Carle Foundation 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
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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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
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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
169	Exempt: No Licensed ICU Beds

Adult CLABSI

Pediatric CLABSI

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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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 97.00 %	97.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 92.00 %	92.00 %
Q4 2020 - Q1 2021 Result 97.00 %	97.00 %
Q4 2019 - Q1 2020 Result 93.00 %	93.00 %
Q4 2018 - Q1 2019 Result 93.00 %	93.00 %
Q4 2017 - Q1 2018 Result 95.00 %	95.00 %

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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 5.15	5.15
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: 5.86	5.86
Q4 2019 - Q3 2020 Rating SIR: 6.03	6.03
Q4 2018 - Q3 2019 Rating SIR: 3.67	3.67
Q2 2018 - Q1 2019 Rating SIR: 4.46	4.46
Q1 2015 - Q4 2015 Rating SIR: 5.61	5.61
Q4 2014 - Q3 2015 Rating SIR: 5.59	5.59
Q1 2014 - Q4 2014 Rating SIR: 6.13	6.13
Q4 2013 - Q3 2014 Rating SIR: 6.18	6.18
Q1 2013 - Q4 2013 Rating SIR: 6.47	6.47
Q3 2012 - Q2 2013 Rating SIR: 7.30	7.30
Q1 2012 - Q4 2012 Rating SIR: 11.21	11.21
Q4 2011 - Q3 2012 Rating SIR: 12.54	12.54
Q2 2011 - Q1 2012 Rating SIR: 0.98	0.98
Q1 2011 - Q4 2011 Rating SIR: 6.68	6.68
Q4 2010 - Q3 2011 Rating SIR: 6.54	6.54
Q1 2010 - Q4 2010 Rating SIR: 8.18	8.18
Q4 2009 - Q3 2010 Rating SIR: 8.77	8.77
Q1 2009 - Q4 2009 Rating SIR: 11.02	11.02
Q3 2008 - Q2 2009 Rating SIR: 9.60	9.60
Q1 2008 - Q4 2008 Rating SIR: 7.10	7.10
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: 0.97	0.97
Q4 2018 - Q3 2019 Rating SIR: 1.05	1.05
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.96	0.96
Q4 2014 - Q3 2015 Rating SIR: 0.99	0.99
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.98	0.98
Q1 2013 - Q4 2013 Rating SIR: 1.18	1.18
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: 0.59	0.59
Q2 2011 - Q1 2012 Rating SIR: 1.23	1.23
Q1 2011 - Q4 2011 Rating SIR: 2.51	2.51
Q4 2010 - Q3 2011 Rating SIR: 0.57	0.57
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 1.21	1.21
Q1 2009 - Q4 2009 Rating SIR: 4.48	4.48
Q3 2008 - Q2 2009 Rating SIR: 0.22	0.22
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 1.76	1.76
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: 2.47	2.47
Q4 2019 - Q3 2020 Rating SIR: 0.46	0.46
Q4 2018 - Q3 2019 Rating SIR: 1.15	1.15
Q2 2018 - Q1 2019 Rating SIR: 1.03	1.03
Q1 2015 - Q4 2015 Rating SIR: 1.05	1.05
Q4 2014 - Q3 2015 Rating SIR: 1.52	1.52
Q1 2014 - Q4 2014 Rating SIR: 1.56	1.56
Q4 2013 - Q3 2014 Rating SIR: 1.12	1.12
Q1 2013 - Q4 2013 Rating SIR: 0.98	0.98
Q3 2012 - Q2 2013 Rating SIR: 0.71	0.71
Q1 2012 - Q4 2012 Rating SIR: 0.77	0.77
Q4 2011 - Q3 2012 Rating SIR: 0.95	0.95
Q2 2011 - Q1 2012 Rating SIR: 0.14	0.14
Q1 2011 - Q4 2011 Rating SIR: 3.19	3.19
Q4 2010 - Q3 2011 Rating SIR: 2.54	2.54
Q1 2010 - Q4 2010 Rating SIR: 3.26	3.26
Q4 2009 - Q3 2010 Rating SIR: 5.87	5.87
Q1 2009 - Q4 2009 Rating SIR: 7.01	7.01
Q3 2008 - Q2 2009 Rating SIR: 5.20	5.20
Q1 2008 - Q4 2008 Rating SIR: 5.90	5.90
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.35	0.35
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: 0.11	0.11
Q4 2018 - Q3 2019 Rating SIR: 0.24	0.24
Q2 2018 - Q1 2019 Rating SIR: 0.20	0.20
Q1 2015 - Q4 2015 Rating SIR: 0.58	0.58
Q4 2014 - Q3 2015 Rating SIR: 0.50	0.50
Q1 2014 - Q4 2014 Rating SIR: 0.54	0.54
Q4 2013 - Q3 2014 Rating SIR: 0.64	0.64
Q1 2013 - Q4 2013 Rating SIR: 0.26	0.26
Q3 2012 - Q2 2013 Rating SIR: 0.27	0.27
Q1 2012 - Q4 2012 Rating SIR: 0.27	0.27
Q4 2011 - Q3 2012 Rating SIR: 0.19	0.19
Q2 2011 - Q1 2012 Rating SIR: 0.02	0.02
Q1 2011 - Q4 2011 Rating SIR: 1.13	1.13
Q4 2010 - Q3 2011 Rating SIR: 0.31	0.31
Q1 2010 - Q4 2010 Rating SIR: 0.56	0.56
Q4 2009 - Q3 2010 Rating SIR: 1.83	1.83
Q1 2009 - Q4 2009 Rating SIR: 2.16	2.16
Q3 2008 - Q2 2009 Rating SIR: 0.80	0.80
Q1 2008 - Q4 2008 Rating SIR: 0.70	0.70
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.82	1.82
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: 2.46	2.46
Q4 2019 - Q3 2020 Rating SIR: 2.64	2.64
Q4 2018 - Q3 2019 Rating SIR: 3.09	3.09
Q2 2018 - Q1 2019 Rating SIR: 3.65	3.65
Q1 2015 - Q4 2015 Rating SIR: 4.22	4.22
Q4 2014 - Q3 2015 Rating SIR: 3.29	3.29
Q1 2014 - Q4 2014 Rating SIR: 3.04	3.04
Q4 2013 - Q3 2014 Rating SIR: 3.64	3.64
Q1 2013 - Q4 2013 Rating SIR: 4.22	4.22
Q3 2012 - Q2 2013 Rating SIR: 3.06	3.06
Q1 2012 - Q4 2012 Rating SIR: 3.33	3.33
Q4 2011 - Q3 2012 Rating SIR: 2.87	2.87
Q2 2011 - Q1 2012 Rating SIR: 3.62	3.62
Q1 2011 - Q4 2011 Rating SIR: 3.62	3.62
Q4 2010 - Q3 2011 Rating SIR: 2.69	2.69
Q1 2010 - Q4 2010 Rating SIR: 2.54	2.54
Q4 2009 - Q3 2010 Rating SIR: 2.90	2.90
Q1 2009 - Q4 2009 Rating SIR: 4.63	4.63
Q3 2008 - Q2 2009 Rating SIR: 0.58	0.58
Q1 2008 - Q4 2008 Rating SIR: 0.46	0.46
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 6.59	6.59
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: 7.73	7.73
Q4 2019 - Q3 2020 Rating SIR: 4.78	4.78
Q4 2018 - Q3 2019 Rating SIR: 3.80	3.80
Q2 2018 - Q1 2019 Rating SIR: 3.86	3.86
Q1 2015 - Q4 2015 Rating SIR: 8.06	8.06
Q4 2014 - Q3 2015 Rating SIR: 8.81	8.81
Q1 2014 - Q4 2014 Rating SIR: 9.10	9.10
Q4 2013 - Q3 2014 Rating SIR: 7.96	7.96
Q1 2013 - Q4 2013 Rating SIR: 10.62	10.62
Q3 2012 - Q2 2013 Rating SIR: 7.85	7.85
Q1 2012 - Q4 2012 Rating SIR: 6.41	6.41
Q4 2011 - Q3 2012 Rating SIR: 8.16	8.16
Q2 2011 - Q1 2012 Rating SIR: 10.72	10.72
Q1 2011 - Q4 2011 Rating SIR: 8.72	8.72
Q4 2010 - Q3 2011 Rating SIR: 10.82	10.82
Q1 2010 - Q4 2010 Rating SIR: 6.83	6.83
Q4 2009 - Q3 2010 Rating SIR: 10.19	10.19
Q1 2009 - Q4 2009 Rating SIR: 12.91	12.91
Q3 2008 - Q2 2009 Rating SIR: 0.69	0.69
Q1 2008 - Q4 2008 Rating SIR: 0.55	0.55
Postoperative Hip Fracture Q4 2021 - Q3 2022 Rating SIR: 0.05	0.05
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: 0.04	0.04
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.05	0.05
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: 0.00	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: 0.49	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: 0.44	0.44
Q4 2019 - Q3 2020 Rating SIR: 0.25	0.25
Q4 2018 - Q3 2019 Rating SIR: 0.14	0.14
Q2 2018 - Q1 2019 Rating SIR: 0.15	0.15
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.21	0.21
Q1 2014 - Q4 2014 Rating SIR: 0.69	0.69
Q4 2013 - Q3 2014 Rating SIR: 3.28	3.28
Q1 2013 - Q4 2013 Rating SIR: 3.53	3.53
Q3 2012 - Q2 2013 Rating SIR: 1.03	1.03
Q1 2012 - Q4 2012 Rating SIR: 1.90	1.90
Q4 2011 - Q3 2012 Rating SIR: 1.47	1.47
Q2 2011 - Q1 2012 Rating SIR: 1.70	1.70
Q1 2011 - Q4 2011 Rating SIR: 3.93	3.93
Q4 2010 - Q3 2011 Rating SIR: 1.04	1.04
Q1 2010 - Q4 2010 Rating SIR: 0.28	0.28
Q4 2009 - Q3 2010 Rating SIR: 21.38	21.38
Q1 2009 - Q4 2009 Rating SIR: 16.88	16.88
Q3 2008 - Q2 2009 Rating SIR: 0.79	0.79
Q1 2008 - Q4 2008 Rating SIR: 0.69	0.69
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 4.45	4.45
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: 4.13	4.13
Q4 2019 - Q3 2020 Rating SIR: 3.12	3.12
Q4 2018 - Q3 2019 Rating SIR: 3.44	3.44
Q2 2018 - Q1 2019 Rating SIR: 4.40	4.40
Q1 2015 - Q4 2015 Rating SIR: 7.56	7.56
Q4 2014 - Q3 2015 Rating SIR: 7.22	7.22
Q1 2014 - Q4 2014 Rating SIR: 5.65	5.65
Q4 2013 - Q3 2014 Rating SIR: 6.89	6.89
Q1 2013 - Q4 2013 Rating SIR: 2.77	2.77
Q3 2012 - Q2 2013 Rating SIR: 5.29	5.29
Q1 2012 - Q4 2012 Rating SIR: 7.81	7.81
Q4 2011 - Q3 2012 Rating SIR: 7.70	7.70
Q2 2011 - Q1 2012 Rating SIR: 6.56	6.56
Q1 2011 - Q4 2011 Rating SIR: 8.85	8.85
Q4 2010 - Q3 2011 Rating SIR: 12.95	12.95
Q1 2010 - Q4 2010 Rating SIR: 11.53	11.53
Q4 2009 - Q3 2010 Rating SIR: 6.99	6.99
Q1 2009 - Q4 2009 Rating SIR: 6.13	6.13
Q3 2008 - Q2 2009 Rating SIR: 1.52	1.52
Q1 2008 - Q4 2008 Rating SIR: 2.12	2.12
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 1.12	1.12
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: 0.89	0.89
Q4 2019 - Q3 2020 Rating SIR: 1.96	1.96
Q4 2018 - Q3 2019 Rating SIR: 0.56	0.56
Q2 2018 - Q1 2019 Rating SIR: 0.66	0.66
Q1 2015 - Q4 2015 Rating SIR: 0.73	0.73
Q4 2014 - Q3 2015 Rating SIR: 0.92	0.92
Q1 2014 - Q4 2014 Rating SIR: 0.93	0.93
Q4 2013 - Q3 2014 Rating SIR: 0.25	0.25
Q1 2013 - Q4 2013 Rating SIR: 0.27	0.27
Q3 2012 - Q2 2013 Rating SIR: 0.25	0.25
Q1 2012 - Q4 2012 Rating SIR: 0.77	0.77
Q4 2011 - Q3 2012 Rating SIR: 0.87	0.87
Q2 2011 - Q1 2012 Rating SIR: 0.31	0.31
Q1 2011 - Q4 2011 Rating SIR: 0.28	0.28
Q4 2010 - Q3 2011 Rating SIR: 0.30	0.30
Q1 2010 - Q4 2010 Rating SIR: 0.27	0.27
Q4 2009 - Q3 2010 Rating SIR: 0.27	0.27
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 3 infections, 142631 patient days Rating SIR: 0.41	3 infections, 142631 patient days	0.41
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 10 infections, 149189 patient days Rating SIR: 1.16	10 infections, 149189 patient days	1.16
Q1 2021 - Q4 2021 Result 12 infections, 141205 patient days Rating SIR: 1.38	12 infections, 141205 patient days	1.38
Q1 2020 - Q4 2020 Result 4 infections, 124857 patient days Rating SIR: 0.37	4 infections, 124857 patient days	0.37
Q1 2019 - Q4 2019 Result 5 infections, 127660 patient days Rating SIR: 0.52	5 infections, 127660 patient days	0.52
Q1 2018 - Q4 2018 Result 3 infections, 123188 patient days Rating SIR: 0.37	3 infections, 123188 patient days	0.37
Q1 2017 - Q4 2017 Result 4 infections, 115679 patient days Rating SIR: 0.38	4 infections, 115679 patient days	0.38
Q1 2016 - Q4 2016 Result 7 infections, 103909 patient days Rating SIR: 0.90	7 infections, 103909 patient days	0.90
Q1 2015 - Q4 2015 Result 11 infections, 102677 patient days Rating SIR: 1.17	11 infections, 102677 patient days	1.17
Q1 2014 - Q4 2014 Result 10 infections, 105909 patient days Rating SIR: 0.95	10 infections, 105909 patient days	0.95
Q1 2013 - Q4 2013 Result 8 infections, 104792 patient days Rating SIR: 1.10	8 infections, 104792 patient days	1.10
Q1 2012 - Q4 2012 Result 10 infections, 100550 patient days Rating SIR: 1.62	10 infections, 100550 patient days	1.62
Q1 2012 - Q2 2012 Result 6 infections, 49762 patient days Rating SIR: 1.21	6 infections, 49762 patient days	1.21
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 15 infections, 127690 patient days Rating SIR: 0.19	15 infections, 127690 patient days	0.19
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 10 infections, 135087 patient days Rating SIR: 0.13	10 infections, 135087 patient days	0.13
Q1 2021 - Q4 2021 Result 16 infections, 127230 patient days Rating SIR: 0.23	16 infections, 127230 patient days	0.23
Q1 2020 - Q4 2020 Result 20 infections, 111587 patient days Rating SIR: 0.37	20 infections, 111587 patient days	0.37
Q1 2019 - Q4 2019 Result 63 infections, 115683 patient days Rating SIR: 0.78	63 infections, 115683 patient days	0.78
Q1 2018 - Q4 2018 Result 69 infections, 109999 patient days Rating SIR: 0.80	69 infections, 109999 patient days	0.80
Q1 2017 - Q4 2017 Result 72 infections, 103758 patient days Rating SIR: 0.79	72 infections, 103758 patient days	0.79
Q1 2016 - Q4 2016 Result 106 infections, 103711 patient days Rating SIR: 1.22	106 infections, 103711 patient days	1.22
Q1 2015 - Q4 2015 Result 88 infections, 98959 patient days Rating SIR: 0.94	88 infections, 98959 patient days	0.94
Q1 2014 - Q4 2014 Result 78 infections, 98932 patient days Rating SIR: 0.82	78 infections, 98932 patient days	0.82
Q1 2013 - Q4 2013 Result 88 infections, 88843 patient days Rating SIR: 0.99	88 infections, 88843 patient days	0.99
Q1 2012 - Q4 2012 Result 94 infections, 86069 patient days Rating SIR: 1.17	94 infections, 86069 patient days	1.17

Adult CLABSI Measure	Result	SIR
Adult Surgical Cardiothoracic ICU Q1 2023 - Q4 2023 Result 1 infections, 2885 central-line days Rating SIR: 0.31	1 infections, 2885 central-line days	0.31
Description Central Line-associated Bloodstream Infection data in the Adult Surgical Cardiothoracic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 2 infections, 3380 central-line days Rating SIR: 0.52	2 infections, 3380 central-line days	0.52
Q1 2021 - Q4 2021 Result 1 infections, 3584 central-line days Rating SIR: 0.25	1 infections, 3584 central-line days	0.25
Q1 2019 - Q4 2019 Result 1 infections, 2824 central-line days Rating SIR: 0.31	1 infections, 2824 central-line days	0.31
Q1 2018 - Q4 2018 Result 2 infections, 2168 central-line days Rating SIR: 0.82	2 infections, 2168 central-line days	0.82
Q1 2017 - Q4 2017 Result 0 infections, 1488 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1488 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 1605 central-line days Rating SIR: 0.55	1 infections, 1605 central-line days	0.55
Q1 2015 - Q4 2015 Result 1 infections, 1779 central-line days Rating SIR: 0.40	1 infections, 1779 central-line days	0.40
Q1 2014 - Q4 2014 Result 4 infections, 2046 central-line days Rating SIR: 1.40	4 infections, 2046 central-line days	1.40
Q1 2013 - Q4 2013 Result 1 infections, 1950 central-line days Rating SIR: 0.37	1 infections, 1950 central-line days	0.37
Q1 2012 - Q4 2012 Result 3 infections, 2512 central-line days Rating SIR: 0.85	3 infections, 2512 central-line days	0.85
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 2138 central-line days Rating SIR: 0.42	1 infections, 2138 central-line days	0.42
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 5 infections, 2769 central-line days Rating SIR: 1.60	5 infections, 2769 central-line days	1.60
Q1 2021 - Q4 2021 Result 8 infections, 3620 central-line days Rating SIR: 1.96	8 infections, 3620 central-line days	1.96
Q1 2020 - Q4 2020 Result 1 infections, 2775 central-line days Rating SIR: 0.32	1 infections, 2775 central-line days	0.32
Q1 2019 - Q4 2019 Result 2 infections, 2155 central-line days Rating SIR: 0.82	2 infections, 2155 central-line days	0.82
Q1 2018 - Q4 2018 Result 1 infections, 2601 central-line days Rating SIR: 0.34	1 infections, 2601 central-line days	0.34
Q1 2017 - Q4 2017 Result 0 infections, 2066 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2066 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 2 infections, 2135 central-line days Rating SIR: 0.83	2 infections, 2135 central-line days	0.83
Q1 2015 - Q4 2015 Result 6 infections, 2509 central-line days Rating SIR: 1.14	6 infections, 2509 central-line days	1.14
Q1 2014 - Q4 2014 Result 6 infections, 2268 central-line days Rating SIR: 1.26	6 infections, 2268 central-line days	1.26
Q1 2013 - Q4 2013 Result 7 infections, 1845 central-line days Rating SIR: 1.68	7 infections, 1845 central-line days	1.68
Q1 2009 - Q4 2009 Result 3 infections, 2048 central-line days Rating SIR: 0.70	3 infections, 2048 central-line days	0.70
Q1 2009 - Q2 2009 Result 1 infections, 1042 central-line days Rating SIR: 0.96	1 infections, 1042 central-line days	0.96
Adult Medical/Surgical ICU, Second Unit Q1 2009 - Q4 2009 Result 1 infections, 2655 central-line days Rating SIR: 0.18	1 infections, 2655 central-line days	0.18
Description Central Line-associated Bloodstream Infection data in the Medical/Surgical ICU summarized as a Standardized Infection Ratio.
Adult Surgical ICU Q1 2012 - Q4 2012 Result 2 infections, 1895 central-line days Rating SIR: 0.46	2 infections, 1895 central-line days	0.46
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2011 - Q4 2011 Result 2 infections, 1785 central-line days Rating SIR: 0.49	2 infections, 1785 central-line days	0.49
Q1 2010 - Q4 2010 Result 5 infections, 2690 central-line days Rating SIR: 0.81	5 infections, 2690 central-line days	0.81

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2023 - Q4 2023 Result 0 infections, 78 central-line days Rating SIR: N/A	0 infections, 78 central-line days	N/A
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 2022 - Q4 2022 Result 0 infections, 123 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 123 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 141 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 141 central-line days ⁴²	N/A ⁴²
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
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 Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 0 central-line days Rating SIR: N/A	0 infections, 0 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, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2021 - Q4 2021 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2019 - Q4 2019 Result 0 infections, 0 central-line days ³³ Rating SIR: N/A ³³	0 infections, 0 central-line days ³³	N/A ³³
Q1 2018 - Q4 2018 Result 0 infections, 7 central-line days ³³ Rating SIR: N/A ³³	0 infections, 7 central-line days ³³	N/A ³³
Q1 2017 - Q4 2017 Result 0 infections, 2 central-line days ³³ Rating SIR: N/A ³³	0 infections, 2 central-line days ³³	N/A ³³
Q1 2016 - Q4 2016 Result 0 infections, 812 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 812 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 4 infections, 973 central-line days Rating SIR: 1.49	4 infections, 973 central-line days	1.49
Q1 2010 - Q2 2010 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
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 1 infections, 1184 central-line days Rating SIR: 0.61	1 infections, 1184 central-line days	0.61
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 0 infections, 998 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 998 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 2 infections, 1165 central-line days Rating SIR: 0.97	2 infections, 1165 central-line days	0.97
Q1 2020 - Q4 2020 Result 1 infections, 1079 central-line days Rating SIR: 0.67	1 infections, 1079 central-line days	0.67
Q1 2019 - Q4 2019 Result 0 infections, 1002 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1002 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 1 infections, 1126 central-line days Rating SIR: 0.54	1 infections, 1126 central-line days	0.54
Q1 2017 - Q4 2017 Result 3 infections, 1325 central-line days Rating SIR: 1.59	3 infections, 1325 central-line days	1.59
Q1 2014 - Q4 2014 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
Q1 2013 - Q4 2013 Result 8 infections, 1188 central-line days Rating SIR: 2.59	8 infections, 1188 central-line days	2.59
Q1 2012 - Q4 2012 Result 1 infections, 877 central-line days Rating SIR: 0.46	1 infections, 877 central-line days	0.46
Q1 2011 - Q4 2011 Result 1 infections, 862 central-line days Rating SIR: 0.46	1 infections, 862 central-line days	0.46
Q1 2010 - Q4 2010 Result 6 infections, 1282 central-line days Rating SIR: 1.75	6 infections, 1282 central-line days	1.75
Q1 2010 - Q2 2010 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

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 0 infections, 647 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 647 procedures ¹¹⁷	0.00 ¹¹⁷
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, 776 procedures Rating SIR: 0.00	0 infections, 776 procedures	0.00
Q1 2018 - Q4 2018 Result 1 infections, 685 procedures Rating SIR: 0.32	1 infections, 685 procedures	0.32
Q1 2017 - Q4 2017 Result 4 infections, 657 procedures Rating SIR: 1.54	4 infections, 657 procedures	1.54
Q1 2016 - Q4 2016 Result 2 infections, 584 procedures Rating SIR: 0.84	2 infections, 584 procedures	0.84
Q1 2015 - Q4 2015 Result 2 infections, 509 procedures Rating SIR: 0.60	2 infections, 509 procedures	0.60
Q1 2014 - Q4 2014 Result 2 infections, 470 procedures Rating SIR: 0.65	2 infections, 470 procedures	0.65
Q3 2013 - Q2 2014 Result 2 infections, 475 procedures Rating SIR: 0.63	2 infections, 475 procedures	0.63
Q3 2012 - Q2 2013 Result 1 infections, 462 procedures Rating SIR: 0.31	1 infections, 462 procedures	0.31
Q3 2011 - Q2 2012 Result 1 infections, 374 procedures Rating SIR: 0.47	1 infections, 374 procedures	0.47
Q3 2010 - Q2 2011 Result 0 infections, 386 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 386 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 3 infections, 173 procedures Rating SIR: 2.05	3 infections, 173 procedures	2.05
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, 215 procedures Rating SIR: 0.52	1 infections, 215 procedures	0.52
Q1 2018 - Q4 2018 Result 4 infections, 214 procedures Rating SIR: 2.02	4 infections, 214 procedures	2.02
Q1 2016 - Q4 2016 Result 5 infections, 208 procedures Rating SIR: 2.70	5 infections, 208 procedures	2.70
Q1 2015 - Q4 2015 Result 0 infections, 251 procedures Rating SIR: 0.00	0 infections, 251 procedures	0.00
Q1 2014 - Q4 2014 Result 1 infections, 248 procedures Rating SIR: 0.32	1 infections, 248 procedures	0.32
Q3 2013 - Q2 2014 Result 2 infections, 216 procedures Rating SIR: 0.72	2 infections, 216 procedures	0.72
Q3 2012 - Q2 2013 Result 2 infections, 231 procedures Rating SIR: 0.69	2 infections, 231 procedures	0.69
Q3 2011 - Q2 2012 Result 5 infections, 282 procedures Rating SIR: 1.37	5 infections, 282 procedures	1.37
Q3 2010 - Q2 2011 Result 3 infections, 248 procedures Rating SIR: 0.91	3 infections, 248 procedures	0.91