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 microorganisms such as bacteria or viruses. These microorganisms are also found in the community, at home, in schools and workplaces.  

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

It’s 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 can be accessed via the links 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. Please note not every hospital will report all rates due to the nature of patients/cases it treats.

Central line bloodstream infections (CLI)

We report our rate of central line bloodstream infections (CLI) on a quarterly basis (every three months) via our website. The rate is posted on the last day of the month following the last quarter.

It is important to monitor rates of CLI because this infection can prolong hospitalization and can result in serious complications in critically ill patients. When a patient requires long-term access to medication or fluids through an intravenous (IV), a central line is put in place. Patients in the intensive care unit (ICU) often require a central line since they are seriously ill and will require a lot of medication, for a long period of time. A central line bloodstream infection can occur when bacteria and/or fungi enters the blood stream. 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 will post the number of cases of CLI and the CLI rate. CLI cases will be posted if they are associated with a central line that was in place during the 48-hour period before the development of the infection. The number of CLI cases will be indicated where the number of cases is zero or totaling five or more associated with that hospital site. If the number is less than five cases, it will state less than five (<5) cases. The CLI rate is the number of ICUpatients (18 years and older) with new CLI per 1,000 central line days.

Public reporting of CLI is not intended to serve as a comparator measure among hospitals but as a tool to help prevent and reduce the occurrences of hospital-acquired infections. Public reporting is another helpful measure to ensure the care provided to our patients is even safer and improves over time. The analysis of our CLI rates will provide us with helpful information that we can use to make quality improvements in our organization.

Click her for a list of frequently asked questions about central line bloodstream infections. 

Current quarterly data by reporting period:

  • April - June 2017
    • Incidents diagnosed after day 2 of admission = 0

    • Rate = 0

  • January - March 2017
    • Incidents diagnosed after day 2 of admission = 0

    • Rate = 0

  • October- December 2016

    • Incidents diagnosed after day 2 of admission = 1
    • Rate = 0.33
  • July-September 2016
    • Incidents diagnosed after day 2 of admission = 0
    • Rate = 0
  • April-June 2016
    • Incidents diagnosed after day 2 of admission = 0
    • Rate = 0
  • January - March 2016
    • Incidents diagnosed after day 2 of admission = 3
    • Rate = 1.08

Previous years quarterly archived data 

Clostridium difficile Infections  (CDI)

We report our rate of Clostridium difficile infections (CDI) monthly via our website. The rate is posted on the last day of each month.

Clostridium Difficile (C. difficile) is a bacteria (germ) that can be found in people’s bowels which may not cause any symptoms. But, in some people, these germs make a toxin that damages the lining of the bowel causing loose watery bowel movements (diarrhea). If a person has diarrhea due to C. difficile, doctors will prescribe a type of antibiotic that kills CDI. The majority of people recover from C. difficile diarrhea.

The C. difficile rate is calculated per 1,000 patient days. An outbreak occurs if a hospital experiences 6 CDAD cases within a 30-day period on one patient care area (3 CDAD cases within one week is a cluster).

Click here for a list of frequently asked questions about C.difficile.

Current monthly data by reporting period:

During 2017, there has been no outbreak of C-difficile at KGH.

  • August 2017
    • Rate per 1,000 patient days = 0.45
    • Case Count = 6
  • July 2017
    • Rate per 1,000 patient days = 0.31
    • Case Count = 4
  • June 2017
    • ​Rate per 1,000 patient days = 0.47
    • Case Count = 6
  • May 2017
    • Rate per 1,000 patient days = 0.23
    • Case Count = 3
  • April 2017
    • Rate per 1,000 patient days = 0.40
    • Case Count = 5
  • March 2017
    • Rate per 1,000 patient days = 0.37
    • Case Count = 5
  • February 2017
    • Rate per 1,000 patient days = 0.85
    • Case count = 11
  • January 2017
    • Rate per 1,000 patient days = 0.50
    • Case count = 7

Previous years monthly archived data 

Hand hygiene compliance

We report our rate of hand hygiene compliance among health-care providers annually via our website. The rate is posted at the end of April.

Hand hygiene is an important practice for health-care providers but also involves everyone in the hospital, including patients, families and visitors. 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.

Hand hygiene compliance is monitored in all patient care areas throughout KGH. Compliance is measured by auditing (direct observation) health care workers in the course of their duties. Rates are calculated by taking the number of times hand hygiene was performed before initial patient or patient environment contact and after patient or patient environment contact and dividing by the number of observed hand hygiene indications for that specific indication. The results are multiplied by 100. This calculation represents the percentage compliance rate for hand hygiene for the reporting facility. Like many Ontario hospitals, we have implemented the provincial Just Clean Your Hands campaign to help drive increased compliance. Since the release of compliance rates for observations for the 2009/2010 fiscal year, our compliance has jumped to over 70 per cent overall.

The collection and public reporting of these rates will allow hospitals to establish a baseline from which to track their hand hygiene improvement over time. Hospitals will use this information to identify areas for improvement and strategies for reducing the incidence of health-care-associated infections.

Click here for a list of frequently asked questions about hand hygiene compliance.

Current annual data by reporting period:

  • April 2016 - March 2017
    • Percent compliance for before initial patient/patient environment contact = 92.4%
    • Percent compliance for after patient/patient environment contact = 91.7%
  • April 2015 - March 2016
    • Percent compliance for before initial patient/patient environment contact = 84.30%
    • Percent compliance for after patient/patient environment contact = 90.20%

​Previous years annual archived data

Hospital standardized mortality ratio (mortality rates)

We report our Hospital Standardized Mortality Ratio (HSMR), also known as mortality rate, annually via our website. The rate is posted in December each year.

HSMR is an overall quality indicator and measurement tool used by all acute care hospitals and regions in Canada to provide a snapshot of a hospital’s performance at any given time.

Methodology

The formula for HSMR is the number of observed deaths divided by the number of expected deaths among diagnoses groups accounting for 80% of inpatient mortality multiplied by 100 which is the ratio of observed to expected deaths.

In 2015, the Canadian Institute for Health Information (CIHI) updated the methodology used to calculate HSMR results.

  • The baseline year for the data was changed to 2012 - 2013
  • Updated methodology was used to re-calculate HSMR results for the last five years i.e. 2010-11, 2011-12, 2012-13, 2013-14 and 2014-15

Because of the new baseline year, HSMR values may look like they have increased for the majority of hospitals when compared to the results released prior to 2015. Generally, HSMR results across the country have increased in light of the re-baselined data; however, the trend remains the same for most organizations.

You can also access these rates on the patient safety page of the CIHI OurHealthSystem.ca website

Click here for a list of frequently asked questions about Hospital Standardized Mortality Ratio (HSMR) 

Current annual data by reporting period:

  • April 2015 - March 2016
    • HSMR all cases = 107
    • 95% confidence interval = 98.3 - 115.4

Previous years annual archived data

Methicillin-resistant Staphylococcus aureus (mrsa) blood stream infections

We report our rate and case count of new Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections quarterly (every three months) via our website. 

Staphylococcus aureus is a germ that 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.  

On the last day of the month following each quarter, KGH will report the MRSA data on its website including: 

  • the hospital acquired MRSA bacteraemia rate

  • the number of new hospital acquired MRSA blood stream infection cases 

The total number of new cases of MRSA bacteraemia acquired in the hospital in a quarter is divided by the total number of patient days for that quarter.

Click here for a list of frequently asked questions about Methicillin-resistant Staphylococcus aureus (MSRA).

Current quarterly data by reporting period:

  • April - June 2017
    • Rate per 1,000 patient days = 0.07
    • Case Count = 3
  • January - March 2017
    • Rate per 1,000 patient days = 0.05
    • Case count = 2
  • October-December 2016
    • Rate per 1,000 patient days = 0.10
    • Case count = 4
  • July-September 2016
    • Rate per 1,000 patient days = 0.07

    • Case count = 3

  • April-June 2016
    • Rate per 1,000 patient days = 0.10
    • Case count = 4
  • ​January-March 2016
    • Rate per 1,000 patient days = 0.05

    • Case count = 2

Previous years quarterly archived data 

Surgical safety checklist (SSCL)

We report our rate of surgical safety checklist (SSCL) compliance percentage on a bi-annual basis (twice a year) via our website. The rate is posted on the last day of the month in July and January.

The surgical safety checklist is a patient safety communication tool that is used by a team of operating room professionals (nurses, surgeons, anesthesiologists, and others) to discuss important details about a surgical case. The checklist, similar to that used by airline pilots prior to take off, is used at three distinct stages or phases during surgery: pre-induction (before the patient is put to sleep), time out (just before the first incision) and debriefing (during or after surgical closure).

All Ontario hospitals that perform surgeries must report their compliance rate. Public reporting of checklist compliance is not intended to serve as a comparator measure among hospitals but as a tool to help improve teamwork and communication in the operating room. This in turn helps improve patient care and safety, decreases complications and deaths from surgery and improves operating room efficiency.

Public reporting of SSCL compliance is another helpful measure to ensure the care provided to our patients is even safer and improves over time. The analysis of our SSCL percentages will provide us with helpful information that we can use to make quality improvements in our organization.

Click here for a list of frequently asked questions on surgical safety checklists.

Current semi-annual data by reporting period:

  • July-December 2016
    • ​Percentage compliance = 99.76%
  • January-June 2016
    • ​Percentage compliance = 99.85%
  • July-December 2015
    • Percentage compliance = 99.76%
  • January-June 2015
    • ​Percentage compliance = 99.0%
  • ​July - December 2014
    • ​Percentage compliance = ​98.73%
  • ​January - June 2014
    • ​Percentage compliance = ​99.01%

Previous years semi-annual archived data 

Surgical site infections (SSI) prevention

We report our rate of surgical site infection (SSI) prevention percentage on a quarterly basis (every three months) via our website. The rate is posted on the last day of the month following the last quarter.

All Ontario hospitals that perform hip and knee joint replacement surgeries must report their rates. The goal is to ensure that one of the most important steps in preventing SSI is being used (i.e., ensuring that antibiotics are administered at a certain time just before a hip or knee joint replacement surgery). Studies have shown that antibiotic administration just before a joint replacement is a good way to reduce the chance of infection.

 The SSI indicator will reveal the percentage of all eligible patients, undergoing joint replacements, who get antibiotics at the right time, just before a joint replacement surgery. We are working toward full compliance of this practice in every hip and knee joint replacement surgery.

Public reporting of SSI prevention percentages is not intended to serve as a comparator measure among hospitals but as a tool to measure processes that  reduce the occurrences of surgical site  infections. Public reporting of SSI prevention is another helpful measure to ensure the care provided to our patients is  safe and improves over time. The analysis of our SSI prevention percentages will provide us with helpful information that we can use to make quality improvements in our organization.

Click here for a list of frequently asked questions on surgical site infection prevention.

Current quarterly data by reporting period:

  • April - June 2017
    • ​Rate = 97.3%
  • January - March 2017
    • Rate = 95.3%
  • October-December 2016
    • Rate = 97.9%
  • July-September 2016
    • Rate = 98.2%
  • ​​April-June 2016
    • Rate  = 94.80 %
  • January-March 2016
    • Rate  = 92.80 %

Previous years quarterly archived data 

Vancomycin-resistant Enterococci (VRE) blood stream infections

We report our rate of Vancomycin-resistant Enterocooci (VRE) blood stream infections (BSI)  quarterly (every three months) via our website. The rate is posted on the last day of the month following the last quarter.

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).  Currently at KGH, we do not screen patients on admission for VRE or place patients on precautions (isolate) who are known to be colonized or infected.

At the end of each quarter, KGH will report the previous quarter’s data on its website by hospital site including:

the number of new hospital acquired VRE bacteraemia cases as either zero, less than five or totaling five or more
the hospital acquired VRE bacteraemia rate

Click here for a list of frequently asked questions on Vancomycin-resistant Enterococci. 

Current quarterly data by reporting period:

  • April - June 2017
    • Rate per 1,000 patient days = 0.02
    • Case Count = 1
  • January - March 2017
    • Rate per 1,000 patient days = 0.05
    • Case count = 2
  • October-December 2016
    • Rate per 1,000 patient days = 0.05
    • Case count = 2
  • July-September 2016
    • Rate per 1,000 patient days = 0.00

    • Case count = 0

  • April-June 2016
    • Rate per 1,000 patient days = 0.07
    • Case count = 3
  • January - March 2016
    • Rate per 1,000 patient days = 0.05
    • Case count = 2

Previous years quarterly archived data 

Ventilator associated pneumonia (VAP)

Ventilator-associated pneumonia (VAP) is defined as pneumonia (a serious lung infection) occurring in patients in the Intensive Care Unit (ICU) requiring intermittent or continuous mechanical ventilation through either a tracheostomy or endotracheal tube for more than 48 hours.  Patients who are on a ventilator are unable to cough or breathe normally and about 15 percent of these patients develop VAP. VAP can develop for many reasons.

All hospitals in Ontario report the number of cases of VAP and the VAP rate to the Critical Care Information System (CCIS) daily. We report our rate of VAP on a quarterly basis (every three months) via our website. The rate is posted on the last day of the month following the last quarter. It is important to monitor rates of VAP because this infection is very serious, can prolong hospitalization and sometimes result in death.

Public reporting of VAP is intended to serve as a tool to help prevent and reduce the occurrences of hospital-acquired infections. Public reporting is another helpful measure to ensure the care provided to our patients is even safer and improves over time. KGH has developed strategies to try to prevent and monitor VAP. The analysis of our VAP rates will provide us with helpful information that we can use to make quality improvements in our organization.

Click her for a list of frequently asked questions about ventilator associated pneumonia

Current quarterly data by reporting period:

  • October-December 2016
    • Case count = 0
    • Rate = 0
  • July-September 2016
    • Case count = 0
    • Rate = 0
  • April-June 2016
    • Case count = 1
    • Rate = 0.47
  • January - March 2016
    • Case count = 4
    • Rate = 1.93

Previous years quarterly archived data