Prime Healthcare St. Joseph Medical Center

Patient Safety - All

Healthcare-Associated Infections

Hospitals in Illinois are participating in programs to reduce the number of infections acquired during hospital stays. While it is difficult to reduce infections to zero, following specific protocols can greatly reduce the risk.

The Hospital Report Card Act (Illinois Public Act 93-563) requires Illinois hospitals to report central line associated bloodstream infections (CLABSIs) as well as surgical site infections (SSIs). As of January 1, 2012, hospitals are also mandated to report Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridioides difficileinfections. Infections are reported through the CDC’s National Healthcare Safety Network (NHSN) surveillance system. The Standardized Infection Ratio (SIR) , a summary measure used to determine whether infection data are statistically different from the national average, is presented for each type of infection shown below. Read more about healthcare-associated infections in Illinois . To learn more about the data collection methods using the CDC's National Health Safety Network (NHSN) surveillance system, read the Report Card methodology .

Clostridioides difficile infections (CDI) and Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections

Facility-wide Healthcare Facility Onset Incidence Rates for CDI and MRSA are presented below. These rates are based on results of laboratory tests that were obtained on or after day four of an inpatient stay and do not consider presence or timing of clinical signs or symptoms. The Standardized Infection Ratio (SIR) is presented, which is a summary measure used to determine if rates of CDI and MRSA bloodstream infections are statistically different from the national average. Statewide summaries of CDI and MRSA data arranged by hospital are also included. Note: Starting with 2016 data, new methods for risk adjustment were used.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
33	Complete Reporting: 50 or Less Central Line Days
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
116	Complete Reporting: Results based on 9 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR

Central Line Associated Bloodstream Infections (CLABSIs)

Presented below are annual central line-associated bloodstream infections (CLABSIs) occurring in critical care units, also known as intensive care units (ICUs). ICU-specific summary data for CLABSI are provided using the Standardized Infection Ratio(SIR) . Statewide summaries of CLABSI data arranged by ICU type and hospital are also included.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
33	Complete Reporting: 50 or Less Central Line Days
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
116	Complete Reporting: Results based on 9 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR

Adult CLABSI

Pediatric CLABSI

Ped. CLABSI Measure	Result	SIR
Pediatric Medical ICU Q1 2018 - Q4 2018 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Description Central Line-associated Bloodstream Infection data in the Medical Pediatric ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2017 - Q4 2017 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2016 - Q4 2016 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2015 - Q4 2015 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2014 - Q4 2014 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2013 - Q4 2013 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2012 - Q4 2012 Result 0 infections, 3 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 3 central-line days ³³	0.00 ³³
Q1 2011 - Q4 2011 Result 0 infections, 25 central-line days ³³ Rating SIR: N/A ³³	0 infections, 25 central-line days ³³	N/A ³³
Q1 2010 - Q4 2010 Result 0 infections, 46 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 46 central-line days ³³	0.00 ³³
Pediatric Medical-Surgical ICU Q1 2010 - Q2 2010 Result N/A infections, N/A central-line days ³⁸ Rating SIR: 0.00 ³⁸	N/A infections, N/A central-line days ³⁸	0.00 ³⁸
Description Central Line-associated Bloodstream Infection (CLABSI) data in the Medical-Surgical Pediatric ICU summarized as a Standardized Infection Ratio.

NICU CLABSI

Surgical Site Infections (SSIs)

Presented below are data for surgical site infections associated with coronary artery bypass graft surgery (CABG) and total knee replacement surgery (KPROs) using the Standardized Infection Ratio (SIR) . Superficial and secondary surgical site infections are not included in the summary data below. Statewide summaries of surgical site infection data arranged by surgical procedure ( CABG , KPRO ) and hospital are also included.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
33	Complete Reporting: 50 or Less Central Line Days
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
116	Complete Reporting: Results based on 9 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR

Immunization Practices

Illinois hospitals are focusing their efforts on boosting immunization treatments and strengthening patient safety protocols. The objective is not merely achieving statistical success, but also enhancing the quality of care and patient well-being.

Data on immunization measures in Illinois hospitals is available through the Medicare comparison tool at medicare.gov/hospitalcompare . This tool provides valuable insights, allowing patients and their families to gauge the quality of care and safety practices at local hospitals, helping them make informed healthcare decisions.

In the realm of Patient Safety, a host of measures are assessed, with risk-adjusted rates available for each. These measures encompass various aspects of patient care and treatment outcomes. However, interpreting these metrics requires an understanding of the complexity and context-specific nature of healthcare.

Immunization

These indicators are used to measure immunization treatments at hospitals. This data comes from medicare.gov/hospitalcompare .

Measure	Result
Healthcare workers given influenza vaccination Q4 2022 - Q1 2023 Result 93.00 %	93.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 78.00 %	78.00 %
Q4 2020 - Q1 2021 Result 82.00 %	82.00 %
Q4 2019 - Q1 2020 Result 92.00 %	92.00 %
Q4 2018 - Q1 2019 Result 93.00 %	93.00 %
Q4 2017 - Q1 2018 Result 89.00 %	89.00 %

Patient Safety

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
33	Complete Reporting: 50 or Less Central Line Days
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
116	Complete Reporting: Results based on 9 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 2.74	2.74
Description The number of cases of deep vein thrombosis or pulmonary embolism per 1,000 surgical discharges (PSI 12). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 3.42	3.42
Q4 2019 - Q3 2020 Rating SIR: 1.98	1.98
Q4 2018 - Q3 2019 Rating SIR: 2.94	2.94
Q2 2018 - Q1 2019 Rating SIR: 2.77	2.77
Q1 2015 - Q4 2015 Rating SIR: 6.55	6.55
Q4 2014 - Q3 2015 Rating SIR: 6.45	6.45
Q1 2014 - Q4 2014 Rating SIR: 7.21	7.21
Q4 2013 - Q3 2014 Rating SIR: 6.99	6.99
Q1 2013 - Q4 2013 Rating SIR: 6.65	6.65
Q3 2012 - Q2 2013 Rating SIR: 5.56	5.56
Q1 2012 - Q4 2012 Rating SIR: 5.00	5.00
Q4 2011 - Q3 2012 Rating SIR: 4.10	4.10
Q2 2011 - Q1 2012 Rating SIR: 0.48	0.48
Q1 2011 - Q4 2011 Rating SIR: 5.43	5.43
Q4 2010 - Q3 2011 Rating SIR: 5.94	5.94
Q1 2010 - Q4 2010 Rating SIR: 5.01	5.01
Q4 2009 - Q3 2010 Rating SIR: 6.84	6.84
Q1 2009 - Q4 2009 Rating SIR: 7.85	7.85
Q3 2008 - Q2 2009 Rating SIR: 6.80	6.80
Q1 2008 - Q4 2008 Rating SIR: 4.70	4.70
Wound Complications in Abdominal Wall Surgery Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. (PSI 14) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 1.77	1.77
Q4 2013 - Q3 2014 Rating SIR: 1.77	1.77
Q1 2013 - Q4 2013 Rating SIR: 3.49	3.49
Q3 2012 - Q2 2013 Rating SIR: 3.23	3.23
Q1 2012 - Q4 2012 Rating SIR: 1.55	1.55
Q4 2011 - Q3 2012 Rating SIR: 0.73	0.73
Q2 2011 - Q1 2012 Rating SIR: 0.68	0.68
Q1 2011 - Q4 2011 Rating SIR: 1.53	1.53
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 1.49	1.49
Q3 2008 - Q2 2009 Rating SIR: 0.29	0.29
Q1 2008 - Q4 2008 Rating SIR: 0.29	0.29
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 0.61	0.61
Description The number of cases of accidental cut, puncture, perforation, or laceration during procedure per 1,000 discharges. (PSI 15) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.59	0.59
Q4 2019 - Q3 2020 Rating SIR: 1.22	1.22
Q4 2018 - Q3 2019 Rating SIR: 1.02	1.02
Q2 2018 - Q1 2019 Rating SIR: 0.50	0.50
Q1 2015 - Q4 2015 Rating SIR: 0.88	0.88
Q4 2014 - Q3 2015 Rating SIR: 0.59	0.59
Q1 2014 - Q4 2014 Rating SIR: 0.97	0.97
Q4 2013 - Q3 2014 Rating SIR: 0.95	0.95
Q1 2013 - Q4 2013 Rating SIR: 0.62	0.62
Q3 2012 - Q2 2013 Rating SIR: 0.61	0.61
Q1 2012 - Q4 2012 Rating SIR: 0.79	0.79
Q4 2011 - Q3 2012 Rating SIR: 1.05	1.05
Q2 2011 - Q1 2012 Rating SIR: 0.13	0.13
Q1 2011 - Q4 2011 Rating SIR: 1.88	1.88
Q4 2010 - Q3 2011 Rating SIR: 1.59	1.59
Q1 2010 - Q4 2010 Rating SIR: 2.17	2.17
Q4 2009 - Q3 2010 Rating SIR: 2.84	2.84
Q1 2009 - Q4 2009 Rating SIR: 2.43	2.43
Q3 2008 - Q2 2009 Rating SIR: 1.30	1.30
Q1 2008 - Q4 2008 Rating SIR: 0.90	0.90
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.09	0.09
Description This measure is used to assess the number of cases of collapsed lung caused by medical care per 1,000 patients. (PSI 06) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.09	0.09
Q4 2019 - Q3 2020 Rating SIR: 0.10	0.10
Q4 2018 - Q3 2019 Rating SIR: 0.07	0.07
Q2 2018 - Q1 2019 Rating SIR: 0.07	0.07
Q1 2015 - Q4 2015 Rating SIR: 0.35	0.35
Q4 2014 - Q3 2015 Rating SIR: 0.39	0.39
Q1 2014 - Q4 2014 Rating SIR: 0.39	0.39
Q4 2013 - Q3 2014 Rating SIR: 0.50	0.50
Q1 2013 - Q4 2013 Rating SIR: 0.42	0.42
Q3 2012 - Q2 2013 Rating SIR: 0.41	0.41
Q1 2012 - Q4 2012 Rating SIR: 0.42	0.42
Q4 2011 - Q3 2012 Rating SIR: 0.24	0.24
Q2 2011 - Q1 2012 Rating SIR: 0.02	0.02
Q1 2011 - Q4 2011 Rating SIR: 1.88	1.88
Q4 2010 - Q3 2011 Rating SIR: 0.28	0.28
Q1 2010 - Q4 2010 Rating SIR: 0.22	0.22
Q4 2009 - Q3 2010 Rating SIR: 1.10	1.10
Q1 2009 - Q4 2009 Rating SIR: 1.51	1.51
Q3 2008 - Q2 2009 Rating SIR: 0.50	0.50
Q1 2008 - Q4 2008 Rating SIR: 0.60	0.60
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of hematoma or hemorrhage requiring a procedure per 1,000 surgical discharges. (PSI 09) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.39	0.39
Q4 2019 - Q3 2020 Rating SIR: 0.43	0.43
Q4 2018 - Q3 2019 Rating SIR: 0.70	0.70
Q2 2018 - Q1 2019 Rating SIR: 0.70	0.70
Q1 2015 - Q4 2015 Rating SIR: 3.53	3.53
Q4 2014 - Q3 2015 Rating SIR: 3.00	3.00
Q1 2014 - Q4 2014 Rating SIR: 4.35	4.35
Q4 2013 - Q3 2014 Rating SIR: 5.20	5.20
Q1 2013 - Q4 2013 Rating SIR: 5.08	5.08
Q3 2012 - Q2 2013 Rating SIR: 4.90	4.90
Q1 2012 - Q4 2012 Rating SIR: 5.59	5.59
Q4 2011 - Q3 2012 Rating SIR: 2.70	2.70
Q2 2011 - Q1 2012 Rating SIR: 1.30	1.30
Q1 2011 - Q4 2011 Rating SIR: 3.53	3.53
Q4 2010 - Q3 2011 Rating SIR: 1.26	1.26
Q1 2010 - Q4 2010 Rating SIR: 2.16	2.16
Q4 2009 - Q3 2010 Rating SIR: 2.05	2.05
Q1 2009 - Q4 2009 Rating SIR: 0.70	0.70
Q3 2008 - Q2 2009 Rating SIR: 0.21	0.21
Q1 2008 - Q4 2008 Rating SIR: 0.21	0.21
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 5.38	5.38
Description The number of cases of acute respiratory failure per 1,000 elective surgical discharges. (PSI 11) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 7.78	7.78
Q4 2019 - Q3 2020 Rating SIR: 6.65	6.65
Q4 2018 - Q3 2019 Rating SIR: 1.29	1.29
Q2 2018 - Q1 2019 Rating SIR: 3.42	3.42
Q1 2015 - Q4 2015 Rating SIR: 23.85	23.85
Q4 2014 - Q3 2015 Rating SIR: 22.84	22.84
Q1 2014 - Q4 2014 Rating SIR: 22.57	22.57
Q4 2013 - Q3 2014 Rating SIR: 22.43	22.43
Q1 2013 - Q4 2013 Rating SIR: 15.15	15.15
Q3 2012 - Q2 2013 Rating SIR: 18.61	18.61
Q1 2012 - Q4 2012 Rating SIR: 16.12	16.12
Q4 2011 - Q3 2012 Rating SIR: 14.33	14.33
Q2 2011 - Q1 2012 Rating SIR: 10.13	10.13
Q1 2011 - Q4 2011 Rating SIR: 12.65	12.65
Q4 2010 - Q3 2011 Rating SIR: 9.01	9.01
Q1 2010 - Q4 2010 Rating SIR: 10.12	10.12
Q4 2009 - Q3 2010 Rating SIR: 18.44	18.44
Q1 2009 - Q4 2009 Rating SIR: 12.87	12.87
Q3 2008 - Q2 2009 Rating SIR: 0.75	0.75
Q1 2008 - Q4 2008 Rating SIR: 1.18	1.18
Postoperative Hip Fracture Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of in-hospital hip fracture per 1,000 surgical discharges(PSI 08). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.08	0.08
Q4 2019 - Q3 2020 Rating SIR: 0.15	0.15
Q4 2018 - Q3 2019 Rating SIR: 0.07	0.07
Q2 2018 - Q1 2019 Rating SIR: 0.07	0.07
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.48	0.48
Q1 2013 - Q4 2013 Rating SIR: 0.45	0.45
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 1.31	1.31
Description The number of cases of pressure ulcer per 1,000 discharges with a length of stay greater than 4 days (PSI 03). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 1.15	1.15
Q4 2019 - Q3 2020 Rating SIR: 1.63	1.63
Q4 2018 - Q3 2019 Rating SIR: 0.72	0.72
Q2 2018 - Q1 2019 Rating SIR: 1.05	1.05
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.38	0.38
Q1 2013 - Q4 2013 Rating SIR: 0.38	0.38
Q3 2012 - Q2 2013 Rating SIR: 0.19	0.19
Q1 2012 - Q4 2012 Rating SIR: 0.20	0.20
Q4 2011 - Q3 2012 Rating SIR: 0.16	0.16
Q2 2011 - Q1 2012 Rating SIR: 0.92	0.92
Q1 2011 - Q4 2011 Rating SIR: 3.04	3.04
Q4 2010 - Q3 2011 Rating SIR: 0.88	0.88
Q1 2010 - Q4 2010 Rating SIR: 0.53	0.53
Q4 2009 - Q3 2010 Rating SIR: 5.70	5.70
Q1 2009 - Q4 2009 Rating SIR: 8.08	8.08
Q3 2008 - Q2 2009 Rating SIR: 0.36	0.36
Q1 2008 - Q4 2008 Rating SIR: 0.62	0.62
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 4.50	4.50
Description The number of cases of sepsis per 1,000 elective surgery patients with a length of stay of 4 days or more (PSI 13). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 3.31	3.31
Q4 2019 - Q3 2020 Rating SIR: 1.10	1.10
Q4 2018 - Q3 2019 Rating SIR: 2.96	2.96
Q2 2018 - Q1 2019 Rating SIR: 2.73	2.73
Q1 2015 - Q4 2015 Rating SIR: 8.48	8.48
Q4 2014 - Q3 2015 Rating SIR: 9.63	9.63
Q1 2014 - Q4 2014 Rating SIR: 8.22	8.22
Q4 2013 - Q3 2014 Rating SIR: 13.12	13.12
Q1 2013 - Q4 2013 Rating SIR: 18.70	18.70
Q3 2012 - Q2 2013 Rating SIR: 23.80	23.80
Q1 2012 - Q4 2012 Rating SIR: 16.76	16.76
Q4 2011 - Q3 2012 Rating SIR: 11.30	11.30
Q2 2011 - Q1 2012 Rating SIR: 10.44	10.44
Q1 2011 - Q4 2011 Rating SIR: 20.06	20.06
Q4 2010 - Q3 2011 Rating SIR: 19.31	19.31
Q1 2010 - Q4 2010 Rating SIR: 13.89	13.89
Q4 2009 - Q3 2010 Rating SIR: 13.92	13.92
Q1 2009 - Q4 2009 Rating SIR: 9.62	9.62
Q3 2008 - Q2 2009 Rating SIR: 0.48	0.48
Q1 2008 - Q4 2008 Rating SIR: 0.83	0.83
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 1.56	1.56
Description This measure is used to assess the number of cases of specified physiological or metabolic derangement per 1,000 elective surgical discharges with an operating room procedure. (PSI 10) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 2.35	2.35
Q4 2018 - Q3 2019 Rating SIR: 0.46	0.46
Q2 2018 - Q1 2019 Rating SIR: 1.16	1.16
Q1 2015 - Q4 2015 Rating SIR: 1.28	1.28
Q4 2014 - Q3 2015 Rating SIR: 2.77	2.77
Q1 2014 - Q4 2014 Rating SIR: 1.22	1.22
Q4 2013 - Q3 2014 Rating SIR: 1.37	1.37
Q1 2013 - Q4 2013 Rating SIR: 1.84	1.84
Q3 2012 - Q2 2013 Rating SIR: 0.94	0.94
Q1 2012 - Q4 2012 Rating SIR: 0.48	0.48
Q4 2011 - Q3 2012 Rating SIR: 1.10	1.10
Q2 2011 - Q1 2012 Rating SIR: 0.56	0.56
Q1 2011 - Q4 2011 Rating SIR: 1.06	1.06
Q4 2010 - Q3 2011 Rating SIR: 0.55	0.55
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 6 infections, 75153 patient days Rating SIR: 0.95	6 infections, 75153 patient days	0.95
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 3 infections, 80641 patient days Rating SIR: 0.47	3 infections, 80641 patient days	0.47
Q1 2021 - Q4 2021 Result 2 infections, 89549 patient days Rating SIR: 0.28	2 infections, 89549 patient days	0.28
Q1 2020 - Q4 2020 Result 5 infections, 77557 patient days Rating SIR: 0.75	5 infections, 77557 patient days	0.75
Q1 2019 - Q4 2019 Result 2 infections, 87139 patient days Rating SIR: 0.26	2 infections, 87139 patient days	0.26
Q1 2018 - Q4 2018 Result 2 infections, 88891 patient days Rating SIR: 0.25	2 infections, 88891 patient days	0.25
Q1 2017 - Q4 2017 Result 3 infections, 98556 patient days Rating SIR: 0.43	3 infections, 98556 patient days	0.43
Q1 2016 - Q4 2016 Result 4 infections, 103759 patient days Rating SIR: 0.53	4 infections, 103759 patient days	0.53
Q1 2015 - Q4 2015 Result 3 infections, 97945 patient days Rating SIR: 0.47	3 infections, 97945 patient days	0.47
Q1 2014 - Q4 2014 Result 6 infections, 108747 patient days Rating SIR: 0.53	6 infections, 108747 patient days	0.53
Q1 2013 - Q4 2013 Result 13 infections, 105363 patient days Rating SIR: 1.31	13 infections, 105363 patient days	1.31
Q1 2012 - Q4 2012 Result 8 infections, 114924 patient days Rating SIR: 1.02	8 infections, 114924 patient days	1.02
Q1 2012 - Q2 2012 Result 5 infections, 59481 patient days Rating SIR: 0.84	5 infections, 59481 patient days	0.84
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 32 infections, 73339 patient days Rating SIR: 0.68	32 infections, 73339 patient days	0.68
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 34 infections, 78635 patient days Rating SIR: 0.24	34 infections, 78635 patient days	0.24
Q1 2021 - Q4 2021 Result 31 infections, 64880 patient days Rating SIR: 0.16	31 infections, 64880 patient days	0.16
Q1 2020 - Q4 2020 Result 35 infections, 75737 patient days Rating SIR: 0.32	35 infections, 75737 patient days	0.32
Q1 2019 - Q4 2019 Result 41 infections, 84882 patient days Rating SIR: 0.22	41 infections, 84882 patient days	0.22
Q1 2018 - Q4 2018 Result 55 infections, 64802 patient days ¹¹⁶ Rating SIR: 0.64 ¹¹⁶	55 infections, 64802 patient days ¹¹⁶	0.64 ¹¹⁶
Q1 2017 - Q4 2017 Result 75 infections, 94954 patient days Rating SIR: 0.61	75 infections, 94954 patient days	0.61
Q1 2016 - Q4 2016 Result 78 infections, 100026 patient days Rating SIR: 0.71	78 infections, 100026 patient days	0.71
Q1 2015 - Q4 2015 Result 70 infections, 93282 patient days Rating SIR: 0.71	70 infections, 93282 patient days	0.71
Q1 2014 - Q4 2014 Result 85 infections, 104699 patient days Rating SIR: 0.81	85 infections, 104699 patient days	0.81
Q1 2013 - Q4 2013 Result 67 infections, 101401 patient days Rating SIR: 0.74	67 infections, 101401 patient days	0.74
Q1 2012 - Q4 2012 Result 95 infections, 110681 patient days Rating SIR: 1.04	95 infections, 110681 patient days	1.04

Adult CLABSI Measure	Result	SIR
Adult Neurologic ICU Q1 2018 - Q4 2018 Result 0 infections, 90 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 90 central-line days ⁴²	N/A ⁴²
Description Central Line-associated Bloodstream Infection data in the Adult Neurologic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2017 - Q4 2017 Result 1 infections, 634 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 634 central-line days ⁴⁴	N/A ⁴⁴
Q1 2016 - Q4 2016 Result 0 infections, 606 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 606 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 610 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 610 central-line days ⁴²	N/A ⁴²
Q1 2014 - Q4 2014 Result 0 infections, 681 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 681 central-line days ⁴²	N/A ⁴²
Q1 2013 - Q4 2013 Result 0 infections, 642 central-line days ⁴³ Rating SIR: N/A ⁴³	0 infections, 642 central-line days ⁴³	N/A ⁴³
Q1 2012 - Q4 2012 Result 2 infections, 774 central-line days Rating SIR: 1.85	2 infections, 774 central-line days	1.85
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 2821 central-line days Rating SIR: 0.31	1 infections, 2821 central-line days	0.31
Description Central Line-associated Bloodstream Infection data in the Adult Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 3051 central-line days Rating SIR: 1.30	4 infections, 3051 central-line days	1.30
Q1 2021 - Q4 2021 Result 3 infections, 2937 central-line days Rating SIR: 1.01	3 infections, 2937 central-line days	1.01
Q1 2020 - Q4 2020 Result 1 infections, 2267 central-line days Rating SIR: 0.44	1 infections, 2267 central-line days	0.44
Q1 2019 - Q4 2019 Result 1 infections, 1562 central-line days Rating SIR: 0.64	1 infections, 1562 central-line days	0.64
Q1 2018 - Q4 2018 Result 1 infections, 1581 central-line days Rating SIR: 0.63	1 infections, 1581 central-line days	0.63
Q1 2017 - Q4 2017 Result 2 infections, 2598 central-line days Rating SIR: 0.76	2 infections, 2598 central-line days	0.76
Q1 2016 - Q4 2016 Result 3 infections, 2181 central-line days Rating SIR: 1.37	3 infections, 2181 central-line days	1.37
Q1 2015 - Q4 2015 Result 2 infections, 2646 central-line days Rating SIR: 0.50	2 infections, 2646 central-line days	0.50
Q1 2014 - Q4 2014 Result 1 infections, 2645 central-line days Rating SIR: 0.25	1 infections, 2645 central-line days	0.25
Q1 2013 - Q4 2013 Result 4 infections, 2070 central-line days Rating SIR: 1.29	4 infections, 2070 central-line days	1.29
Q1 2012 - Q4 2012 Result 3 infections, 2019 central-line days Rating SIR: 0.99	3 infections, 2019 central-line days	0.99
Q1 2011 - Q4 2011 Result 3 infections, 1835 central-line days Rating SIR: 1.09	3 infections, 1835 central-line days	1.09
Q1 2010 - Q4 2010 Result 4 infections, 1941 central-line days Rating SIR: 1.37	4 infections, 1941 central-line days	1.37
Q1 2009 - Q4 2009 Result N/A infections, N/A central-line days ³⁶ Rating SIR: N/A ³⁶	N/A infections, N/A central-line days ³⁶	N/A ³⁶
Q1 2009 - Q2 2009 Result 1 infections, 599 central-line days Rating SIR: 1.67	1 infections, 599 central-line days	1.67
Adult Medical/Surgical ICU, Second Unit Q1 2023 - Q4 2023 Result 0 infections, 154 central-line days Rating SIR: N/A	0 infections, 154 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 799 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 799 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 5 infections, 2314 central-line days Rating SIR: 2.15	5 infections, 2314 central-line days	2.15
Q1 2020 - Q4 2020 Result 0 infections, 2247 central-line days Rating SIR: 0.00	0 infections, 2247 central-line days	0.00
Q1 2019 - Q4 2019 Result 0 infections, 2033 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2033 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 0 infections, 2282 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2282 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 1 infections, 1837 central-line days Rating SIR: 0.54	1 infections, 1837 central-line days	0.54
Q1 2016 - Q4 2016 Result 2 infections, 2692 central-line days Rating SIR: 0.74	2 infections, 2692 central-line days	0.74
Q1 2015 - Q4 2015 Result 2 infections, 2183 central-line days Rating SIR: 0.61	2 infections, 2183 central-line days	0.61
Q1 2014 - Q4 2014 Result 0 infections, 1906 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1906 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2013 - Q4 2013 Result 4 infections, 2843 central-line days Rating SIR: 0.94	4 infections, 2843 central-line days	0.94
Q1 2012 - Q4 2012 Result 4 infections, 2662 central-line days Rating SIR: 1.00	4 infections, 2662 central-line days	1.00
Adult Medical ICU Q1 2009 - Q4 2009 Result 1 infections, N/A central-line days Rating SIR: 0.00	1 infections, N/A central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Adult Medical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2009 - Q2 2009 Result 1 infections, 558 central-line days Rating SIR: 1.79	1 infections, 558 central-line days	1.79

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 59 central-line days Rating SIR: N/A	0 infections, 59 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Level II/III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 46 central-line days ³³ Rating SIR: N/A ³³	0 infections, 46 central-line days ³³	N/A ³³
Q1 2021 - Q4 2021 Result 0 infections, 48 central-line days ³³ Rating SIR: N/A ³³	0 infections, 48 central-line days ³³	N/A ³³
Q1 2020 - Q4 2020 Result 0 infections, 15 central-line days ³³ Rating SIR: N/A ³³	0 infections, 15 central-line days ³³	N/A ³³
Q1 2019 - Q4 2019 Result 0 infections, 49 central-line days ³³ Rating SIR: N/A ³³	0 infections, 49 central-line days ³³	N/A ³³
Q1 2018 - Q4 2018 Result 0 infections, 45 central-line days ³³ Rating SIR: N/A ³³	0 infections, 45 central-line days ³³	N/A ³³
Q1 2017 - Q4 2017 Result 0 infections, 78 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 78 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 0 infections, 65 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 65 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 35 central-line days ³³ Rating SIR: N/A ³³	0 infections, 35 central-line days ³³	N/A ³³
Q1 2014 - Q4 2014 Result 0 infections, 75 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 75 central-line days ⁴²	N/A ⁴²
Q1 2013 - Q4 2013 Result 0 infections, 46 central-line days ³³ Rating SIR: N/A ³³	0 infections, 46 central-line days ³³	N/A ³³
Q1 2012 - Q4 2012 Result 0 infections, 87 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 87 central-line days ⁴²	N/A ⁴²
Q1 2011 - Q4 2011 Result 0 infections, 120 central-line days Rating SIR: N/A	0 infections, 120 central-line days	N/A
Q1 2010 - Q4 2010 Result 1 infections, 135 central-line days ⁴⁴ Rating SIR: 0.00 ⁴⁴	1 infections, 135 central-line days ⁴⁴	0.00 ⁴⁴
Level III Neonatal ICU Q1 2010 - Q2 2010 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Description Central Line-associated Bloodstream Infection data in the Level III Neonatal ICU summarized as a Standardized Infection Ratio.

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 1 infections, 112 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 112 procedures ¹⁵⁴	N/A ¹⁵⁴
Description Surgical Site Infections Associated with Total Knee Replacement Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2019 - Q4 2019 Result 2 infections, 234 procedures Rating SIR: 1.80	2 infections, 234 procedures	1.80
Q1 2018 - Q4 2018 Result 1 infections, 268 procedures Rating SIR: 0.90	1 infections, 268 procedures	0.90
Q1 2017 - Q4 2017 Result 0 infections, 312 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 312 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 385 procedures Rating SIR: 0.58	1 infections, 385 procedures	0.58
Q1 2015 - Q4 2015 Result 4 infections, 318 procedures Rating SIR: 1.96	4 infections, 318 procedures	1.96
Q1 2014 - Q4 2014 Result 0 infections, 327 procedures Rating SIR: 0.00	0 infections, 327 procedures	0.00
Q3 2013 - Q2 2014 Result 4 infections, 346 procedures Rating SIR: 1.75	4 infections, 346 procedures	1.75
Q3 2012 - Q2 2013 Result 0 infections, 399 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 399 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 375 procedures Rating SIR: 0.42	1 infections, 375 procedures	0.42
Q3 2010 - Q2 2011 Result 1 infections, 378 procedures Rating SIR: 0.40	1 infections, 378 procedures	0.40
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 0 infections, 104 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 104 procedures ¹¹⁷	0.00 ¹¹⁷
Description Surgical Site Infections Associated with Coronary Artery Bypass Graft Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2019 - Q4 2019 Result 0 infections, 131 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 131 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 195 procedures Rating SIR: 1.08	2 infections, 195 procedures	1.08
Q1 2016 - Q4 2016 Result 1 infections, 142 procedures Rating SIR: 0.87	1 infections, 142 procedures	0.87
Q1 2015 - Q4 2015 Result 2 infections, 187 procedures Rating SIR: 0.81	2 infections, 187 procedures	0.81
Q1 2014 - Q4 2014 Result 2 infections, 187 procedures Rating SIR: 0.84	2 infections, 187 procedures	0.84
Q3 2013 - Q2 2014 Result 2 infections, 196 procedures Rating SIR: 0.78	2 infections, 196 procedures	0.78
Q3 2012 - Q2 2013 Result 0 infections, 175 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 175 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 2 infections, 212 procedures ⁴⁶ Rating SIR: 0.76 ⁴⁶	2 infections, 212 procedures ⁴⁶	0.76 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 199 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 199 procedures ⁴⁶	0.00 ⁴⁶