February 27, 2009 OUR HOSPITAL SAFETY REPORTING

Clostridium Difficile Reporting (C-Diff)

The C. Diff Infection rate is calculated as a rate per 1,000 patient days.

The “total patient days” represents the sum of the number of days during which services were provided to all inpatients during the given time period.

The rate is calculated as follows:

Number of new hospital acquired cases of C. Diff in our facility x 1000

Total number of patient days (for one month)

 Methicillin Resistant Staphylococcus Aureus (MRSA)

MRSA Public Reporting

A case is a patient identified with a laboratory confirmed bloodstream infection with methicillin resistant staphyloccus aureus (MRSA bacteremia).  A blood stream infection is a single positive blood culture for MRSA.

Hospital Acquired MRSA

The infection is not present on admission (ie: onset of symptoms<72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility within the last 72 hours.

Method of Calculation

The rate is calculated as a rate per 1000 patient days.

The calculation of the MRSA bacteremia infection rate for the reporting period (on a quarterly basis) is:

 Number of new hospital acquired cases of MRSA in our facility x 1000
Total number of patient days

Vancomycin-Resistant Enterococcus (VRE)

 VRE Public reporting

A case is a patient identified with laboratoy confirmed bloodstream infection with vancomycin-resistant enterococcus (VRE bacteremia).  A blood stream infection is a single positive  blood culture for VRE.

Hospital acquired VRE

The infection was present on admission (ie onset of symptoms <72 hours after admission) or the infection was present at the time of admission but was related to a previous admission to the same facility in the last 72 hours.

Method of Calculation

The rate is calculated as a rate per 1000 patient days.

The calculation of the VRE bacteremia infection rate for the reporting period ( on a quarterly basis) is:

  Number of new hospital acquired cases of VRE in our facility x 1000
Total number of patient days

Infection Control rates may vary from month to month. The smaller the facility, the greater the rates will vary. This is because a change in even one case in a small facility will cause the rate to go up and down considerably.

HAND HYGIENE COMPLIANCE RATE

Hand hygiene is an important practice for health care providers and has a significant impact on reducing the spread of infections in hospitals. Hand hygiene is a different way of thinking about safety and patient care and involves everyone in the hospital, including patients and health care providers.  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. To be clear, health care providers are washing their hands. What the provincial audit tool does is help ensure that they are washing them the right way at the right times.

Surgical Checklist

What is a surgical safety checklist?

A surgical safety checklist is a patient safety communication tool that is used by a team of operating professionals (nurses, surgeons, anesthesiologists) to discuss important details about each surgical case.  If you undergo surgery at this hospital, you can expect that the surgical safety checklist will be used before, during and after your surgery to verify your identity , the procedure, important medical information, equipment availability and to ensure a positive, safe experience.  

The surgical safety checklist is considered "performed" when all necessary tasks in each of three phases: Briefing, Time Out and Debriefing are completed.

The Surgical Safety Checklist compliance is calculated as:

 # of times all three phases of the surgical safety checklist was performed x 100  =       % compliance

Total Surgeries