We take your safety very seriously at St. Joseph’s Health Centre and we are committed to providing you with quality health care services.
When you come to St. Joe’s for care, you should not be worried about getting sick with an infection you pick up from our hospital environment. These types of infections are called hospital-acquired infections and include some names you may have heard about: C. difficile, MRSA, VRE.
To help reduce the chances of you getting these hospital-acquired infections, our healthcare teams are constantly practicing and following infection prevention and control standards.
Paying close attention to the spread of these infectious diseases is a very important step in understanding where safety issues exist and shows us what we need to do to improve. We post information about our infection rates in accordance with the Ministry of Health and Long-Term Care’s new reporting framework for patient safety indicators.
We also show you how we are doing because we believe it’s the right thing to do.
For more information on each of our patient safety indicators, please click one of the following links:
See how we are performing
Clostridium Difficile Infection Rate: 0.54 (December 2018)
Summary of our Clostridium difficle (also known as C. difficile, C. diff) rate.
We report the number of C. difficile cases in the Health Centre on a monthly basis throughout the year. We are required to do this reporting by the Ministry of Health and Long-Term Care, but we also believe it’s the right thing to do so you know how we are performing.
What is C. difficile?
Clostridium difficile is one of many types of bacteria that can be found in feces (bowel movement). C. difficile occurs when antibiotics kill your good bowel bacteria and allow the C. diff to grow. C. diff produces toxins that can damage the bowel and may cause diarrhea. It can be mild, severe possibly requiring surgery and in extreme cases C. diff may cause death. There are three things that we need to do all the time:
- Practice proper hand hygiene. Our healthcare teams are practicing the four moments of hand hygiene every time we approach a patient. This means washing their hands with soap and water or using alcohol-based hand rub whenever we are working with patients.
- Make patients and families partners in care. We are educating them about the importance of hand hygiene and the extra precautions to take when caring for a loved one with C. difficile. We are also encouraging our patients and their families to ask their healthcare providers if they have washed their hands. Clean hands are everyone’s business! Click here to learn more about proper hand hygiene.
- Practice antibiotic stewardship. We are making sure we are giving patients the right antibiotic for the right period of time.
We have also been auditing our cleaning practices for the hospital environment and patient equipment, and have made changes to ensure cleaning is consistent, thorough and done with a cleaning product that is registered with Health Canada to kill C. difficile. Enhanced cleaning is being done in our high traffic areas such as the Emergency Department.
The rate is calculated as follows:
|Number of new cases||x 1000|
|Total number of patient days (for one month)|
What determines the C. difficile rate?
We report the number of new hospital-acquired C. difficile cases on a monthly basis.
Hand Hygiene Rate: 75.6% (December 2018)
Summary of our hand hygiene rates:
Hand hygiene relates to the removal of visible soil and the removal or killing of transient microorganisms from the hands and may be accomplished using soap and running water or an alcohol-based hand rub.
Hand hygiene compliance rates are calculated with this formula:
|# of times hand hygiene performed||x 100|
|# of observed hand hygiene indications|
Public reporting of hand hygiene compliance is another measure to ensure care becomes even safer and improves over time. It provides a benchmark for tracking and monitoring performance improvement measures.
We are continuing to educate our staff about the importance of practicing the four moments of hand hygiene. We are also constantly checking and monitoring our infection prevention and control practices to ensure they are aligned with the Provincial Infectious Diseases Advisory Committee (PIDAC) best practices documents and the Ministry of Health and Long-Term Care’s Just Clean Your Hands program.
We are also educating our patients, their families and visitors about proper hand hygiene and encouraging them to ask their healthcare providers if they have cleaned their hands with alcohol-based hand rub or soap and water before coming into their room to treat them.
Hospital Standardized Mortality Ratio: 71 (September 2018)
We report our Hospital Standardized Mortality Ratio (HSMR) cases once a year.
How to interpret HSMR
- An HSMR equal to 100 suggests that there is no difference between the hospital’s mortality rate and the overall average rate.
- An HSMR greater than 100 suggests that the local mortality rate is higher than the overall average.
- An HSMR less than 100 suggests that the local mortality rate is lower than the overall average.
It is important to note that the HSMR is not designed for comparisons between hospitals; it is intended to track a hospital’s trend over time
Methicillin-Resistant Staphylococcus Aureus: 0.00 (December 2018)
Summary of our Methicillin-resistant Staphylococcus aureus (MRSA) rate:
We report the number of Methicillin-resistant Staphylococcus aureus (MRSA) cases and our rate on a quarterly basis (every three months). We are required to do this reporting by the Ministry of Health and Long-Term Care, but we also believe it’s the right thing to do so you know how we are performing.
What is MRSA?
Staphylococcus aureus is a bacteria that lives on the skin and mucous membranes of healthy people. When Staphylococcus aureus becomes resistant to certain antibiotics it is called Methicillin-resistant Staphylococcus aureus or MRSA. MRSA can also live in the nose and on the skin of some individuals. People who carry the bacteria but do not get sick are known as carriers. If people get sick from MRSA, there are a few antibiotics that can be used to treat them. MRSA does not usually pose a problem to healthy individuals.
What determines the rate?
The MRSA bacteraemia rate is calculated by dividing the number of new cases observed in the hospital by the average number of patient days per reporting period for the facility (e.g. 100 patients staying an average of 10 days = 1,000 patient-days). This rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals. Rates are expressed as cases per 1,000 patient-days.
Surgical Safety Check List: 100% (December 2018)
Summary of our Surgical Safety Checklist performance:
We report our Surgical Safety Checklist compliance rate on a bi-annual basis (every six months). We are required to do this reporting by the Ministry of Health and Long-Term Care, but we also believe it’s the right thing to do so you know how we are performing.
What is the Surgical Safety Checklist?
The Surgical Safety Checklist provides the opportunity for everyone on a surgical team to discuss important information regarding the patient and procedure. It guides the surgical team members – nurses, surgeons, anaesthesiologists – in verifying all information to ensure that we are performing the right procedure on the right patient.
Our compliance rate is intended to help us set a starting point so that we can track results over time. Should our compliance increase, we will try to sustain our successes. If our compliance decreases, we will look at our operating room processes to target areas for improvement.
For patients having surgery, you can expect that your healthcare team will use the Surgical Safety Checklist as part of your care.
What determines the rate?
|# of times all three phases of the surgical safety checklist was performed||x 100|
Surgical Site Infection: 97.73% (December 2018)
Summary of our Surgical Site Infection (SSI) Prevention rate:
We report our Surgical Site Infection (SSI) Prevention Rate on a quarterly basis (every three months). We are required to do this reporting by the Ministry of Health and Long-Term Care, but we also believe it’s the right thing to do so you know how we are performing.
What are surgical site infections?
Surgical site infections occur when harmful germs enter your body through the surgical site (any cut the surgeon makes in the skin to perform the operation). Infections happen because germs are everywhere – on your skin, in the air and on things you touch. Most infections are caused by germs found on and in your body.
What determines the rate?
One of the ways to prevent surgical site infections is by giving patients antibiotics 0 to 60 minutes (for common antibiotics) or 0 to 120 minutes (for a specific antibiotic known as vancomycin) before they go into surgery. The Surgical Site Infection indicator reports the percentage of time the healthcare team gave patients their antibiotics within the appropriate time period before the surgery. This will apply only to patients who are 18 years or older who are about to undergo primary hip or knee joint replacement surgery. This does not measure the number of actual surgical site infections after surgery.
What determines the rate?
|# of Hip/Knee total joint replacement surgeries who received usual antibiotics within 60 min of skin incision||+||# of Hip/Knee total joint replacement surgeries who received vancomycin* within 120 min of skin incision||x 100|
|Total number of patients during the reporting period who had a primary knee/hip total joint replacement surgical procedure|
*vancomycin is a type of antibiotic
Vancomycin-Resistant Enterococcus Rate: 0.00 (December 2018)
Summary of our Vancomycin-resistant Enterococcus (VRE) Rate
We report our Vancomycin-resistant Enterococcus (VRE) rate on a quarterly basis (every three months). We are required to do this reporting by the Ministry of Health and Long-Term Care, but we also believe it’s the right thing to do so you know how we are performing.
What is VRE?
Enterococci are bacteria (bugs) that are part of the normal human bowel. All normal bugs can cause infection if they are given an opportunity, for example, moving from their usual home onto a surgical incision or drain. Certain strains of the Enterococci bug have learned how to survive even with the use of antibiotics. This is called antibiotic resistance. One such strain has become resistant to the antibiotic called Vancomycin.
What determines the rate?
The VRE bacteraemia rate is calculated by dividing the number of new cases observed in the hospital by the average number of patient days per reporting period for the facility (e.g. 100 patients staying an average of 10 days = 1,000 patient-days). This rate calculation allows the level of hospital activity to be taken into account because this will fluctuate over time and is different across hospitals. Rates are expressed as cases per 1,000 patient-days.