s multifaceted hand hygiene program, “Just Clean Your Hands”, was been introduced in an effort to promote effective hand hygiene, not only for health care providers, but for patients and visitors as well.

Annual hand hygiene compliance rates for Ontario hospitals are publically reported within their respective facilities. Compliance is achieved through first providing education to health care providers and support services, to ensure proper hand hygiene techniques are performed before and after patient environment contact. Audits are then conducted as staff perform their daily activities, observing the number of times hand hygiene procedures are performed at each of these opportunities.

Compliance rates are calculated by dividing the number of times that hand hygiene was performed for each of the indications by the number of observed hand hygiene opportunities for that specific indication.

Current hand hygiene annual data by reporting period:

Hand Hygiene	April 2023 – March 2024
Before initial patient environment contact	92%
After initial patient environment contact	95%

Methicillin Resistant Staphylococcus Aureus (MRSA) Bloodstream Infections

Rates of new methicillin-resistant staphylococcus aureus (MRSA) blood stream infections are publicly reported via our website on a quarterly basis (every three months).

Staphylococcus aureus is a germ which can live on the skin and mucous membranes of healthy people. Occasionally, staphylococcus aureus can cause an infection. When staphylococcus aureus develops resistance to certain antibiotics, it is called methicillin-resistant staphylococcus aureus or MRSA.

Current quarterly MRSA data by reporting period:

MRSA	Q1 Apr – Jun 2023	Q2 Jul – Sep 2023	Q3 Oct – Dec 2023	Q4 Jan – Mar 2024
# of new cases	0	0	0	0
Rate/1000 pt days	0	0	0	0

Vancomycin Resistant Enterococci (VRE) Bloodstream Infections

Rates of new vancomycin resistant enterococci (VRE) blood stream infections are publicly reported via our website on a quarterly basis (every three months).

Enterococci are bacteria that are normally present in the human intestines, in the female genital tract and are often found in the environment. These bacteria can sometimes cause infection. 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 therefore called vancomycin resistant enterococci (VRE). Currently, we do not screen patients on admission for VRE, or place patients on precautions (isolate) those who are known to be colonized or infected.

Current VRE data by reporting period:

VRE	Q1 Apr – Jun 2023	Q2 Jul – Sep 2023	Q3 Oct – Dec 2023	Q4 Jan – Mar 2024
# of new cases	0	0	0	0
rate/1000 pt days	0	0	0	0

Surgical Safety Checklist (SSCL)

Our rate of SSCL compliance percentage is reported quarterly via our website.

The SSCL is a patient safety communication tool, which is used by our team of operating room professionals (surgeons, anesthetist or nursing staff) to discuss important case details.

The SSCL dialogue occurs at three key times during the operating room experience:

• Before the patient is given anesthesia,
• Before skin incision, and
• Before closing or completing a procedure.

Research has shown that the practice of using a SSCL reduces the risk of errors leading to complications and mortality. The very nature of the checklist improves overall teamwork, communication and patient wellbeing.

Compliance with the SSCL is one of several safety indicators we must report, and we strongly support the provincial government’s reporting regime. Implementing the mandatory use of the SSCL and publicly reporting it is another very useful step in helping our hospital monitor improved quality and patient safety efforts.

Current SSCL compliance rates by reporting period: