Patient Safety Indicators

At Mackenzie Health, quality care and patient safety are our top priorities. 

We believe in being accountable and open with our community about our performance and the quality services they can expect from us. The health and safety of  patients and staff is our first priority and we take the prevention of infectious diseases very seriously.

Preventing the Spread of Hospital Acquired Infections

Sometimes when patients are admitted to the hospital, they can get infections. These are called hospital-acquired infections. Hospital-acquired mean that the infection is identified 72 hours after admission to the hospital; or that the infection was present at the time of admission, but was related to a previous admission to that hospital within the last four weeks.

At Mackenzie Health, we follow the Provincial Infectious Disease Advisory Committee (PIDAC) guidelines and comply with the all recommended legislative standards and guidelines. Procedures in patient precautions and treatment, environmental cleaning, monitoring and surveillance, hand hygiene,  and education and awareness have been established to control and manage the spread of all infectious diseases.

Patient Indicators and Reporting

Clostridium difficile (also known as C. difficile or C. diff) is a type of bacteria that is found in the intestinal tracts. The C. difficile bacteria produce a toxin that can cause inflammation. The affected person may experience diarrhea and other serious intestinal conditions. It usually does not cause illness except under certain circumstances.

The use of antibiotics increases the chances of developing C. difficile diarrhea as it alters the normal level of good bacteria found in the intestines and colon. With disruption of the good bacteria, the C. difficile bacteria may start to grow and multiply and produce a toxin that can damage the walls of our bowel. In addition to antibiotics, certain medications and health conditions can make a person more susceptible. C. difficile can be picked up on the hands and can get into the stomach once the mouth is touched, or if food is handled and then swallowed.

Cases

The number of new hospital acquired C. difficile infections will be reported on a monthly basis.

Infection Rate per 1,000 Patient Days

The C. difficile 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, over one year of age, during the given time period.

Rates

Reporting Period Case Count Rate per 1,000 patient days
Dec 1 to Dec 31, 2020 1 0.08
Nov 1 to Nov 30, 2020 1 0.08
Oct 1 to Oct 31, 2020 1 0.08
Sep 1 to Sep 30, 2020 0 0
Aug 1 to Aug 31, 2020 3 0.24
July 1 to July 31, 2020 4 0.33
June 1 to June 30, 2020 3 0.27
May 1 to May 31, 2020 3 0.28
Apr 1 to Apr 30, 2020 2 0.23
Mar 1 to Mar 31,2020 4 0.34
Feb 1 to Feb 29, 2020 3 0.23
Jan 1 to Jan 31, 2020 0 0
Dec 1 to Dec 31, 2019 5 0.36
Nov 1 to Nov 30, 2019 2 0.15
Oct 1 to Oct 31, 2019 3  0.21
Sep 1 to Sep 30, 2019 2 0.14
Aug 1 to Aug 31, 2019 1 0.07
July 1 to July 31, 2019 0 0
June 1 to June 30, 2018 3 0.22
May 1 to May 31, 2018 1 0.07 
April 1 to April 30, 2019  1 0.07 
March 1 to March 31, 2019  0
February 1 to February 28, 2019 3 0.23 
January 1 to January 31, 2019 3 0.2 
December 1 to December 31, 2018 0 0
November 1 to November 30, 2018 2 0.15
October 1 to October 31, 2018 1 0.07
September 1 to September 30, 2018 1 0.08
August 1 to August 31, 2018 3 0.23
July 1 to July 31, 2018 3 0.22
June 1 to June 30, 2018 3 0.24
May 1 to May 31, 2018 3 0.22
April 1 to April 30, 2018 4 0.31
March 1 to March 31, 2018 2 0.18
February 1 to February 28, 2018 5 0.43
January 1 to January 31, 2018 3 0.23
December 1 to December 31, 2017 3 0.25
November 1 to November 30, 2017 1 0.09
October 1 to October 31, 2017 0 0
September 1 to September 30, 2017 1 0.09
August 1 to August 31, 2017 4 0.35
July 1 to July 31, 2017 1 0.09
June 1 to June 30, 2017 2 0.18
May 1 to May 31, 2017 3 0.27
April 1 to April 30, 2017 1 0.09
March 1 to March 31, 2017 3 0.26
February 1 to February 28, 2017 5 0.47
January 1 to January 31, 2017 2 0.16
December 1 to December 31, 2016 4 0.34
November 1 to November 30, 2016 4 0.35
October 1 to October 31, 2015 2 0.17
September 1 to September 30, 2016 4 0.35
August 1 to August 31, 2016 6 0.53
July 1 to July 31, 2016 4 0.37
June 1 to June 30, 2016 3 0.27
May 1 to May 31, 2016 <5 0.09
April 1 to April 30, 2016 <5 0.27
March 1 to March 31, 2016 <5 0.18
February 1 to February 28, 2016 <5 0.28
January 1 to January 31, 2016 <5 0.26

What is Mackenzie Health doing to keep our C. difficile rate low?

We closely monitor and track our infection rates. Every case of C. difficile Infection that originates within the hospital is investigated. Our current measures to prevent hospital associated infections are:

  • Regular meetings of a multidisciplinary committee with representation from the York Region Public Health Department
  • Aggressive environmental cleaning processes using sporicidal cleaning agents, specialized room cleaning and environmental cleaning audits
  • An Antibiotic Stewardship Program to provide education and review antibiotics used in the hospital
  • Widespread use of Hand Hygiene dispensers
  • A Hand Hygiene Program, which includes a Just Clean Your Hands education program for healthcare providers, and regular monitoring of hand hygiene through an auditing process
  • Infection Prevention and Control education sessions for staff and physicians on the importance of early diagnosis and treatment of this infection
  • Close monitoring of our CDI rates and the effectiveness of our strategies in the organization's Quality Improvement Plan.

More patient-specific information is available at www.ontario.ca/patientsafety.
If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

A central venous catheter (or "line") is put into a patient's vein usually when a patient requires long-term access to medication, fluids or nutrition intravenously (through an IV). A central line blood stream infection (CLI) can occur when bacteria and/or fungi enters the blood stream, causing a patient to become sick. The bacteria most often comes from the patient's skin but can come from a variety of places including wounds, and the environment.

The Ministry of Health has asked that CLI bloodstream infection rates in ICUs be publicly reported because this is where the majority of patients have central lines. You can get a CLI in any environment if you have a central line in place (i.e., a hospital ward or at home). 

Ontario hospitals are posting quarterly CLI rate and case count for infections acquired in their facility.

CLI Cases

Only central line associated blood stream infections that occur 48 hours or more after insertion and in a hospitalized ICU patient are being publicly reported.

CLI Rate per 1,000 Central Line Days

The CLI rate is the number of ICU patients (18 years and older) with a new CLI per 1,000 central line days. Central line days are the total number of days a central line was used in ICU patients who are 18 years and older

Reporting Period Case Count Rate Per 1,000 central line days
May 2020 to January 2021  0  0
Apr 1 to Apr 30, 2020 0 0
Mar 1 to Mar 31,2020 0 0
Feb 1 to Feb 29, 2020 0 0
Jan 1 to Jan 31, 2020 0 0
Dec 1 to Dec 31, 2019 0 0
Nov 1 to Nov 30, 2019 0 0
Oct 1 to Oct 31, 2019 1 2.47
Sep 1 to Sep 30, 2019 1 2.24
Aug 1 to Aug 31, 2019 0 0
July 1 to July 31, 2019 1 2.12 
April 1 - June 30, 2019 0 0
January 1 - March 31, 2019 0 0
October 1 - December 31, 2018 0 0
July 1 - September 30, 2018 0 0
April 1 - June 30, 2018 0 0
January 1 - March 31, 2018 0 0
October 1 - December 31, 2017 0 0
July 1 - September 30, 2017 0 0
April 1 - June 30, 2017 0 0
January 1 - March 31, 2017 0 0
October 1 - December 31, 2016 0 0
July 1 - September 30, 2016 0 0
April 1 - June 30, 2016 0 0
January 1 - March 31, 2016 0 0

Prevention of Central Line Infections

Mackenzie Health ICU follows best practices around the prevention of CLIs. Such practices include: 

  • Practicing the Four Moments of hand hygiene
  • Using a skin antiseptic called clorhexidine prior to inserting the catheter
  • Checking entry site for signs of infection daily and with every dressing change
  • Using maximal barrier protection during line insertions and for those assisting including a full body drape for patients
  • Prompt removal of the catheter as soon as possible.

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

Hand hygiene is something we all do but there is a specific set of hand hygiene guidelines for healthcare providers set out by the Ontario Ministry of Health, along with many other international organizations concerned with infection prevention and control.

Experts agree that good hand hygiene is the single most effective way to reduce the risk of healthcare-associated infections. Through auditing the practices of our healthcare providers, we are able to find out if in fact, they are cleaning their hands the right way and at the right times, in keeping with the Ontario Ministry of Health's guidelines. Using hand sanitizer is the preferred way to clean your hands, except when hands are visibly soiled, then washing hands with soap and water is the best method.

Hand Hygiene Compliance Rate

Hospitals across Ontario are required to audit and report their hand hygiene compliance rates annually on two indicators, the Before Initial Patient or Patient Environment Contact, and, After Patient or Patient Environment Contact.

Rates

Month Number of times hand hygiene was performed before initial patient/patient environment contact Number of times hand hygiene was performed after initial patient/patient environment contact Percent compliance for before initial patient/patient environment contact Percent compliance for after patient/patient environment contact
April 1 2019 to March 31 2020 8172 9864 84% 90%
April 1 2018 to March 31 2019 9587 10095 87% 93%
April 1 2017 to March 31 2018 6711 7063 84% 90%
April 1 2016 to March 31 2017 8201 7857 87% 90%
April 1 2015 to 
March 31 2016
7985 7467 87.65% 89.49%
April 1 2014 to 
March 31 2015
7771 7895 87% 92%

What is Mackenzie Health doing to keep our Hand Hygiene rates high?

Over the past number of years we have been focused on improving hand hygiene among our healthcare professionals, support staff, volunteers, patients and visitors at our hospitals. Our current measures to monitor and improve hand hygiene rates are:

  • We promote best practices for hand hygiene and incorporated hand hygiene into our policies and procedures. All nursing staff must complete Ministry of Health and Long-Term Care (MOHLTC) learning modules on hand hygiene. The MOHLTC also has a program called Just Clean Your Hands which we actively promote at Mackenzie Health.
  • We have created easy access points for staff and visitors to practice hand hygiene. Hand sanitizer dispensers are placed in the main lobbies and in the halls on patient floors throughout the hospital. This increases the number of opportunities for our staff to practice hand hygiene.
  • We offer ongoing sessions on diseases that are most commonly spread through hand contact. We are committed to teaching proper hand hygiene and effective infection control practices to our healthcare providers. We also promote best practices regarding hand hygiene routines. We post brochures, leaflets and reminders throughout the hospital.
  • We work with our local health integration network and the Infectious Diseases Control Division, Public Health Branch of the York Region Health Services Department.
  • Our Infection Prevention and Control team conduct our own internal audits on a monthly basis. When they visit patient units to do these audits they gather staff for brief overviews of the four moments, and the importance of hand hygiene. Information is reported back to each unit.
  • Managers encourage their staff who are concerned about skin irritation to book an appointment with our Occupational Health department for clinical assessment and advice.
  • We incorporate expert advice from our Infection Prevention and Control practitioners throughout the hospital. Our infection control professionals monitor infectious disease rates to look for opportunities to provide further education and promote hand hygiene best practices.
  • Close monitoring of our hand hygiene rates and the effectiveness of our strategies in the organization's Quality Improvement Plan.

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

The Ministry of Health requires that all eligible hospitals publicly report their Hospital Standardized Mortality Ratio(HSMR). This is one of eight patient safety indicators that are included in the Ministry's mandatory reporting initiative.

What is HSMR and what does it measure?

HSMR is one of a number of important quality and safety measures designed to improve patient care. It is a new measure of patient safety which tracks hospital mortality (death) rates in order to reduce avoidable deaths in hospitals and improve quality of care. HSMR compares an individual hospital's mortality rate with the average Canadian rate. It examines observed versus expected deaths and is adjusted for various factors including age, sex, diagnoses and admission status of patients.

Why is HSMR important?

HSMR was developed in the United Kingdom in the mid 1990's, and is used in hospitals worldwide to assess in-hospital mortality rates and to help organizations identify areas for improvement. HSMR is a quality indicator and a measure to help hospitals and health professionals follow trends in their hospital mortality rates. It is yet another tool to help improve quality of care and patient safety over time.

How will HSMR be used in hospitals?

Ontario hospitals are beginning to use HSMR results for internal benchmarking purposes. The reporting of HSMR shows hospitals how their ratio has changed, where they have made progress and where they can continue to improve. Through HSMR, hospitals will learn more about the tool, more effectively examine their results, identify areas for improvement, implement strategies to lower mortality and track results over time.

How is HSMR calculated?

The Canadian Institute for Health Information (CIHI) has calculated the HSMR for eligible acute care hospitals and regions in Canada (excluding Quebec). The HSMR is the ratio of the actual number of deaths, compared to the expected number of deaths, times 100.

HSMR =   Number of (actual) observed deaths x 100
                  Number of expected deaths

How are HSMR scores interpreted?

  • A ratio that is equal to 100 suggests that there is no difference between the hospital's mortality rate and the average national rate.
  • A ratio greater than 100 suggests that the hospital's mortality rate is higher than the average national rate.
  • A ratio less than 100 suggests that the hospital's mortality rate is lower than the average national rate.

How often will HSMR results be reported?

The mandatory public reporting requirement for the Ministry of Health is that hospitals post their HSMR results annually.

Rates

Reporting Period Mackenzie Health's HSMR
October 2020 70
September 2020 89
August 2020 71
July 2020 68
June 2020 73
May 2020 98
April 2020 95
March 2020 92
Feb 1 to Feb 29, 2020 85
Jan 1 to Jan 31, 2020 71
October 2019 87
September 2019 87
August 2019 80
July 2019 44
June 2019 64
May 2019 62
April 2019  74
March 2019  55
February 2019  62
January 2019  67
December 2018  85
November 2018  90
October 2018  61
September 2018  77
August 2018  66
July 2018  84
June 2018  66
May 2018  62
April 2018  80
March 2018  65
February 1 to February 28, 2018 73
January 1 to January 31, 2018 94
December 1 to December 31, 2017 68
November 1 to November 30, 201 101
October 1 to October 31, 2017 74
September 1 to September 30, 2017 61
August 1 to August 31, 2017 84
July 1 to July 31, 2017 90
June 1 to June 30, 2017 65
May 1 to May 31, 2017 65
April 1 to April 30, 2017 87
March 1 to March 31, 2017 77
February 1 to February 28, 2017 98
January 1 to January 31, 2017 83
December 1 to December 31, 2016 80
November 1 - to November 30, 2016 65
October 1 - to October 31, 2016 72
September 1 - to September 30, 2016 78
August 1 - to August 31, 2016 101
July 1 - to July 31, 2016 62
June 1 to June 30, 2016 58
May 1 to May 31, 2016 68
April 1 to April 30, 2016 83
March 1 to March 31, 2016 74
February 1 to February 30, 2016 70
January 1 to January 31, 2016 71
   

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

Staphylococcus aureus (Staph aureus, often called "Staph") is a type of bacteria that normally lives on the skin and in the nose and lower intestine and may cause a variety of different infections.

Methicillin is an antibiotic developed specifically to treat infections caused by Staph aureus. Some Staph aureus have become resistant to methicillin, making this medication (and many others), ineffective against these resistant strains. Staph aureus that have become resistant to methicillin are referred to as methicillin-resistant Staphylococcus aureus, or MRSA for short.

In people who are colonized with MRSA, we typically find the germ living inside the nose, in the area of the rectum, and sometimes in the axilla (the armpit). When we rub our nose we can transfer the bacteria from our nose to our hands. Once on our hands it is easy to spread it throughout our surroundings, by touching other things and other people. Good hand hygiene is the single-most effective way to prevent the spread of MRSA.

Bacteremia is the presence of bacteria in the bloodstream and is referred to as a bloodstream infection. Risk factors for MRSA bacteremia include invasive procedures, prior treatment with antibiotics, prolonged hospital stay; or having an MRSA wound infection.

Cases

The number of new hospital acquired MRSA infections will be reported on a quarterly basis.

Infection Rate per 1,000 Patient Days

The MRSA 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, over one year of age, during the given time period.

Rates of New Hospital Acquired MRSA Bacteremia

Reporting Period Case Count Rate per 1,000 patient days
April 2020 to January 2021 0 0
January 1 to March 31, 2020 0 0
October 1 - December 31, 2019 0 0
April 1 - June 30, 2019 0 0
January 1 - March 31, 2019 0 0
October 1 - December 31, 2018 0 0
July 1 - September 30, 2018 0 0
April 1 - June 30, 2018 2 0.05
January 1 - March 31, 2018 0 0
October 1 - December 31, 2017 0 0
July 1 - September 30, 2017 2 0.06
April 1 - June 30, 2017 0 0
January 1 - March 31, 2017 1 0.03
October 1 - December 31, 2016 1 0.03
July 1 - September 30, 2016 0 0.00
April 1 - June 30, 2016 1 0.03
January 1 - March 31, 2016 <5 0.03

More patient-specific information is available at www.ontario.ca/patientsafety.
If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

The SSCC 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 at three distinct stages or phases during surgery: Briefing (before the patient is put to sleep), Time Out (just before the first incision), and Debriefing (during or after surgical closure). The SSCC is used to facilitate operating room team discussion so that everyone is familiar about the case, and reduces reliance on memory for certain necessary interventions.

Essentially, the checklist is about improving overall teamwork - a critical factor in producing positive clinical outcomes.

Do hospitals use one standard SSCC?

The Canadian Patient Safety Institute has a SSCC that is generally considered the base for Ontario hospitals to use as a starting template. Hospitals may adapt or customize the checklist to fit their individual circumstances, including case-mix and the type of surgeries performed.

What type of information is included in a SSCC?

SSCCs are divided into three parts relating to different phases of surgery, and each section has information relevant to that phase.

SSCC Rate

SSCC compliance indicator measures the degree to which all three phases - briefing, time out and debriefing - of the checklist were performed correctly and appropriately for each surgical patient. All three steps must be fully completed during all surgeries to achieve a rating of 100%. Compliance is reported bi-annually.

  1. Briefing Phase
    • Verify with the patient their name and the procedure to be done
    • Allergy Check
    • Medications Check
    • Operation site, side and procedure
    • Lab tests, x-rays
  2. Time Out Phase
    • Patient position
    • Operation site and side and procedure
    • Antibiotics check
  3. Debriefing Phase
    • Surgeon reviews important items
    • Anesthesiologist reviews important items
    • Nurse reviews correct counts

SSCC Rates

Reporting Period Case Count Percent (%)
July 1, 2020 - December 31, 2020 - 100%
January 1, 2020 - June 30, 2020 - 100%
July 1, 2019 - December 31, 2019 - 100%
January 1, 2019 - June 30, 2019 - 100%
July 1, 2018 - December 31, 2018 - 100%
January 1, 2018 - June 30, 2018 - 100%
July 1, 2017 - December 31, 2017 - 100%
January 1, 2017 - June 30, 2017 - 99.70
July 1, 2016 - December 31, 2016 - 99.70%
January 1, 2016 - June 30, 2016 - 99.70%
July 1, 2015 - December 31, 2015 - 99.60%
January 1, 2015 - June 30, 2015 - 100%

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

VRE is the short form for Vancomycin-resistant enterococci. Enterococci are common bacteria that are normally found in the bowel, the female genital tract and often found in the environment. Vancomycin is a powerful antibiotic used to treat serious infections. Vancomycin-resistant enterococci (VRE) are a type of bacteria which no longer responds to treatment with vancomycin.

Healthy people are usually not at risk of becoming infected with Vancomycin-resistant enterococci (VRE). Risk factors for getting VRE include severity of underlying illness, presence of invasive devices, prior colonization with VRE, antibiotic use and length of hospital stay.

Enterococci bacteria in the lower intestine, urine, blood, and/or skin, may cause an infection and resist Vancomycin antibiotic. Some people may carry the bacteria without having symptoms.

VRE can cause illnesses such as blood infections (bacterermia), urinary tract infections, or abscesses.

Cases 

The number of new hospital acquired VRE infections will be reported on a quarterly basis.

Infection Rate per 1,000 Patient Days

The VRE 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, over one year of age, during the given time period.

Rates of New Hospital Acquired VRE Bacteremia

Reporting Period Case Count Rate per 1,000 patient days
April 2020 to January 2021 0 0
Jan 1 to March 31, 2020 0 0
October 1 - December 31, 2019 0 0
April 1 - June 30, 2019 0 0.0
January 1 - March 31, 2019  0 0.0
October 1 - December 31, 2018 0 0.0
July 1 - September 30, 2018 0 0.0
April 1 - June 30, 2018 0 0.0
January 1 - March 31, 2018 0 0.0
October 1 - December 31, 2017 0 0.0
July 1 - September 30, 2017 0 0.0
April 1 - June 30, 2017 0 0.0
January 1 - March 31, 2017 0 0.0
October 1 - December 31, 2016 0 0.0
July 1 - September 30, 2016 0 0.0
April 1 - June 30, 2016 0 0.0
January 1 - March 31, 2016 0 0.0

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

Mackenzie Health follows best practice guidelines for the prevention of surgical site infections, and is a participant in the Safer Healthcare Now surgical site infection program. The Safer Healthcare Now program (or bundle), includes the administration of appropriately-timed antibiotics before surgery, prompt discontinuation of antibiotics after surgery, the use of hair clippers rather than razors when hair removal is needed, and ensuring that the patient's body temperature is maintained at an optimal level.

After a thorough analysis and review, our peri-operative services, in conjunction with the departments of surgery and anesthesia, have changed protocols for the administration of pre-operative antibiotics. Our best practice for administration of pre-operative antibiotics ensures that antibiotics are administered within the currently recommended 60-minute time frame (120-minutes for Vancomycin).

The departments of surgery and anesthesia, the peri-operative service and infection control continue to work together to create programmatic change that will ensure that all our patients receive the best care possible.

SSI Prevention Rate (Antibiotic Timing)

The percentage of time out health care team gave patients the antibiotics within the appropriate time period (60 minutes for usual antibiotics and 120 for vancomycin) before a hip or knee replacement surgery. Only patients 18 years or older are included in the bi-annually reported rate.

Mackenzie Health SSI Prevention Rate

Reporting Period Percent (%)
October 2019 - December 2020 80.00%
July 2019 - September 2020 71.00%
April 1 - June 30, 2020 95.00%
January 1 to March 31, 2020 81.00%
October 2019 - December 2019 89.00%
July 2019 - September 2019 90.00%
April 1 - June 30, 2019 92.00% 
January 1 - March 31, 2019 90.00% 
October 1 - December 31, 2018 94.00% 
July 1 - September 30, 2018 96.00% 
April 1 - June 30, 2018 90.00%
January 1 - March 31, 2018 97.00%
October 1 - December 31, 2017 90.00%
July 1 - September 30, 2017 97.00%
April 1 - June 30, 2017 87.86%
January 1 - March 31, 2017 97.00%
October 1 - December 31, 2016 97.00%
July 1 - September 30, 2016 95.00%
April 1 - June 30, 2016 100.00%
January 1 - March 31, 2016 95.63%

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.

For our public reporting purposes, ventilator-associated pneumonia (VAP) is defined as a pneumonia (lung infection) occurring in patients in an intensive care unit (ICU), requiring external mechanical breathing support (a ventilator) through a breathing tube for more than 48 hours.

VAP can develop in patients for many reasons. Because patients are relying on an external machine (ventilator) to breath, their normal coughing, yawning, and deep breath reflexes are suppressed. Patients may also have a depressed immune system, making them more vulnerable to infection. ICU teams have many ways to try to assist patients with these normal breathing reflexes, but despite this, patients are still at risk for developing pneumonia.

Since VAP is caused by a bacterial infection in the lungs, it is treated using antibiotics. Sometimes it can be difficult to tell if a patient has developed a VAP, as they are already critically ill, and may have a pre-existing infection.

VAP Cases

Includes only VAPs that develop 48 hours after the patient was placed on a ventilator in ICU. Includes only ICU patients, 18 year and older, who are mechanically ventilated.

VAP Rate

The VAP Rate is the number of ICU patients (18 years and older) with new VAP per 1,000 ventilator days. Ventilator days are the number of days spent on a ventilator for all patients in the ICU 18 years and older.

Reporting Period Case Count Rate per 1,000 ventilator days
Apr 1 to Apr 30, 2020 0 0
Mar 1 to Mar 31,2020 0 0
Feb 1 to Feb 29, 2020 0 0
Jan 1 to Jan 31, 2020 5 9.36
Dec 1 to Dec 31, 2019 1 2.34
Nov 1 to Nov 30, 2019 0 0
Oct 1 to Oct 31, 2019 0 0
Sep 1 to Sep 30, 2019 0 0
Aug 1 to Aug 31, 2019 0 0
July 1 to July 31, 2019 0 0
April 1 - June 30, 2019 1 0.69 
January 1 - March 31, 2019  0 0
October 1 - December 31, 2018 5 3.55 
July 1 - September 30, 2018 6 4.51
April 1 - June 30, 2018  0
January 1 - March 31, 2018 0 0.00
October 1 - December 31, 2017 1 0.75
July 1 - September 30, 2017 0 0.00
April 1 - June 30, 2017 1 0.80
January 1 - March 31, 2017 0 0.00
October 1 - December 31, 2016 0 0.0
July 1 - September 30, 2016 0 0.0
April 1 - June 30, 2016 1 0.89
January 1 - March 31, 2016 <5 0.75

Patient safety remains the most important priority for Mackenzie Health and this involves ensuring that patients are not at risk for contracting healthcare-associated infections such as VAP. 

  • Mackenzie Health tracks VAP closely through the Critical Care Information System.
  • We use the best practice guidelines supported by the Canadian Patient Safety Institute.
  • We also have a number of practices in place to help prevent and control infections, including a comprehensive hand hygiene program.

More patient-specific information is available at www.ontario.ca/patientsafety.

If you have any questions about our hospital's infection prevention and control program, please contact Mackenzie Health's Infection Prevention and Control Department at ipac@mackenziehealth.ca.