Springfield Memorial 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
32	Complete Reporting: Unit Operational Limited Time
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
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
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
32	Complete Reporting: Unit Operational Limited Time
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
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
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

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

NICU CLABSI Measure	Result	SIR
Level III Neonatal 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 data in the Level III Neonatal 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 ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2015 - Q4 2015 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 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 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 2012 - Q4 2012 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 2011 - Q4 2011 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 2010 - Q4 2010 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2010 - Q2 2010 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹

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
32	Complete Reporting: Unit Operational Limited Time
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
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
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 89.00 %	89.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 85.00 %	85.00 %
Q4 2020 - Q1 2021 Result 92.00 %	92.00 %
Q4 2019 - Q1 2020 Result N/A %	N/A %
Q4 2018 - Q1 2019 Result 92.00 %	92.00 %
Q4 2017 - Q1 2018 Result 90.00 %	90.00 %

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
32	Complete Reporting: Unit Operational Limited Time
38	Exempt: No Licensed PICU Beds
39	Exempt: No Licensed NICU Beds
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
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: 4.59	4.59
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: 4.67	4.67
Q4 2019 - Q3 2020 Rating SIR: 3.22	3.22
Q4 2018 - Q3 2019 Rating SIR: 2.90	2.90
Q2 2018 - Q1 2019 Rating SIR: 3.61	3.61
Q1 2015 - Q4 2015 Rating SIR: 2.90	2.90
Q4 2014 - Q3 2015 Rating SIR: 4.04	4.04
Q1 2014 - Q4 2014 Rating SIR: 3.99	3.99
Q4 2013 - Q3 2014 Rating SIR: 3.18	3.18
Q1 2013 - Q4 2013 Rating SIR: 2.01	2.01
Q3 2012 - Q2 2013 Rating SIR: 2.70	2.70
Q1 2012 - Q4 2012 Rating SIR: 3.55	3.55
Q4 2011 - Q3 2012 Rating SIR: 3.07	3.07
Q2 2011 - Q1 2012 Rating SIR: 0.31	0.31
Q1 2011 - Q4 2011 Rating SIR: 3.53	3.53
Q4 2010 - Q3 2011 Rating SIR: 3.58	3.58
Q1 2010 - Q4 2010 Rating SIR: 3.73	3.73
Q4 2009 - Q3 2010 Rating SIR: 3.92	3.92
Q1 2009 - Q4 2009 Rating SIR: 4.46	4.46
Q3 2008 - Q2 2009 Rating SIR: 4.80	4.80
Q1 2008 - Q4 2008 Rating SIR: 4.80	4.80
Wound Complications in Abdominal Wall Surgery Q4 2021 - Q3 2022 Rating SIR: 2.90	2.90
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: 2.93	2.93
Q4 2019 - Q3 2020 Rating SIR: 1.72	1.72
Q4 2018 - Q3 2019 Rating SIR: 0.94	0.94
Q2 2018 - Q1 2019 Rating SIR: 1.43	1.43
Q1 2015 - Q4 2015 Rating SIR: 3.71	3.71
Q4 2014 - Q3 2015 Rating SIR: 4.51	4.51
Q1 2014 - Q4 2014 Rating SIR: 5.30	5.30
Q4 2013 - Q3 2014 Rating SIR: 5.81	5.81
Q1 2013 - Q4 2013 Rating SIR: 1.70	1.70
Q3 2012 - Q2 2013 Rating SIR: 2.64	2.64
Q1 2012 - Q4 2012 Rating SIR: 2.41	2.41
Q4 2011 - Q3 2012 Rating SIR: 1.68	1.68
Q2 2011 - Q1 2012 Rating SIR: 0.75	0.75
Q1 2011 - Q4 2011 Rating SIR: 1.58	1.58
Q4 2010 - Q3 2011 Rating SIR: 0.71	0.71
Q1 2010 - Q4 2010 Rating SIR: 2.51	2.51
Q4 2009 - Q3 2010 Rating SIR: 3.63	3.63
Q1 2009 - Q4 2009 Rating SIR: 3.10	3.10
Q3 2008 - Q2 2009 Rating SIR: 0.53	0.53
Q1 2008 - Q4 2008 Rating SIR: 0.31	0.31
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 1.18	1.18
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: 0.86	0.86
Q4 2019 - Q3 2020 Rating SIR: 0.82	0.82
Q4 2018 - Q3 2019 Rating SIR: 1.03	1.03
Q2 2018 - Q1 2019 Rating SIR: 1.07	1.07
Q1 2015 - Q4 2015 Rating SIR: 1.43	1.43
Q4 2014 - Q3 2015 Rating SIR: 1.63	1.63
Q1 2014 - Q4 2014 Rating SIR: 1.47	1.47
Q4 2013 - Q3 2014 Rating SIR: 1.14	1.14
Q1 2013 - Q4 2013 Rating SIR: 0.98	0.98
Q3 2012 - Q2 2013 Rating SIR: 2.48	2.48
Q1 2012 - Q4 2012 Rating SIR: 3.52	3.52
Q4 2011 - Q3 2012 Rating SIR: 3.22	3.22
Q2 2011 - Q1 2012 Rating SIR: 0.27	0.27
Q1 2011 - Q4 2011 Rating SIR: 4.81	4.81
Q4 2010 - Q3 2011 Rating SIR: 3.69	3.69
Q1 2010 - Q4 2010 Rating SIR: 3.24	3.24
Q4 2009 - Q3 2010 Rating SIR: 5.38	5.38
Q1 2009 - Q4 2009 Rating SIR: 6.93	6.93
Q3 2008 - Q2 2009 Rating SIR: 4.30	4.30
Q1 2008 - Q4 2008 Rating SIR: 3.80	3.80
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.07	0.07
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: 0.13	0.13
Q4 2019 - Q3 2020 Rating SIR: 0.18	0.18
Q4 2018 - Q3 2019 Rating SIR: 0.22	0.22
Q2 2018 - Q1 2019 Rating SIR: 0.16	0.16
Q1 2015 - Q4 2015 Rating SIR: 0.20	0.20
Q4 2014 - Q3 2015 Rating SIR: 0.28	0.28
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: 0.29	0.29
Q3 2012 - Q2 2013 Rating SIR: 0.47	0.47
Q1 2012 - Q4 2012 Rating SIR: 0.60	0.60
Q4 2011 - Q3 2012 Rating SIR: 0.46	0.46
Q2 2011 - Q1 2012 Rating SIR: 0.04	0.04
Q1 2011 - Q4 2011 Rating SIR: 2.09	2.09
Q4 2010 - Q3 2011 Rating SIR: 0.28	0.28
Q1 2010 - Q4 2010 Rating SIR: 0.28	0.28
Q4 2009 - Q3 2010 Rating SIR: 0.73	0.73
Q1 2009 - Q4 2009 Rating SIR: 0.92	0.92
Q3 2008 - Q2 2009 Rating SIR: 0.50	0.50
Q1 2008 - Q4 2008 Rating SIR: 0.40	0.40
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.03	1.03
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: 2.89	2.89
Q4 2019 - Q3 2020 Rating SIR: 2.07	2.07
Q4 2018 - Q3 2019 Rating SIR: 1.92	1.92
Q2 2018 - Q1 2019 Rating SIR: 2.15	2.15
Q1 2015 - Q4 2015 Rating SIR: 2.83	2.83
Q4 2014 - Q3 2015 Rating SIR: 3.83	3.83
Q1 2014 - Q4 2014 Rating SIR: 6.13	6.13
Q4 2013 - Q3 2014 Rating SIR: 5.56	5.56
Q1 2013 - Q4 2013 Rating SIR: 3.41	3.41
Q3 2012 - Q2 2013 Rating SIR: 4.71	4.71
Q1 2012 - Q4 2012 Rating SIR: 7.16	7.16
Q4 2011 - Q3 2012 Rating SIR: 3.03	3.03
Q2 2011 - Q1 2012 Rating SIR: 2.32	2.32
Q1 2011 - Q4 2011 Rating SIR: 2.33	2.33
Q4 2010 - Q3 2011 Rating SIR: 1.83	1.83
Q1 2010 - Q4 2010 Rating SIR: 2.49	2.49
Q4 2009 - Q3 2010 Rating SIR: 2.81	2.81
Q1 2009 - Q4 2009 Rating SIR: 3.97	3.97
Q3 2008 - Q2 2009 Rating SIR: 0.28	0.28
Q1 2008 - Q4 2008 Rating SIR: 0.14	0.14
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 5.95	5.95
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: 4.07	4.07
Q4 2019 - Q3 2020 Rating SIR: 6.49	6.49
Q4 2018 - Q3 2019 Rating SIR: 4.96	4.96
Q2 2018 - Q1 2019 Rating SIR: 6.99	6.99
Q1 2015 - Q4 2015 Rating SIR: 7.74	7.74
Q4 2014 - Q3 2015 Rating SIR: 7.55	7.55
Q1 2014 - Q4 2014 Rating SIR: 7.05	7.05
Q4 2013 - Q3 2014 Rating SIR: 7.64	7.64
Q1 2013 - Q4 2013 Rating SIR: 7.59	7.59
Q3 2012 - Q2 2013 Rating SIR: 6.92	6.92
Q1 2012 - Q4 2012 Rating SIR: 7.58	7.58
Q4 2011 - Q3 2012 Rating SIR: 9.70	9.70
Q2 2011 - Q1 2012 Rating SIR: 7.27	7.27
Q1 2011 - Q4 2011 Rating SIR: 7.72	7.72
Q4 2010 - Q3 2011 Rating SIR: 8.46	8.46
Q1 2010 - Q4 2010 Rating SIR: 9.79	9.79
Q4 2009 - Q3 2010 Rating SIR: 15.16	15.16
Q1 2009 - Q4 2009 Rating SIR: 15.39	15.39
Q3 2008 - Q2 2009 Rating SIR: 0.96	0.96
Q1 2008 - Q4 2008 Rating SIR: 0.91	0.91
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: 0.05	0.05
Q4 2018 - Q3 2019 Rating SIR: 0.06	0.06
Q2 2018 - Q1 2019 Rating SIR: 0.12	0.12
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: 0.51	0.51
Q4 2011 - Q3 2012 Rating SIR: 0.50	0.50
Q2 2011 - Q1 2012 Rating SIR: 0.02	0.02
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 1.01	1.01
Description The number of cases of pressure ulcer per 1,000 discharges with a length of stay greater than 4 days (PSI 03). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 1.00	1.00
Q4 2019 - Q3 2020 Rating SIR: 0.31	0.31
Q4 2018 - Q3 2019 Rating SIR: 0.65	0.65
Q2 2018 - Q1 2019 Rating SIR: 0.50	0.50
Q1 2015 - Q4 2015 Rating SIR: 0.55	0.55
Q4 2014 - Q3 2015 Rating SIR: 0.64	0.64
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.20	0.20
Q1 2013 - Q4 2013 Rating SIR: 0.20	0.20
Q3 2012 - Q2 2013 Rating SIR: 0.20	0.20
Q1 2012 - Q4 2012 Rating SIR: 0.40	0.40
Q4 2011 - Q3 2012 Rating SIR: 0.33	0.33
Q2 2011 - Q1 2012 Rating SIR: 0.18	0.18
Q1 2011 - Q4 2011 Rating SIR: 0.53	0.53
Q4 2010 - Q3 2011 Rating SIR: 0.18	0.18
Q1 2010 - Q4 2010 Rating SIR: 0.72	0.72
Q4 2009 - Q3 2010 Rating SIR: 1.85	1.85
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.12	0.12
Q1 2008 - Q4 2008 Rating SIR: 0.20	0.20
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 4.67	4.67
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: 4.05	4.05
Q4 2019 - Q3 2020 Rating SIR: 5.64	5.64
Q4 2018 - Q3 2019 Rating SIR: 3.74	3.74
Q2 2018 - Q1 2019 Rating SIR: 3.96	3.96
Q1 2015 - Q4 2015 Rating SIR: 11.67	11.67
Q4 2014 - Q3 2015 Rating SIR: 10.04	10.04
Q1 2014 - Q4 2014 Rating SIR: 8.90	8.90
Q4 2013 - Q3 2014 Rating SIR: 6.18	6.18
Q1 2013 - Q4 2013 Rating SIR: 6.78	6.78
Q3 2012 - Q2 2013 Rating SIR: 7.83	7.83
Q1 2012 - Q4 2012 Rating SIR: 14.11	14.11
Q4 2011 - Q3 2012 Rating SIR: 15.41	15.41
Q2 2011 - Q1 2012 Rating SIR: 9.03	9.03
Q1 2011 - Q4 2011 Rating SIR: 11.57	11.57
Q4 2010 - Q3 2011 Rating SIR: 8.51	8.51
Q1 2010 - Q4 2010 Rating SIR: 11.89	11.89
Q4 2009 - Q3 2010 Rating SIR: 14.59	14.59
Q1 2009 - Q4 2009 Rating SIR: 13.67	13.67
Q3 2008 - Q2 2009 Rating SIR: 1.17	1.17
Q1 2008 - Q4 2008 Rating SIR: 1.44	1.44
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 1.32	1.32
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: 0.30	0.30
Q4 2019 - Q3 2020 Rating SIR: 0.81	0.81
Q4 2018 - Q3 2019 Rating SIR: 1.57	1.57
Q2 2018 - Q1 2019 Rating SIR: 0.46	0.46
Q1 2015 - Q4 2015 Rating SIR: 1.25	1.25
Q4 2014 - Q3 2015 Rating SIR: 1.20	1.20
Q1 2014 - Q4 2014 Rating SIR: 0.85	0.85
Q4 2013 - Q3 2014 Rating SIR: 0.90	0.90
Q1 2013 - Q4 2013 Rating SIR: 0.95	0.95
Q3 2012 - Q2 2013 Rating SIR: 1.21	1.21
Q1 2012 - Q4 2012 Rating SIR: 1.25	1.25
Q4 2011 - Q3 2012 Rating SIR: 1.40	1.40
Q2 2011 - Q1 2012 Rating SIR: 0.87	0.87
Q1 2011 - Q4 2011 Rating SIR: 0.33	0.33
Q4 2010 - Q3 2011 Rating SIR: 0.88	0.88
Q1 2010 - Q4 2010 Rating SIR: 0.70	0.70
Q4 2009 - Q3 2010 Rating SIR: 0.17	0.17
Q1 2009 - Q4 2009 Rating SIR: 0.65	0.65
Q3 2008 - Q2 2009 Rating SIR: 0.08	0.08
Q1 2008 - Q4 2008 Rating SIR: 0.07	0.07

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 4 infections, 119152 patient days Rating SIR: 0.36	4 infections, 119152 patient days	0.36
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 8 infections, 122908 patient days Rating SIR: 0.65	8 infections, 122908 patient days	0.65
Q1 2021 - Q4 2021 Result 8 infections, 117035 patient days Rating SIR: 0.81	8 infections, 117035 patient days	0.81
Q1 2020 - Q4 2020 Result 8 infections, 107356 patient days Rating SIR: 0.69	8 infections, 107356 patient days	0.69
Q1 2019 - Q4 2019 Result 11 infections, 114179 patient days Rating SIR: 0.96	11 infections, 114179 patient days	0.96
Q1 2018 - Q4 2018 Result 7 infections, 111906 patient days Rating SIR: 0.58	7 infections, 111906 patient days	0.58
Q1 2017 - Q4 2017 Result 11 infections, 112140 patient days Rating SIR: 1.17	11 infections, 112140 patient days	1.17
Q1 2016 - Q4 2016 Result 8 infections, 115036 patient days Rating SIR: 0.77	8 infections, 115036 patient days	0.77
Q1 2015 - Q4 2015 Result 7 infections, 109262 patient days Rating SIR: 0.65	7 infections, 109262 patient days	0.65
Q1 2014 - Q4 2014 Result 8 infections, 123943 patient days Rating SIR: 0.54	8 infections, 123943 patient days	0.54
Q1 2013 - Q4 2013 Result 8 infections, 119725 patient days Rating SIR: 0.46	8 infections, 119725 patient days	0.46
Q1 2012 - Q4 2012 Result 10 infections, 129452 patient days Rating SIR: 0.54	10 infections, 129452 patient days	0.54
Q1 2012 - Q2 2012 Result 7 infections, 65303 patient days Rating SIR: 1.07	7 infections, 65303 patient days	1.07
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 34 infections, 117217 patient days Rating SIR: 0.45	34 infections, 117217 patient days	0.45
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 39 infections, 121002 patient days Rating SIR: 0.44	39 infections, 121002 patient days	0.44
Q1 2021 - Q4 2021 Result 45 infections, 115024 patient days Rating SIR: 0.57	45 infections, 115024 patient days	0.57
Q1 2020 - Q4 2020 Result 51 infections, 104928 patient days Rating SIR: 0.58	51 infections, 104928 patient days	0.58
Q1 2019 - Q4 2019 Result 133 infections, 111432 patient days Rating SIR: 1.01	133 infections, 111432 patient days	1.01
Q1 2018 - Q4 2018 Result 115 infections, 109049 patient days Rating SIR: 0.94	115 infections, 109049 patient days	0.94
Q1 2017 - Q4 2017 Result 123 infections, 109190 patient days Rating SIR: 0.96	123 infections, 109190 patient days	0.96
Q1 2016 - Q4 2016 Result 99 infections, 112119 patient days Rating SIR: 0.88	99 infections, 112119 patient days	0.88
Q1 2015 - Q4 2015 Result 111 infections, 106379 patient days Rating SIR: 1.10	111 infections, 106379 patient days	1.10
Q1 2014 - Q4 2014 Result 110 infections, 121132 patient days Rating SIR: 1.06	110 infections, 121132 patient days	1.06
Q1 2013 - Q4 2013 Result 98 infections, 116858 patient days Rating SIR: 0.81	98 infections, 116858 patient days	0.81
Q1 2012 - Q4 2012 Result 109 infections, 128460 patient days Rating SIR: 0.77	109 infections, 128460 patient days	0.77

Adult CLABSI Measure	Result	SIR
Adult Surgical Cardiothoracic ICU Q1 2023 - Q4 2023 Result 2 infections, 1326 central-line days Rating SIR: 1.34	2 infections, 1326 central-line days	1.34
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, 1383 central-line days Rating SIR: 1.28	2 infections, 1383 central-line days	1.28
Q1 2021 - Q4 2021 Result 3 infections, 1260 central-line days Rating SIR: 2.11	3 infections, 1260 central-line days	2.11
Q1 2020 - Q4 2020 Result 2 infections, 1299 central-line days Rating SIR: 1.37	2 infections, 1299 central-line days	1.37
Q1 2019 - Q4 2019 Result 0 infections, 1077 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1077 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 1 infections, 1244 central-line days Rating SIR: 0.71	1 infections, 1244 central-line days	0.71
Q1 2017 - Q4 2017 Result 1 infections, 1431 central-line days Rating SIR: 0.62	1 infections, 1431 central-line days	0.62
Q1 2016 - Q4 2016 Result 2 infections, 1354 central-line days Rating SIR: 1.31	2 infections, 1354 central-line days	1.31
Q1 2015 - Q4 2015 Result 2 infections, 1474 central-line days Rating SIR: 0.97	2 infections, 1474 central-line days	0.97
Q1 2014 - Q4 2014 Result 1 infections, 1306 central-line days Rating SIR: 0.55	1 infections, 1306 central-line days	0.55
Q1 2013 - Q4 2013 Result 1 infections, 1457 central-line days Rating SIR: 0.49	1 infections, 1457 central-line days	0.49
Q1 2012 - Q4 2012 Result 0 infections, 1541 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 1541 central-line days ⁴³	0.00 ⁴³
Adult Medical/Surgical ICU Q1 2020 - Q4 2020 Result 1 infections, 380 central-line days Rating SIR: N/A	1 infections, 380 central-line days	N/A
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 2019 - Q4 2019 Result 1 infections, 554 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 554 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 1 infections, 680 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 680 central-line days ⁴⁴	N/A ⁴⁴
Q1 2017 - Q4 2017 Result 4 infections, 1018 central-line days Rating SIR: 3.48	4 infections, 1018 central-line days	3.48
Q1 2016 - Q4 2016 Result 4 infections, 1102 central-line days Rating SIR: 3.22	4 infections, 1102 central-line days	3.22
Q1 2015 - Q4 2015 Result 7 infections, 1175 central-line days Rating SIR: 2.84	7 infections, 1175 central-line days	2.84
Q1 2014 - Q4 2014 Result 5 infections, 1215 central-line days Rating SIR: 1.96	5 infections, 1215 central-line days	1.96
Q1 2013 - Q4 2013 Result 1 infections, 953 central-line days Rating SIR: 0.50	1 infections, 953 central-line days	0.50
Q1 2012 - Q4 2012 Result 1 infections, 1294 central-line days Rating SIR: 0.37	1 infections, 1294 central-line days	0.37
Q1 2011 - Q4 2011 Result 4 infections, 1213 central-line days Rating SIR: 1.57	4 infections, 1213 central-line days	1.57
Q1 2010 - Q4 2010 Result 1 infections, 2962 central-line days Rating SIR: 0.16	1 infections, 2962 central-line days	0.16
Q1 2009 - Q4 2009 Result 4 infections, 2838 central-line days Rating SIR: 0.67	4 infections, 2838 central-line days	0.67
Q1 2009 - Q2 2009 Result 3 infections, 1507 central-line days Rating SIR: 1.99	3 infections, 1507 central-line days	1.99
Adult Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 1027 central-line days Rating SIR: 0.86	1 infections, 1027 central-line days	0.86
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 6 infections, 1319 central-line days Rating SIR: 4.03	6 infections, 1319 central-line days	4.03
Q1 2021 - Q4 2021 Result 2 infections, 1137 central-line days Rating SIR: 1.56	2 infections, 1137 central-line days	1.56
Q1 2020 - Q4 2020 Result 3 infections, 1535 central-line days Rating SIR: 1.73	3 infections, 1535 central-line days	1.73
Q1 2019 - Q4 2019 Result 1 infections, 1271 central-line days Rating SIR: 0.70	1 infections, 1271 central-line days	0.70
Q1 2018 - Q4 2018 Result 4 infections, 1494 central-line days Rating SIR: 2.37	4 infections, 1494 central-line days	2.37
Q1 2017 - Q4 2017 Result 1 infections, 1885 central-line days Rating SIR: 0.47	1 infections, 1885 central-line days	0.47
Q1 2016 - Q4 2016 Result 2 infections, 2055 central-line days Rating SIR: 0.86	2 infections, 2055 central-line days	0.86
Q1 2015 - Q4 2015 Result 4 infections, 2380 central-line days Rating SIR: 0.73	4 infections, 2380 central-line days	0.73
Q1 2014 - Q4 2014 Result 2 infections, 2148 central-line days Rating SIR: 0.41	2 infections, 2148 central-line days	0.41
Q1 2013 - Q4 2013 Result 0 infections, 2318 central-line days Rating SIR: 0.00	0 infections, 2318 central-line days	0.00
Q1 2012 - Q4 2012 Result 3 infections, 2639 central-line days Rating SIR: 0.49	3 infections, 2639 central-line days	0.49
Q1 2011 - Q4 2011 Result 2 infections, 2892 central-line days Rating SIR: 0.30	2 infections, 2892 central-line days	0.30
Q1 2010 - Q4 2010 Result 4 infections, 2941 central-line days Rating SIR: 0.59	4 infections, 2941 central-line days	0.59
Q1 2009 - Q4 2009 Result 3 infections, 2420 central-line days Rating SIR: 0.54	3 infections, 2420 central-line days	0.54
Q1 2009 - Q2 2009 Result 1 infections, 1129 central-line days Rating SIR: 0.89	1 infections, 1129 central-line days	0.89
Adult Surgical ICU, Second Unit Q1 2023 - Q4 2023 Result 4 infections, 1322 central-line days Rating SIR: 2.68	4 infections, 1322 central-line days	2.68
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 6 infections, 1602 central-line days Rating SIR: 3.32	6 infections, 1602 central-line days	3.32
Q1 2021 - Q4 2021 Result 3 infections, 1418 central-line days Rating SIR: 1.88	3 infections, 1418 central-line days	1.88
Adult Medical ICU Q1 2023 - Q4 2023 Result 1 infections, 1243 central-line days Rating SIR: 0.71	1 infections, 1243 central-line days	0.71
Description Central Line-associated Bloodstream Infection data in the Adult Medical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 9 infections, 1483 central-line days Rating SIR: 5.38	9 infections, 1483 central-line days	5.38
Q1 2021 - Q4 2021 Result 6 infections, 1951 central-line days Rating SIR: 2.73	6 infections, 1951 central-line days	2.73
Q1 2020 - Q4 2020 Result 7 infections, 1847 central-line days Rating SIR: 3.36	7 infections, 1847 central-line days	3.36
Q1 2019 - Q4 2019 Result 1 infections, 1539 central-line days Rating SIR: 0.58	1 infections, 1539 central-line days	0.58
Q1 2018 - Q4 2018 Result 2 infections, 1553 central-line days Rating SIR: 1.14	2 infections, 1553 central-line days	1.14
Q1 2017 - Q4 2017 Result 2 infections, 1778 central-line days Rating SIR: 1.00	2 infections, 1778 central-line days	1.00
Q1 2016 - Q4 2016 Result 4 infections, 2168 central-line days Rating SIR: 1.64	4 infections, 2168 central-line days	1.64
Q1 2015 - Q4 2015 Result 1 infections, 2195 central-line days Rating SIR: 0.18	1 infections, 2195 central-line days	0.18
Q1 2014 - Q4 2014 Result 4 infections, 2220 central-line days Rating SIR: 0.69	4 infections, 2220 central-line days	0.69
Q1 2013 - Q4 2013 Result 2 infections, 2275 central-line days Rating SIR: 0.34	2 infections, 2275 central-line days	0.34
Q1 2012 - Q4 2012 Result 2 infections, 2780 central-line days Rating SIR: 0.28	2 infections, 2780 central-line days	0.28
Q1 2011 - Q4 2011 Result 2 infections, 1946 central-line days ³² Rating SIR: 0.40 ³²	2 infections, 1946 central-line days ³²	0.40 ³²

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 4 infections, 521 procedures Rating SIR: 2.11	4 infections, 521 procedures	2.11
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 3 infections, 762 procedures Rating SIR: 1.04	3 infections, 762 procedures	1.04
Q1 2018 - Q4 2018 Result 6 infections, 833 procedures Rating SIR: 1.99	6 infections, 833 procedures	1.99
Q1 2017 - Q4 2017 Result 3 infections, 844 procedures Rating SIR: 0.96	3 infections, 844 procedures	0.96
Q1 2016 - Q4 2016 Result 3 infections, 889 procedures Rating SIR: 0.95	3 infections, 889 procedures	0.95
Q1 2015 - Q4 2015 Result 4 infections, 826 procedures Rating SIR: 0.75	4 infections, 826 procedures	0.75
Q1 2014 - Q4 2014 Result 1 infections, 799 procedures Rating SIR: 0.18	1 infections, 799 procedures	0.18
Q3 2013 - Q2 2014 Result 4 infections, 797 procedures Rating SIR: 0.76	4 infections, 797 procedures	0.76
Q3 2012 - Q2 2013 Result 5 infections, 821 procedures Rating SIR: 0.90	5 infections, 821 procedures	0.90
Q3 2011 - Q2 2012 Result 6 infections, 887 procedures Rating SIR: 0.93	6 infections, 887 procedures	0.93
Q3 2010 - Q2 2011 Result 6 infections, 955 procedures Rating SIR: 0.90	6 infections, 955 procedures	0.90
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 7 infections, 213 procedures Rating SIR: 5.04	7 infections, 213 procedures	5.04
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, 231 procedures Rating SIR: 0.58	1 infections, 231 procedures	0.58
Q1 2018 - Q4 2018 Result 2 infections, 326 procedures Rating SIR: 0.75	2 infections, 326 procedures	0.75
Q1 2016 - Q4 2016 Result 3 infections, 338 procedures Rating SIR: 1.12	3 infections, 338 procedures	1.12
Q1 2015 - Q4 2015 Result 4 infections, 303 procedures Rating SIR: 1.09	4 infections, 303 procedures	1.09
Q1 2014 - Q4 2014 Result 2 infections, 201 procedures Rating SIR: 0.79	2 infections, 201 procedures	0.79
Q3 2013 - Q2 2014 Result 3 infections, 195 procedures Rating SIR: 1.19	3 infections, 195 procedures	1.19
Q3 2012 - Q2 2013 Result 2 infections, 239 procedures Rating SIR: 0.66	2 infections, 239 procedures	0.66
Q3 2011 - Q2 2012 Result 0 infections, 239 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 239 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 1 infections, 232 procedures Rating SIR: 0.31	1 infections, 232 procedures	0.31