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Apr-09 |
May-09 |
Jun-09 |
Jul-09 |
Aug-09 |
Sep-09 |
Oct-09 |
Nov-09 |
Dec-09 |
Jan 10/2010 |
Feb-10 |
Mar-10 |
Apr-10 |
May-10 |
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Clostridium Difficile (C. difficile) |
Number of new cases |
0 |
0 |
0 |
1 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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|
C. Difficile Rate |
0 |
0 |
0 |
1.0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
Methicillin Resistant Staphylococcus Aureus
(MRSA) Bacteremia |
|
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
|
Vancomycin Resistant Enterococcus (VRE) Bacteremia |
|
0 |
0 |
0 |
0 |
0 |
0 |
0 |
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0 |
0 |
0 |
0 |
0 |
0 |
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Hospital Standardized Mortality Ratio (HSMR) |
Exempt from reporting |
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Central-Line Primary Blood Stream Infection (CLI) |
Quarterly |
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0 |
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0 |
0 |
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0 |
0 |
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Ventilator-Associated Pneumonia (VAP) |
Quarterly |
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0 |
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0 |
0 |
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0 |
0 |
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Surgical Site Infection Prevention |
Exempt from reporting |
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Hand Hygiene compliance |
% Compliance before initial contact
Quarterly |
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66.27 |
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Hand Hygiene compliance |
% Compliance after initial contact
Annually |
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81.54 |
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Surgical Safety Checklist (SSCL) Compliance |
Quarterly |
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For smaller facilities: |
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C. difficile 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 or down considerably. |
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Compare with other hospitals: |
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http://www.ontario.ca/patient_safety |
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Outbreak Status: |
There are currrently no outbreaks of C. Difficile at Kirkland and District Hospital |
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C. Diff
Definitions: |
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New nosocomial case of C.DIFF associated with reporting
facility: |
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A case that meets the case definition for C.DIFF |
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AND |
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C.DIFF was not present on admission (i.e., onset of symptoms more than 72 hours
after admission); |
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OR |
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the infection was present at time of admission and patient was admitted to the same
facility within the last 4 weeks; |
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AND |
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the case has not had C.DIFF in the past 8 weeks. |
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* Nosocomial infections
are infections which are a result of treatment in a hospital for a
health care service unit, but secondary to the patient's original condition. |
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C. Diff Rate: |
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The C.DIFF infection rate is calculated as a rate per
1,000 patient days. |
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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. |
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The rate is calculated as follows: |
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Number of new hospital acquired cases of C.
difficile in our facility |
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Total number of patient days (for one month) |
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Defining Outbreak: |
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Facility-level outbreak |
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• Baseline C.DIFF rate is the cumulative number of new nosocomial cases of C.DIFF
associated with the reporting facility divided by the # of patient days and expressed
as a rate per 1,000 patient days. |
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• Facility-level outbreak must be declared when baseline C.DIFF rate is at or above
the 80th percentile of the average rate for comparator facilities calculated on
a quarterly basis. |
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• Facilities that are under the 80th percentile for their category but have experienced
a doubling of their new nosocomial cases of C.DIFF for 2 consecutive months should
trigger investigation and notification of their local public health unit. |
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Ward/unit level outbreak |
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• Three or more new nosocomial cases of CDIFF associated with the reporting facility
within a 7 day period
on a single ward/unit shall be treated as a cluster |
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• Investigation and review should be actively undertaken and Infection Prevention
and Control (IPAC) team must notify and liaise with the local public health unit
to determine if this represents an outbreak. |
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• Six or more new nosocomial cases of C.DIFF associated with the reporting facility
within a 30 day
period on a single ward/unit constitutes an
outbreak |
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Surgical Safety Checklist Compliance
The percentage of compliance for the reporting period calculated as: (number of
times all 3 phases of the surgical safety checklist were performed) / (Total number
of surgeries) x 100 |
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