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

Current quarterly data:

  • Q1: April - June 2019
    • Incident diagnosed after day 2 of admission=0
    • Rate = 0
  • Q4: Jan-March 2019
    • Incident diagnosed after day 2 of admission=0
    • Rate = 0

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. 

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.

Current monthly data by reporting period:

  • June 2019
    • Rate per 1,000 patient days =0.07
    • Case count = 1
  • May 2019
    • Rate per 1,000 patient days = 0.33
    • Case count = 5
  • April 2019
    • Rate per 1,000 patient days = 0.20
    • Case count = 3
  • March 2019
    • Rate per 1,000 patient days = 0.19
    • Case count = 3
  • February 2019
    • Rate per 1,000 patient days=0.28
    • Case count=4
  • January 2019
    • Rate per 1,000 patient days=0.13
    • Case count = 2

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.

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. For 2017-2018 the rates for Kingston General Hospital site and Hotel Dieu Hospital site have been combined and reported as Kingston Health Sciences Centre. 

Current annual data by reporting period:

  • At Kingston Health Sciences Centre between April 2018 - March 2019
    • ​Percent compliance for before initial patient/patient environment contact = 93.8%
    • Percent compliance for after patient/patient environment contact = 92.7%
  • At Kingston Health Sciences Centre between April 2017 - March 2018 there were 5,519 observed opportunities with compliance for  April 2017-March 2018
    • ​Percent compliance for before initial patient/patient environment contact = 91%
    • Percent compliance for after patient/patient environment contact = 90%

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 KHSC. 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.

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.

Current annual data by reporting period:

  • April 2017-March 2018
    • HSMR all cases = 102
  • April 2016 - March 2017
    • HSMR all cases = 105

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.

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) 

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) including, the hospital acquired MRSA bacteraemia rate and 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.

Current quarterly data by reporting period:

  • Q1: April-June 2019
    • 4 cases, for a rate of 0.08 per 1000 patient days

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.  

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

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.

Current semi-annual data by reporting period:

  • July-December 2018

    • Percentage compliance = 98%

  • January-June 2018

    • Percentage compliance=100%

  • July-December 2017

    • Percentage compliance=100%

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.

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.

Current quarterly data by reporting period:

  • Q1: April-June 2019
    • Rate=96.6% HDH site
    • Rate=98.9% KGH site

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.

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.

Current quarterly data by reporting period:

  • Q1: April-June 2019
    • 3 cases, for a rate of 0.06 per 1000 patient days

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. 

Ventilator associated pneumonia (VAP)

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.

Current quarterly data by reporting period:

  • Q1: April-June 2019
    • Rate per 1,000 patient days = 0.96
    • Case count = 2

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.

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