Endeavor Evanston Hospital

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
38	Exempt: No Licensed PICU Beds
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
169	Exempt: No Licensed ICU Beds

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
38	Exempt: No Licensed PICU Beds
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
169	Exempt: No Licensed ICU Beds

Adult CLABSI

Pediatric CLABSI

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2019 - Q4 2019 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Description Central Line-associated Bloodstream Infection (CLABSI) data in the Medical-Surgical Pediatric ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Q1 2017 - Q4 2017 Result N/A infections, N/A central-line days ¹⁶⁹ Rating SIR: N/A ¹⁶⁹	N/A infections, N/A central-line days ¹⁶⁹	N/A ¹⁶⁹
Q1 2016 - Q4 2016 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2015 - Q4 2015 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2014 - Q4 2014 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2013 - Q4 2013 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2012 - Q4 2012 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2011 - Q4 2011 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
Q1 2010 - Q4 2010 Result N/A infections, N/A central-line days ³⁸ Rating SIR: N/A ³⁸	N/A infections, N/A central-line days ³⁸	N/A ³⁸
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

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
38	Exempt: No Licensed PICU Beds
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
169	Exempt: No Licensed ICU Beds

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 2017 - Q1 2018 Result 99.00 %	99.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel

Measure

Healthcare workers given influenza vaccination

Q4 2017 - Q1 2018

Result: 99.00 %

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
38	Exempt: No Licensed PICU Beds
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 1.85	1.85
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: 2.47	2.47
Q4 2019 - Q3 2020 Rating SIR: 2.04	2.04
Q4 2018 - Q3 2019 Rating SIR: 3.99	3.99
Q2 2018 - Q1 2019 Rating SIR: 5.34	5.34
Q1 2015 - Q4 2015 Rating SIR: 9.40	9.40
Q4 2014 - Q3 2015 Rating SIR: 14.75	14.75
Q1 2014 - Q4 2014 Rating SIR: 20.16	20.16
Q4 2013 - Q3 2014 Rating SIR: 16.11	16.11
Q1 2013 - Q4 2013 Rating SIR: 15.27	15.27
Q3 2012 - Q2 2013 Rating SIR: 16.15	16.15
Q1 2012 - Q4 2012 Rating SIR: 14.82	14.82
Q4 2011 - Q3 2012 Rating SIR: 15.14	15.14
Q2 2011 - Q1 2012 Rating SIR: 1.74	1.74
Q1 2011 - Q4 2011 Rating SIR: 18.15	18.15
Q4 2010 - Q3 2011 Rating SIR: 20.70	20.70
Q1 2010 - Q4 2010 Rating SIR: 16.65	16.65
Q4 2009 - Q3 2010 Rating SIR: 15.87	15.87
Q1 2009 - Q4 2009 Rating SIR: 19.87	19.87
Q3 2008 - Q2 2009 Rating SIR: 20.30	20.30
Q1 2008 - Q4 2008 Rating SIR: 22.80	22.80
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: 2.47	2.47
Q4 2018 - Q3 2019 Rating SIR: 1.01	1.01
Q2 2018 - Q1 2019 Rating SIR: 2.43	2.43
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: 0.00	0.00
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 1.59	1.59
Q4 2011 - Q3 2012 Rating SIR: 2.15	2.15
Q2 2011 - Q1 2012 Rating SIR: 1.48	1.48
Q1 2011 - Q4 2011 Rating SIR: 4.32	4.32
Q4 2010 - Q3 2011 Rating SIR: 0.73	0.73
Q1 2010 - Q4 2010 Rating SIR: 2.84	2.84
Q4 2009 - Q3 2010 Rating SIR: 2.83	2.83
Q1 2009 - Q4 2009 Rating SIR: 3.94	3.94
Q3 2008 - Q2 2009 Rating SIR: 0.11	0.11
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 0.38	0.38
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: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.31	0.31
Q4 2018 - Q3 2019 Rating SIR: 0.39	0.39
Q2 2018 - Q1 2019 Rating SIR: 1.28	1.28
Q1 2015 - Q4 2015 Rating SIR: 1.39	1.39
Q4 2014 - Q3 2015 Rating SIR: 1.28	1.28
Q1 2014 - Q4 2014 Rating SIR: 1.65	1.65
Q4 2013 - Q3 2014 Rating SIR: 1.68	1.68
Q1 2013 - Q4 2013 Rating SIR: 1.94	1.94
Q3 2012 - Q2 2013 Rating SIR: 1.95	1.95
Q1 2012 - Q4 2012 Rating SIR: 2.41	2.41
Q4 2011 - Q3 2012 Rating SIR: 2.54	2.54
Q2 2011 - Q1 2012 Rating SIR: 0.25	0.25
Q1 2011 - Q4 2011 Rating SIR: 3.66	3.66
Q4 2010 - Q3 2011 Rating SIR: 2.60	2.60
Q1 2010 - Q4 2010 Rating SIR: 2.52	2.52
Q4 2009 - Q3 2010 Rating SIR: 4.04	4.04
Q1 2009 - Q4 2009 Rating SIR: 5.31	5.31
Q3 2008 - Q2 2009 Rating SIR: 3.90	3.90
Q1 2008 - Q4 2008 Rating SIR: 4.20	4.20
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.16	0.16
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: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.14	0.14
Q4 2018 - Q3 2019 Rating SIR: 0.08	0.08
Q2 2018 - Q1 2019 Rating SIR: 0.17	0.17
Q1 2015 - Q4 2015 Rating SIR: 0.13	0.13
Q4 2014 - Q3 2015 Rating SIR: 0.15	0.15
Q1 2014 - Q4 2014 Rating SIR: 0.21	0.21
Q4 2013 - Q3 2014 Rating SIR: 0.36	0.36
Q1 2013 - Q4 2013 Rating SIR: 0.35	0.35
Q3 2012 - Q2 2013 Rating SIR: 0.46	0.46
Q1 2012 - Q4 2012 Rating SIR: 0.22	0.22
Q4 2011 - Q3 2012 Rating SIR: 0.14	0.14
Q2 2011 - Q1 2012 Rating SIR: 0.03	0.03
Q1 2011 - Q4 2011 Rating SIR: 2.14	2.14
Q4 2010 - Q3 2011 Rating SIR: 0.25	0.25
Q1 2010 - Q4 2010 Rating SIR: 0.08	0.08
Q4 2009 - Q3 2010 Rating SIR: 0.41	0.41
Q1 2009 - Q4 2009 Rating SIR: 0.65	0.65
Q3 2008 - Q2 2009 Rating SIR: 0.20	0.20
Q1 2008 - Q4 2008 Rating SIR: 0.40	0.40
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.83	1.83
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: 1.63	1.63
Q4 2019 - Q3 2020 Rating SIR: 1.81	1.81
Q4 2018 - Q3 2019 Rating SIR: 4.05	4.05
Q2 2018 - Q1 2019 Rating SIR: 4.30	4.30
Q1 2015 - Q4 2015 Rating SIR: 4.32	4.32
Q4 2014 - Q3 2015 Rating SIR: 5.15	5.15
Q1 2014 - Q4 2014 Rating SIR: 5.91	5.91
Q4 2013 - Q3 2014 Rating SIR: 7.50	7.50
Q1 2013 - Q4 2013 Rating SIR: 7.50	7.50
Q3 2012 - Q2 2013 Rating SIR: 8.92	8.92
Q1 2012 - Q4 2012 Rating SIR: 8.73	8.73
Q4 2011 - Q3 2012 Rating SIR: 3.51	3.51
Q2 2011 - Q1 2012 Rating SIR: 3.10	3.10
Q1 2011 - Q4 2011 Rating SIR: 3.07	3.07
Q4 2010 - Q3 2011 Rating SIR: 3.81	3.81
Q1 2010 - Q4 2010 Rating SIR: 4.51	4.51
Q4 2009 - Q3 2010 Rating SIR: 2.99	2.99
Q1 2009 - Q4 2009 Rating SIR: 1.09	1.09
Q3 2008 - Q2 2009 Rating SIR: 0.18	0.18
Q1 2008 - Q4 2008 Rating SIR: 0.32	0.32
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 1.30	1.30
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: 5.73	5.73
Q4 2019 - Q3 2020 Rating SIR: 3.50	3.50
Q4 2018 - Q3 2019 Rating SIR: 3.57	3.57
Q2 2018 - Q1 2019 Rating SIR: 3.63	3.63
Q1 2015 - Q4 2015 Rating SIR: 5.58	5.58
Q4 2014 - Q3 2015 Rating SIR: 6.36	6.36
Q1 2014 - Q4 2014 Rating SIR: 6.47	6.47
Q4 2013 - Q3 2014 Rating SIR: 5.60	5.60
Q1 2013 - Q4 2013 Rating SIR: 6.87	6.87
Q3 2012 - Q2 2013 Rating SIR: 7.63	7.63
Q1 2012 - Q4 2012 Rating SIR: 8.85	8.85
Q4 2011 - Q3 2012 Rating SIR: 8.84	8.84
Q2 2011 - Q1 2012 Rating SIR: 10.28	10.28
Q1 2011 - Q4 2011 Rating SIR: 8.30	8.30
Q4 2010 - Q3 2011 Rating SIR: 10.95	10.95
Q1 2010 - Q4 2010 Rating SIR: 8.53	8.53
Q4 2009 - Q3 2010 Rating SIR: 14.80	14.80
Q1 2009 - Q4 2009 Rating SIR: 16.93	16.93
Q3 2008 - Q2 2009 Rating SIR: 0.83	0.83
Q1 2008 - Q4 2008 Rating SIR: 1.07	1.07
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: 0.06	0.06
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: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.00	0.00
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
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: 0.40	0.40
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 0.49	0.49
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: 0.24	0.24
Q4 2019 - Q3 2020 Rating SIR: 1.61	1.61
Q4 2018 - Q3 2019 Rating SIR: 2.02	2.02
Q2 2018 - Q1 2019 Rating SIR: 1.59	1.59
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: 0.37	0.37
Q1 2013 - Q4 2013 Rating SIR: 0.75	0.75
Q3 2012 - Q2 2013 Rating SIR: 0.36	0.36
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.31	0.31
Q2 2011 - Q1 2012 Rating SIR: 0.32	0.32
Q1 2011 - Q4 2011 Rating SIR: 0.92	0.92
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 1.12	1.12
Q4 2009 - Q3 2010 Rating SIR: 3.37	3.37
Q1 2009 - Q4 2009 Rating SIR: 3.29	3.29
Q3 2008 - Q2 2009 Rating SIR: 0.27	0.27
Q1 2008 - Q4 2008 Rating SIR: 0.77	0.77
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 0.80	0.80
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: 2.81	2.81
Q4 2019 - Q3 2020 Rating SIR: 3.92	3.92
Q4 2018 - Q3 2019 Rating SIR: 4.43	4.43
Q2 2018 - Q1 2019 Rating SIR: 2.70	2.70
Q1 2015 - Q4 2015 Rating SIR: 10.99	10.99
Q4 2014 - Q3 2015 Rating SIR: 10.60	10.60
Q1 2014 - Q4 2014 Rating SIR: 7.20	7.20
Q4 2013 - Q3 2014 Rating SIR: 5.56	5.56
Q1 2013 - Q4 2013 Rating SIR: 14.76	14.76
Q3 2012 - Q2 2013 Rating SIR: 11.60	11.60
Q1 2012 - Q4 2012 Rating SIR: 6.22	6.22
Q4 2011 - Q3 2012 Rating SIR: 7.12	7.12
Q2 2011 - Q1 2012 Rating SIR: 7.67	7.67
Q1 2011 - Q4 2011 Rating SIR: 6.62	6.62
Q4 2010 - Q3 2011 Rating SIR: 8.82	8.82
Q1 2010 - Q4 2010 Rating SIR: 6.86	6.86
Q4 2009 - Q3 2010 Rating SIR: 5.98	5.98
Q1 2009 - Q4 2009 Rating SIR: 11.95	11.95
Q3 2008 - Q2 2009 Rating SIR: 1.27	1.27
Q1 2008 - Q4 2008 Rating SIR: 1.32	1.32
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 0.42	0.42
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: 0.91	0.91
Q4 2019 - Q3 2020 Rating SIR: 1.06	1.06
Q4 2018 - Q3 2019 Rating SIR: 1.15	1.15
Q2 2018 - Q1 2019 Rating SIR: 1.48	1.48
Q1 2015 - Q4 2015 Rating SIR: 1.25	1.25
Q4 2014 - Q3 2015 Rating SIR: 1.78	1.78
Q1 2014 - Q4 2014 Rating SIR: 0.70	0.70
Q4 2013 - Q3 2014 Rating SIR: 0.23	0.23
Q1 2013 - Q4 2013 Rating SIR: 0.45	0.45
Q3 2012 - Q2 2013 Rating SIR: 0.93	0.93
Q1 2012 - Q4 2012 Rating SIR: 1.13	1.13
Q4 2011 - Q3 2012 Rating SIR: 1.40	1.40
Q2 2011 - Q1 2012 Rating SIR: 0.76	0.76
Q1 2011 - Q4 2011 Rating SIR: 0.69	0.69
Q4 2010 - Q3 2011 Rating SIR: 0.94	0.94
Q1 2010 - Q4 2010 Rating SIR: 0.68	0.68
Q4 2009 - Q3 2010 Rating SIR: 0.50	0.50
Q1 2009 - Q4 2009 Rating SIR: 0.25	0.25
Q3 2008 - Q2 2009 Rating SIR: 0.16	0.16
Q1 2008 - Q4 2008 Rating SIR: 0.24	0.24

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 4 infections, 95573 patient days Rating SIR: 0.58	4 infections, 95573 patient days	0.58
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 2 infections, 97608 patient days Rating SIR: 0.28	2 infections, 97608 patient days	0.28
Q1 2021 - Q4 2021 Result 3 infections, 102140 patient days Rating SIR: 0.48	3 infections, 102140 patient days	0.48
Q1 2020 - Q4 2020 Result 4 infections, 99844 patient days Rating SIR: 0.57	4 infections, 99844 patient days	0.57
Q1 2019 - Q4 2019 Result 5 infections, 92687 patient days Rating SIR: 1.07	5 infections, 92687 patient days	1.07
Q1 2018 - Q4 2018 Result 5 infections, 81106 patient days Rating SIR: 1.49	5 infections, 81106 patient days	1.49
Q1 2017 - Q4 2017 Result 1 infections, 78037 patient days Rating SIR: 0.26	1 infections, 78037 patient days	0.26
Q1 2016 - Q4 2016 Result 3 infections, 74061 patient days Rating SIR: 0.67	3 infections, 74061 patient days	0.67
Q1 2015 - Q4 2015 Result 1 infections, 77669 patient days Rating SIR: 0.25	1 infections, 77669 patient days	0.25
Q1 2014 - Q4 2014 Result 1 infections, 93043 patient days Rating SIR: 0.21	1 infections, 93043 patient days	0.21
Q1 2013 - Q4 2013 Result 2 infections, 96031 patient days Rating SIR: 0.38	2 infections, 96031 patient days	0.38
Q1 2012 - Q4 2012 Result 2 infections, 100191 patient days Rating SIR: 0.38	2 infections, 100191 patient days	0.38
Q1 2012 - Q2 2012 Result 1 infections, 50045 patient days Rating SIR: 0.20	1 infections, 50045 patient days	0.20
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 4 infections, 80398 patient days Rating SIR: 0.11	4 infections, 80398 patient days	0.11
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 14 infections, 82215 patient days Rating SIR: 0.28	14 infections, 82215 patient days	0.28
Q1 2021 - Q4 2021 Result 11 infections, 85180 patient days Rating SIR: 0.21	11 infections, 85180 patient days	0.21
Q1 2020 - Q4 2020 Result 15 infections, 82755 patient days Rating SIR: 0.30	15 infections, 82755 patient days	0.30
Q1 2019 - Q4 2019 Result 13 infections, 74585 patient days Rating SIR: 0.28	13 infections, 74585 patient days	0.28
Q1 2018 - Q4 2018 Result 14 infections, 62292 patient days Rating SIR: 0.37	14 infections, 62292 patient days	0.37
Q1 2017 - Q4 2017 Result 33 infections, 58873 patient days Rating SIR: 0.90	33 infections, 58873 patient days	0.90
Q1 2016 - Q4 2016 Result 33 infections, 55318 patient days Rating SIR: 0.95	33 infections, 55318 patient days	0.95
Q1 2015 - Q4 2015 Result 38 infections, 57230 patient days Rating SIR: 0.77	38 infections, 57230 patient days	0.77
Q1 2014 - Q4 2014 Result 35 infections, 73970 patient days Rating SIR: 0.55	35 infections, 73970 patient days	0.55
Q1 2013 - Q4 2013 Result 53 infections, 76517 patient days Rating SIR: 0.80	53 infections, 76517 patient days	0.80
Q1 2012 - Q4 2012 Result 74 infections, 80218 patient days Rating SIR: 1.03	74 infections, 80218 patient days	1.03

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 3497 central-line days Rating SIR: 0.25	1 infections, 3497 central-line days	0.25
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 0 infections, 3650 central-line days Rating SIR: 0.00	0 infections, 3650 central-line days	0.00
Q1 2021 - Q4 2021 Result 0 infections, 4150 central-line days Rating SIR: 0.00	0 infections, 4150 central-line days	0.00
Q1 2020 - Q4 2020 Result 1 infections, 3463 central-line days Rating SIR: 0.26	1 infections, 3463 central-line days	0.26
Q1 2019 - Q4 2019 Result 0 infections, 3336 central-line days Rating SIR: 0.00	0 infections, 3336 central-line days	0.00
Q1 2018 - Q4 2018 Result 0 infections, 3112 central-line days Rating SIR: 0.00	0 infections, 3112 central-line days	0.00
Q1 2017 - Q4 2017 Result 2 infections, 3062 central-line days Rating SIR: 0.58	2 infections, 3062 central-line days	0.58
Q1 2016 - Q4 2016 Result 2 infections, 3236 central-line days Rating SIR: 0.55	2 infections, 3236 central-line days	0.55
Q1 2015 - Q4 2015 Result 0 infections, 2725 central-line days Rating SIR: 0.00	0 infections, 2725 central-line days	0.00
Q1 2014 - Q4 2014 Result 2 infections, 2289 central-line days Rating SIR: 0.42	2 infections, 2289 central-line days	0.42
Q1 2013 - Q4 2013 Result 0 infections, 2440 central-line days Rating SIR: 0.00	0 infections, 2440 central-line days	0.00
Q1 2012 - Q4 2012 Result 2 infections, 3176 central-line days Rating SIR: 0.30	2 infections, 3176 central-line days	0.30
Q1 2011 - Q4 2011 Result 5 infections, 3193 central-line days Rating SIR: 0.75	5 infections, 3193 central-line days	0.75
Q1 2010 - Q4 2010 Result 3 infections, 2658 central-line days Rating SIR: 0.54	3 infections, 2658 central-line days	0.54
Q1 2009 - Q4 2009 Result 6 infections, 3138 central-line days Rating SIR: 0.91	6 infections, 3138 central-line days	0.91
Q1 2009 - Q2 2009 Result 3 infections, 1697 central-line days Rating SIR: 1.77	3 infections, 1697 central-line days	1.77

NICU CLABSI Measure	Result	SIR
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 1421 central-line days Rating SIR: 0.00	0 infections, 1421 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Level III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 2 infections, 1586 central-line days Rating SIR: 0.80	2 infections, 1586 central-line days	0.80
Q1 2021 - Q4 2021 Result 1 infections, 1278 central-line days Rating SIR: 0.52	1 infections, 1278 central-line days	0.52
Q1 2020 - Q4 2020 Result 1 infections, 1594 central-line days Rating SIR: 0.40	1 infections, 1594 central-line days	0.40
Q1 2019 - Q4 2019 Result 1 infections, 1413 central-line days Rating SIR: 0.49	1 infections, 1413 central-line days	0.49
Q1 2018 - Q4 2018 Result 1 infections, 1439 central-line days Rating SIR: 0.42	1 infections, 1439 central-line days	0.42
Q1 2017 - Q4 2017 Result 0 infections, 1515 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1515 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 3 infections, 1730 central-line days Rating SIR: 1.19	3 infections, 1730 central-line days	1.19
Q1 2015 - Q4 2015 Result 6 infections, 2100 central-line days Rating SIR: 1.15	6 infections, 2100 central-line days	1.15
Q1 2014 - Q4 2014 Result 0 infections, 2087 central-line days Rating SIR: 0.00	0 infections, 2087 central-line days	0.00
Q1 2013 - Q4 2013 Result 2 infections, 2811 central-line days Rating SIR: 0.27	2 infections, 2811 central-line days	0.27
Q1 2012 - Q4 2012 Result 4 infections, 3239 central-line days Rating SIR: 0.47	4 infections, 3239 central-line days	0.47
Q1 2011 - Q4 2011 Result 5 infections, 3406 central-line days Rating SIR: 0.56	5 infections, 3406 central-line days	0.56
Q1 2010 - Q4 2010 Result 8 infections, 4103 central-line days Rating SIR: 0.80	8 infections, 4103 central-line days	0.80
Q1 2010 - Q2 2010 Result 2 infections, 968 central-line days Rating SIR: 0.64	2 infections, 968 central-line days	0.64

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
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 N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2018 - Q4 2018 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2017 - Q4 2017 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2016 - Q4 2016 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2015 - Q4 2015 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2014 - Q4 2014 Result N/A infections, N/A procedures Rating SIR: N/A	N/A infections, N/A procedures	N/A
Q3 2013 - Q2 2014 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q3 2012 - Q2 2013 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q3 2011 - Q2 2012 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q3 2010 - Q2 2011 Result N/A infections, N/A procedures Rating SIR: N/A	N/A infections, N/A procedures	N/A
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 1 infections, 82 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 82 procedures ¹⁵⁴	N/A ¹⁵⁴
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 1 infections, 114 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 114 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2018 - Q4 2018 Result 1 infections, 108 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 108 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2016 - Q4 2016 Result 0 infections, 123 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 123 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 2 infections, 79 procedures Rating SIR: 1.57	2 infections, 79 procedures	1.57
Q1 2014 - Q4 2014 Result 2 infections, 117 procedures Rating SIR: 1.11	2 infections, 117 procedures	1.11
Q3 2013 - Q2 2014 Result 1 infections, 150 procedures Rating SIR: 0.43	1 infections, 150 procedures	0.43
Q3 2012 - Q2 2013 Result 0 infections, 108 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 108 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 125 procedures Rating SIR: 0.50	1 infections, 125 procedures	0.50
Q3 2010 - Q2 2011 Result 5 infections, 139 procedures ⁴⁸ Rating SIR: 2.69 ⁴⁸	5 infections, 139 procedures ⁴⁸	2.69 ⁴⁸