Rush Copley 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
38	Exempt: No Licensed PICU 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
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
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
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
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
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 2022 - Q1 2023 Result 90.00 %	90.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 83.00 %	83.00 %
Q4 2020 - Q1 2021 Result 94.00 %	94.00 %
Q4 2019 - Q1 2020 Result 92.00 %	92.00 %
Q4 2018 - Q1 2019 Result 90.00 %	90.00 %
Q4 2017 - Q1 2018 Result 93.00 %	93.00 %

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
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
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: 2.35	2.35
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: 1.52	1.52
Q4 2019 - Q3 2020 Rating SIR: 1.34	1.34
Q4 2018 - Q3 2019 Rating SIR: 2.22	2.22
Q2 2018 - Q1 2019 Rating SIR: 1.83	1.83
Q1 2015 - Q4 2015 Rating SIR: 3.74	3.74
Q4 2014 - Q3 2015 Rating SIR: 4.69	4.69
Q1 2014 - Q4 2014 Rating SIR: 6.56	6.56
Q4 2013 - Q3 2014 Rating SIR: 6.42	6.42
Q1 2013 - Q4 2013 Rating SIR: 5.17	5.17
Q3 2012 - Q2 2013 Rating SIR: 5.81	5.81
Q1 2012 - Q4 2012 Rating SIR: 5.09	5.09
Q4 2011 - Q3 2012 Rating SIR: 2.78	2.78
Q2 2011 - Q1 2012 Rating SIR: 0.24	0.24
Q1 2011 - Q4 2011 Rating SIR: 2.45	2.45
Q4 2010 - Q3 2011 Rating SIR: 3.05	3.05
Q1 2010 - Q4 2010 Rating SIR: 6.02	6.02
Q4 2009 - Q3 2010 Rating SIR: 9.86	9.86
Q1 2009 - Q4 2009 Rating SIR: 8.84	8.84
Q3 2008 - Q2 2009 Rating SIR: 5.80	5.80
Q1 2008 - Q4 2008 Rating SIR: 4.20	4.20
Wound Complications in Abdominal Wall Surgery Q4 2021 - Q3 2022 Rating SIR: 2.40	2.40
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: 1.47	1.47
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: 2.32	2.32
Q3 2012 - Q2 2013 Rating SIR: 2.25	2.25
Q1 2012 - Q4 2012 Rating SIR: 2.34	2.34
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: 2.98	2.98
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: 4.59	4.59
Q3 2008 - Q2 2009 Rating SIR: 0.38	0.38
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 0.87	0.87
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: 2.18	2.18
Q4 2019 - Q3 2020 Rating SIR: 1.42	1.42
Q4 2018 - Q3 2019 Rating SIR: 0.75	0.75
Q2 2018 - Q1 2019 Rating SIR: 1.56	1.56
Q1 2015 - Q4 2015 Rating SIR: 1.15	1.15
Q4 2014 - Q3 2015 Rating SIR: 1.67	1.67
Q1 2014 - Q4 2014 Rating SIR: 2.18	2.18
Q4 2013 - Q3 2014 Rating SIR: 2.28	2.28
Q1 2013 - Q4 2013 Rating SIR: 3.17	3.17
Q3 2012 - Q2 2013 Rating SIR: 2.80	2.80
Q1 2012 - Q4 2012 Rating SIR: 2.42	2.42
Q4 2011 - Q3 2012 Rating SIR: 2.51	2.51
Q2 2011 - Q1 2012 Rating SIR: 0.25	0.25
Q1 2011 - Q4 2011 Rating SIR: 3.42	3.42
Q4 2010 - Q3 2011 Rating SIR: 2.62	2.62
Q1 2010 - Q4 2010 Rating SIR: 2.67	2.67
Q4 2009 - Q3 2010 Rating SIR: 4.08	4.08
Q1 2009 - Q4 2009 Rating SIR: 2.92	2.92
Q3 2008 - Q2 2009 Rating SIR: 2.00	2.00
Q1 2008 - Q4 2008 Rating SIR: 4.40	4.40
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.39	0.39
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: 0.17	0.17
Q4 2018 - Q3 2019 Rating SIR: 0.19	0.19
Q2 2018 - Q1 2019 Rating SIR: 0.17	0.17
Q1 2015 - Q4 2015 Rating SIR: 0.32	0.32
Q4 2014 - Q3 2015 Rating SIR: 0.30	0.30
Q1 2014 - Q4 2014 Rating SIR: 0.29	0.29
Q4 2013 - Q3 2014 Rating SIR: 0.33	0.33
Q1 2013 - Q4 2013 Rating SIR: 0.63	0.63
Q3 2012 - Q2 2013 Rating SIR: 0.66	0.66
Q1 2012 - Q4 2012 Rating SIR: 0.17	0.17
Q4 2011 - Q3 2012 Rating SIR: 0.11	0.11
Q2 2011 - Q1 2012 Rating SIR: 0.01	0.01
Q1 2011 - Q4 2011 Rating SIR: 0.90	0.90
Q4 2010 - Q3 2011 Rating SIR: 0.15	0.15
Q1 2010 - Q4 2010 Rating SIR: 0.29	0.29
Q4 2009 - Q3 2010 Rating SIR: 0.65	0.65
Q1 2009 - Q4 2009 Rating SIR: 0.92	0.92
Q3 2008 - Q2 2009 Rating SIR: 0.70	0.70
Q1 2008 - Q4 2008 Rating SIR: 0.60	0.60
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.72	1.72
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: 4.86	4.86
Q4 2019 - Q3 2020 Rating SIR: 1.01	1.01
Q4 2018 - Q3 2019 Rating SIR: 5.60	5.60
Q2 2018 - Q1 2019 Rating SIR: 7.06	7.06
Q1 2015 - Q4 2015 Rating SIR: 5.80	5.80
Q4 2014 - Q3 2015 Rating SIR: 6.26	6.26
Q1 2014 - Q4 2014 Rating SIR: 5.73	5.73
Q4 2013 - Q3 2014 Rating SIR: 6.36	6.36
Q1 2013 - Q4 2013 Rating SIR: 7.55	7.55
Q3 2012 - Q2 2013 Rating SIR: 6.56	6.56
Q1 2012 - Q4 2012 Rating SIR: 6.18	6.18
Q4 2011 - Q3 2012 Rating SIR: 2.07	2.07
Q2 2011 - Q1 2012 Rating SIR: 1.44	1.44
Q1 2011 - Q4 2011 Rating SIR: 3.08	3.08
Q4 2010 - Q3 2011 Rating SIR: 1.10	1.10
Q1 2010 - Q4 2010 Rating SIR: 2.37	2.37
Q4 2009 - Q3 2010 Rating SIR: 3.32	3.32
Q1 2009 - Q4 2009 Rating SIR: 2.53	2.53
Q3 2008 - Q2 2009 Rating SIR: 0.25	0.25
Q1 2008 - Q4 2008 Rating SIR: 0.45	0.45
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 7.82	7.82
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: 7.37	7.37
Q4 2019 - Q3 2020 Rating SIR: 10.70	10.70
Q4 2018 - Q3 2019 Rating SIR: 3.10	3.10
Q2 2018 - Q1 2019 Rating SIR: 1.11	1.11
Q1 2015 - Q4 2015 Rating SIR: 4.93	4.93
Q4 2014 - Q3 2015 Rating SIR: 4.06	4.06
Q1 2014 - Q4 2014 Rating SIR: 7.48	7.48
Q4 2013 - Q3 2014 Rating SIR: 9.86	9.86
Q1 2013 - Q4 2013 Rating SIR: 7.48	7.48
Q3 2012 - Q2 2013 Rating SIR: 5.34	5.34
Q1 2012 - Q4 2012 Rating SIR: 3.39	3.39
Q4 2011 - Q3 2012 Rating SIR: 9.26	9.26
Q2 2011 - Q1 2012 Rating SIR: 9.65	9.65
Q1 2011 - Q4 2011 Rating SIR: 9.94	9.94
Q4 2010 - Q3 2011 Rating SIR: 5.92	5.92
Q1 2010 - Q4 2010 Rating SIR: 10.52	10.52
Q4 2009 - Q3 2010 Rating SIR: 17.32	17.32
Q1 2009 - Q4 2009 Rating SIR: 16.55	16.55
Q3 2008 - Q2 2009 Rating SIR: 0.98	0.98
Q1 2008 - Q4 2008 Rating SIR: 0.76	0.76
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: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.11	0.11
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: 0.00	0.00
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 0.65	0.65
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: 0.21	0.21
Q4 2019 - Q3 2020 Rating SIR: 0.19	0.19
Q4 2018 - Q3 2019 Rating SIR: 0.59	0.59
Q2 2018 - Q1 2019 Rating SIR: 0.43	0.43
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: 0.59	0.59
Q1 2013 - Q4 2013 Rating SIR: 0.60	0.60
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: 3.46	3.46
Q3 2008 - Q2 2009 Rating SIR: 0.16	0.16
Q1 2008 - Q4 2008 Rating SIR: 0.31	0.31
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 3.01	3.01
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: 1.37	1.37
Q4 2019 - Q3 2020 Rating SIR: 1.25	1.25
Q4 2018 - Q3 2019 Rating SIR: 3.78	3.78
Q2 2018 - Q1 2019 Rating SIR: 2.11	2.11
Q1 2015 - Q4 2015 Rating SIR: 5.19	5.19
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 5.43	5.43
Q4 2013 - Q3 2014 Rating SIR: 11.65	11.65
Q1 2013 - Q4 2013 Rating SIR: 9.82	9.82
Q3 2012 - Q2 2013 Rating SIR: 5.14	5.14
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 4.69	4.69
Q2 2011 - Q1 2012 Rating SIR: 17.67	17.67
Q1 2011 - Q4 2011 Rating SIR: 21.60	21.60
Q4 2010 - Q3 2011 Rating SIR: 18.29	18.29
Q1 2010 - Q4 2010 Rating SIR: 19.92	19.92
Q4 2009 - Q3 2010 Rating SIR: 19.35	19.35
Q1 2009 - Q4 2009 Rating SIR: 3.90	3.90
Q3 2008 - Q2 2009 Rating SIR: 0.67	0.67
Q1 2008 - Q4 2008 Rating SIR: 1.86	1.86
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
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: 1.12	1.12
Q4 2019 - Q3 2020 Rating SIR: 1.20	1.20
Q4 2018 - Q3 2019 Rating SIR: 0.72	0.72
Q2 2018 - Q1 2019 Rating SIR: 0.87	0.87
Q1 2015 - Q4 2015 Rating SIR: 0.81	0.81
Q4 2014 - Q3 2015 Rating SIR: 0.75	0.75
Q1 2014 - Q4 2014 Rating SIR: 0.72	0.72
Q4 2013 - Q3 2014 Rating SIR: 0.77	0.77
Q1 2013 - Q4 2013 Rating SIR: 0.76	0.76
Q3 2012 - Q2 2013 Rating SIR: 1.42	1.42
Q1 2012 - Q4 2012 Rating SIR: 2.11	2.11
Q4 2011 - Q3 2012 Rating SIR: 3.12	3.12
Q2 2011 - Q1 2012 Rating SIR: 2.27	2.27
Q1 2011 - Q4 2011 Rating SIR: 0.73	0.73
Q4 2010 - Q3 2011 Rating SIR: 0.76	0.76
Q1 2010 - Q4 2010 Rating SIR: 1.48	1.48
Q4 2009 - Q3 2010 Rating SIR: 0.75	0.75
Q1 2009 - Q4 2009 Rating SIR: 1.31	1.31
Q3 2008 - Q2 2009 Rating SIR: 0.10	0.10
Q1 2008 - Q4 2008 Rating SIR: 0.05	0.05

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 5 infections, 57371 patient days Rating SIR: 1.61	5 infections, 57371 patient days	1.61
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 2 infections, 48876 patient days Rating SIR: 0.77	2 infections, 48876 patient days	0.77
Q1 2021 - Q4 2021 Result 1 infections, 55210 patient days Rating SIR: 0.32	1 infections, 55210 patient days	0.32
Q1 2020 - Q4 2020 Result 1 infections, 52620 patient days Rating SIR: 0.37	1 infections, 52620 patient days	0.37
Q1 2019 - Q4 2019 Result 1 infections, 48576 patient days Rating SIR: 0.41	1 infections, 48576 patient days	0.41
Q1 2018 - Q4 2018 Result 0 infections, 49943 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 49943 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 48395 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 48395 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 52936 patient days Rating SIR: 0.40	1 infections, 52936 patient days	0.40
Q1 2015 - Q4 2015 Result 0 infections, 52030 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 52030 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 1 infections, 57673 patient days Rating SIR: 0.27	1 infections, 57673 patient days	0.27
Q1 2013 - Q4 2013 Result 0 infections, 56458 patient days Rating SIR: 0.00	0 infections, 56458 patient days	0.00
Q1 2012 - Q4 2012 Result 3 infections, 56127 patient days Rating SIR: 0.95	3 infections, 56127 patient days	0.95
Q1 2012 - Q2 2012 Result 2 infections, 27803 patient days Rating SIR: 0.72	2 infections, 27803 patient days	0.72
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 25 infections, 48600 patient days Rating SIR: 0.77	25 infections, 48600 patient days	0.77
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 19 infections, 41500 patient days Rating SIR: 0.62	19 infections, 41500 patient days	0.62
Q1 2021 - Q4 2021 Result 23 infections, 47402 patient days Rating SIR: 0.57	23 infections, 47402 patient days	0.57
Q1 2020 - Q4 2020 Result 9 infections, 44572 patient days Rating SIR: 0.29	9 infections, 44572 patient days	0.29
Q1 2019 - Q4 2019 Result 23 infections, 39123 patient days Rating SIR: 0.77	23 infections, 39123 patient days	0.77
Q1 2018 - Q4 2018 Result 28 infections, 39913 patient days Rating SIR: 0.88	28 infections, 39913 patient days	0.88
Q1 2017 - Q4 2017 Result 26 infections, 40130 patient days Rating SIR: 0.78	26 infections, 40130 patient days	0.78
Q1 2016 - Q4 2016 Result 17 infections, 42126 patient days Rating SIR: 0.57	17 infections, 42126 patient days	0.57
Q1 2015 - Q4 2015 Result 21 infections, 42527 patient days Rating SIR: 0.55	21 infections, 42527 patient days	0.55
Q1 2014 - Q4 2014 Result 29 infections, 46962 patient days Rating SIR: 0.72	29 infections, 46962 patient days	0.72
Q1 2013 - Q4 2013 Result 36 infections, 45286 patient days Rating SIR: 0.93	36 infections, 45286 patient days	0.93
Q1 2012 - Q4 2012 Result 33 infections, 45910 patient days Rating SIR: 0.84	33 infections, 45910 patient days	0.84

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 0 infections, 1920 central-line days Rating SIR: 0.00	0 infections, 1920 central-line days	0.00
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 1 infections, 2430 central-line days Rating SIR: 0.37	1 infections, 2430 central-line days	0.37
Q1 2021 - Q4 2021 Result 4 infections, 2699 central-line days Rating SIR: 1.31	4 infections, 2699 central-line days	1.31
Q1 2020 - Q4 2020 Result 2 infections, 2660 central-line days Rating SIR: 0.67	2 infections, 2660 central-line days	0.67
Q1 2019 - Q4 2019 Result 1 infections, 1944 central-line days Rating SIR: 0.46	1 infections, 1944 central-line days	0.46
Q1 2018 - Q4 2018 Result 0 infections, 2093 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2093 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 1731 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1731 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 2020 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2020 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 4 infections, 2058 central-line days Rating SIR: 0.93	4 infections, 2058 central-line days	0.93
Q1 2014 - Q4 2014 Result 0 infections, 1763 central-line days Rating SIR: 0.00	0 infections, 1763 central-line days	0.00
Q1 2013 - Q4 2013 Result 0 infections, 2407 central-line days Rating SIR: 0.00	0 infections, 2407 central-line days	0.00
Q1 2012 - Q4 2012 Result 2 infections, 2333 central-line days Rating SIR: 0.41	2 infections, 2333 central-line days	0.41
Q1 2011 - Q4 2011 Result 0 infections, 2369 central-line days Rating SIR: 0.00	0 infections, 2369 central-line days	0.00
Q1 2010 - Q4 2010 Result 1 infections, 2225 central-line days Rating SIR: 0.21	1 infections, 2225 central-line days	0.21
Q1 2009 - Q4 2009 Result 1 infections, 1967 central-line days Rating SIR: 0.24	1 infections, 1967 central-line days	0.24
Q1 2009 - Q2 2009 Result 1 infections, 995 central-line days Rating SIR: 1.01	1 infections, 995 central-line days	1.01

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 2 infections, 541 central-line days Rating SIR: N/A	2 infections, 541 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 1 infections, 598 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 598 central-line days ⁴⁴	N/A ⁴⁴
Q1 2021 - Q4 2021 Result 2 infections, 505 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	2 infections, 505 central-line days ⁴⁴	N/A ⁴⁴
Q1 2020 - Q4 2020 Result 1 infections, 542 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 542 central-line days ⁴⁴	N/A ⁴⁴
Q1 2019 - Q4 2019 Result 1 infections, 636 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 636 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 0 infections, 888 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 888 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 316 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 316 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 1 infections, 1111 central-line days Rating SIR: 0.53	1 infections, 1111 central-line days	0.53
Q1 2015 - Q4 2015 Result 0 infections, 416 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 416 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 0 infections, 548 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 548 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2013 - Q4 2013 Result 4 infections, 928 central-line days Rating SIR: 1.48	4 infections, 928 central-line days	1.48
Q1 2012 - Q4 2012 Result 0 infections, 854 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 854 central-line days ⁴³	0.00 ⁴³
Q1 2011 - Q4 2011 Result 1 infections, 1009 central-line days Rating SIR: 0.34	1 infections, 1009 central-line days	0.34
Q1 2010 - Q4 2010 Result 0 infections, 763 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 763 central-line days ⁴³	0.00 ⁴³
Q1 2010 - Q2 2010 Result 0 infections, 285 central-line days Rating SIR: 0.00	0 infections, 285 central-line days	0.00

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 1 infections, 312 procedures Rating SIR: 0.76	1 infections, 312 procedures	0.76
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 0 infections, 404 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 404 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 1 infections, 365 procedures Rating SIR: 0.60	1 infections, 365 procedures	0.60
Q1 2017 - Q4 2017 Result 1 infections, 375 procedures Rating SIR: 0.55	1 infections, 375 procedures	0.55
Q1 2016 - Q4 2016 Result 0 infections, 330 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 330 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 352 procedures Rating SIR: 0.00	0 infections, 352 procedures	0.00
Q1 2014 - Q4 2014 Result 0 infections, 335 procedures Rating SIR: 0.00	0 infections, 335 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 333 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 333 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 304 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 304 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 0 infections, 327 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 327 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 283 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 283 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 1 infections, 116 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 116 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 3 infections, 134 procedures Rating SIR: 2.95	3 infections, 134 procedures	2.95
Q1 2018 - Q4 2018 Result 3 infections, 124 procedures Rating SIR: 2.93	3 infections, 124 procedures	2.93
Q1 2016 - Q4 2016 Result 1 infections, 69 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 69 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2015 - Q4 2015 Result 0 infections, 104 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 104 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 0 infections, 90 procedures Rating SIR: 0.00	0 infections, 90 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 84 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 84 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 1 infections, 111 procedures Rating SIR: 0.53	1 infections, 111 procedures	0.53
Q3 2011 - Q2 2012 Result 0 infections, 123 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 123 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 108 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 108 procedures ⁴⁶	0.00 ⁴⁶