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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:

CDIApr 2021May 2021Jun 2021Jul 2021Aug 2021Sep 2021Oct 2021Nov 2021Dec 2021Jan 2022Feb 2022Mar 2022
# of new cases100000000000
Rate/1000 pt. days0.7100000000000
NV = no value; data not yet available

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 HygieneApril 2020 – March 2021
Before initial patient environment contact69%
After initial patient environment contact78%

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:

Apr – Jun 2021
Jul – Sep 2021
Oct – Dec 2021
Jan – Mar 2022
# of new cases0000
Rate/1000 pt days0000
NV = no value; data not yet available

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:

Apr – Jun 2021
Jul – Sep 2021
Oct – Dec 2021
Jan – Mar 2022
# of new cases1000
rate/1000 pt days0.63000
NV = no value; data not yet available

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:

Apr – Jun 2021
Jul – Sept 2021
Oct – Dec 2021
Jan – Mar 2022
Percentage of surgeries with completed SSCL. 100%100%100%100%
NV= no value; data not yet available.