Endeavor Elmhurst 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
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
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
115	Complete Reporting: Results based on 6 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
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
33	Complete Reporting: 50 or Less Central Line Days
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
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
115	Complete Reporting: Results based on 6 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
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
33	Complete Reporting: 50 or Less Central Line Days
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
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
115	Complete Reporting: Results based on 6 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
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 96.00 %	96.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 94.00 %	94.00 %
Q4 2020 - Q1 2021 Result 99.00 %	99.00 %
Q4 2019 - Q1 2020 Result N/A %	N/A %
Q4 2018 - Q1 2019 Result 98.00 %	98.00 %
Q4 2017 - Q1 2018 Result 97.00 %	97.00 %

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
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
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
115	Complete Reporting: Results based on 6 months reporting due to statistical modelling exclusion criteria
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
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: 4.27	4.27
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: 7.06	7.06
Q4 2019 - Q3 2020 Rating SIR: 3.97	3.97
Q4 2018 - Q3 2019 Rating SIR: 3.81	3.81
Q2 2018 - Q1 2019 Rating SIR: 4.65	4.65
Q1 2015 - Q4 2015 Rating SIR: 6.30	6.30
Q4 2014 - Q3 2015 Rating SIR: 5.03	5.03
Q1 2014 - Q4 2014 Rating SIR: 3.88	3.88
Q4 2013 - Q3 2014 Rating SIR: 4.37	4.37
Q1 2013 - Q4 2013 Rating SIR: 4.20	4.20
Q3 2012 - Q2 2013 Rating SIR: 7.13	7.13
Q1 2012 - Q4 2012 Rating SIR: 8.43	8.43
Q4 2011 - Q3 2012 Rating SIR: 6.22	6.22
Q2 2011 - Q1 2012 Rating SIR: 0.48	0.48
Q1 2011 - Q4 2011 Rating SIR: 4.38	4.38
Q4 2010 - Q3 2011 Rating SIR: 4.58	4.58
Q1 2010 - Q4 2010 Rating SIR: 3.64	3.64
Q4 2009 - Q3 2010 Rating SIR: 2.87	2.87
Q1 2009 - Q4 2009 Rating SIR: 5.40	5.40
Q3 2008 - Q2 2009 Rating SIR: 8.00	8.00
Q1 2008 - Q4 2008 Rating SIR: 9.00	9.00
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: 1.07	1.07
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: 3.08	3.08
Q3 2012 - Q2 2013 Rating SIR: 3.00	3.00
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
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 0.34	0.34
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: 1.12	1.12
Q4 2019 - Q3 2020 Rating SIR: 0.37	0.37
Q4 2018 - Q3 2019 Rating SIR: 0.39	0.39
Q2 2018 - Q1 2019 Rating SIR: 1.27	1.27
Q1 2015 - Q4 2015 Rating SIR: 0.59	0.59
Q4 2014 - Q3 2015 Rating SIR: 1.41	1.41
Q1 2014 - Q4 2014 Rating SIR: 1.48	1.48
Q4 2013 - Q3 2014 Rating SIR: 1.12	1.12
Q1 2013 - Q4 2013 Rating SIR: 1.30	1.30
Q3 2012 - Q2 2013 Rating SIR: 1.12	1.12
Q1 2012 - Q4 2012 Rating SIR: 1.00	1.00
Q4 2011 - Q3 2012 Rating SIR: 1.05	1.05
Q2 2011 - Q1 2012 Rating SIR: 0.17	0.17
Q1 2011 - Q4 2011 Rating SIR: 2.72	2.72
Q4 2010 - Q3 2011 Rating SIR: 1.63	1.63
Q1 2010 - Q4 2010 Rating SIR: 1.75	1.75
Q4 2009 - Q3 2010 Rating SIR: 2.93	2.93
Q1 2009 - Q4 2009 Rating SIR: 1.70	1.70
Q3 2008 - Q2 2009 Rating SIR: 1.20	1.20
Q1 2008 - Q4 2008 Rating SIR: 1.90	1.90
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.28	0.28
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: 0.21	0.21
Q4 2019 - Q3 2020 Rating SIR: 0.07	0.07
Q4 2018 - Q3 2019 Rating SIR: 0.07	0.07
Q2 2018 - Q1 2019 Rating SIR: 0.07	0.07
Q1 2015 - Q4 2015 Rating SIR: 0.36	0.36
Q4 2014 - Q3 2015 Rating SIR: 0.21	0.21
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.11	0.11
Q1 2013 - Q4 2013 Rating SIR: 0.50	0.50
Q3 2012 - Q2 2013 Rating SIR: 0.30	0.30
Q1 2012 - Q4 2012 Rating SIR: 0.09	0.09
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.03	0.03
Q1 2011 - Q4 2011 Rating SIR: 1.75	1.75
Q4 2010 - Q3 2011 Rating SIR: 0.48	0.48
Q1 2010 - Q4 2010 Rating SIR: 0.32	0.32
Q4 2009 - Q3 2010 Rating SIR: 0.19	0.19
Q1 2009 - Q4 2009 Rating SIR: 0.55	0.55
Q3 2008 - Q2 2009 Rating SIR: 0.20	0.20
Q1 2008 - Q4 2008 Rating SIR: 0.30	0.30
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 2.73	2.73
Description The number of cases of hematoma or hemorrhage requiring a procedure per 1,000 surgical discharges. (PSI 09) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 1.73	1.73
Q4 2019 - Q3 2020 Rating SIR: 1.06	1.06
Q4 2018 - Q3 2019 Rating SIR: 2.71	2.71
Q2 2018 - Q1 2019 Rating SIR: 2.44	2.44
Q1 2015 - Q4 2015 Rating SIR: 3.55	3.55
Q4 2014 - Q3 2015 Rating SIR: 4.39	4.39
Q1 2014 - Q4 2014 Rating SIR: 3.46	3.46
Q4 2013 - Q3 2014 Rating SIR: 3.31	3.31
Q1 2013 - Q4 2013 Rating SIR: 3.47	3.47
Q3 2012 - Q2 2013 Rating SIR: 3.86	3.86
Q1 2012 - Q4 2012 Rating SIR: 3.76	3.76
Q4 2011 - Q3 2012 Rating SIR: 3.57	3.57
Q2 2011 - Q1 2012 Rating SIR: 1.32	1.32
Q1 2011 - Q4 2011 Rating SIR: 2.48	2.48
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.95	0.95
Q4 2009 - Q3 2010 Rating SIR: 1.26	1.26
Q1 2009 - Q4 2009 Rating SIR: 1.80	1.80
Q3 2008 - Q2 2009 Rating SIR: 0.15	0.15
Q1 2008 - Q4 2008 Rating SIR: 0.15	0.15
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 4.79	4.79
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: 6.79	6.79
Q4 2019 - Q3 2020 Rating SIR: 4.16	4.16
Q4 2018 - Q3 2019 Rating SIR: 2.06	2.06
Q2 2018 - Q1 2019 Rating SIR: 1.39	1.39
Q1 2015 - Q4 2015 Rating SIR: 11.99	11.99
Q4 2014 - Q3 2015 Rating SIR: 8.93	8.93
Q1 2014 - Q4 2014 Rating SIR: 5.52	5.52
Q4 2013 - Q3 2014 Rating SIR: 4.81	4.81
Q1 2013 - Q4 2013 Rating SIR: 7.27	7.27
Q3 2012 - Q2 2013 Rating SIR: 7.38	7.38
Q1 2012 - Q4 2012 Rating SIR: 4.83	4.83
Q4 2011 - Q3 2012 Rating SIR: 5.45	5.45
Q2 2011 - Q1 2012 Rating SIR: 7.14	7.14
Q1 2011 - Q4 2011 Rating SIR: 5.89	5.89
Q4 2010 - Q3 2011 Rating SIR: 7.78	7.78
Q1 2010 - Q4 2010 Rating SIR: 7.97	7.97
Q4 2009 - Q3 2010 Rating SIR: 13.60	13.60
Q1 2009 - Q4 2009 Rating SIR: 7.09	7.09
Q3 2008 - Q2 2009 Rating SIR: 0.82	0.82
Q1 2008 - Q4 2008 Rating SIR: 0.94	0.94
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: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.00	0.00
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
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: 0.14	0.14
Q4 2019 - Q3 2020 Rating SIR: 0.13	0.13
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: 0.53	0.53
Q4 2014 - Q3 2015 Rating SIR: 0.61	0.61
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.28	0.28
Q1 2013 - Q4 2013 Rating SIR: 0.26	0.26
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.28	0.28
Q4 2011 - Q3 2012 Rating SIR: 0.21	0.21
Q2 2011 - Q1 2012 Rating SIR: 0.70	0.70
Q1 2011 - Q4 2011 Rating SIR: 1.45	1.45
Q4 2010 - Q3 2011 Rating SIR: 0.75	0.75
Q1 2010 - Q4 2010 Rating SIR: 0.46	0.46
Q4 2009 - Q3 2010 Rating SIR: 0.78	0.78
Q1 2009 - Q4 2009 Rating SIR: 2.22	2.22
Q3 2008 - Q2 2009 Rating SIR: 0.42	0.42
Q1 2008 - Q4 2008 Rating SIR: 0.69	0.69
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 3.62	3.62
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: 6.90	6.90
Q4 2019 - Q3 2020 Rating SIR: 3.74	3.74
Q4 2018 - Q3 2019 Rating SIR: 1.82	1.82
Q2 2018 - Q1 2019 Rating SIR: 1.81	1.81
Q1 2015 - Q4 2015 Rating SIR: 4.30	4.30
Q4 2014 - Q3 2015 Rating SIR: 11.40	11.40
Q1 2014 - Q4 2014 Rating SIR: 12.70	12.70
Q4 2013 - Q3 2014 Rating SIR: 9.13	9.13
Q1 2013 - Q4 2013 Rating SIR: 9.64	9.64
Q3 2012 - Q2 2013 Rating SIR: 7.08	7.08
Q1 2012 - Q4 2012 Rating SIR: 5.08	5.08
Q4 2011 - Q3 2012 Rating SIR: 4.59	4.59
Q2 2011 - Q1 2012 Rating SIR: 2.06	2.06
Q1 2011 - Q4 2011 Rating SIR: 2.07	2.07
Q4 2010 - Q3 2011 Rating SIR: 4.38	4.38
Q1 2010 - Q4 2010 Rating SIR: 12.27	12.27
Q4 2009 - Q3 2010 Rating SIR: 16.32	16.32
Q1 2009 - Q4 2009 Rating SIR: 9.98	9.98
Q3 2008 - Q2 2009 Rating SIR: 0.20	0.20
Q1 2008 - Q4 2008 Rating SIR: 0.39	0.39
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 1.33	1.33
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: 1.72	1.72
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.98	0.98
Q2 2018 - Q1 2019 Rating SIR: 1.60	1.60
Q1 2015 - Q4 2015 Rating SIR: 0.48	0.48
Q4 2014 - Q3 2015 Rating SIR: 0.97	0.97
Q1 2014 - Q4 2014 Rating SIR: 1.51	1.51
Q4 2013 - Q3 2014 Rating SIR: 1.63	1.63
Q1 2013 - Q4 2013 Rating SIR: 1.19	1.19
Q3 2012 - Q2 2013 Rating SIR: 0.58	0.58
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: 0.52	0.52
Q4 2009 - Q3 2010 Rating SIR: 0.54	0.54
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.05	0.05
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 2 infections, 88647 patient days Rating SIR: 0.65	2 infections, 88647 patient days	0.65
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 85913 patient days Rating SIR: 1.18	4 infections, 85913 patient days	1.18
Q1 2021 - Q4 2021 Result 1 infections, 83092 patient days Rating SIR: 0.33	1 infections, 83092 patient days	0.33
Q1 2020 - Q4 2020 Result 3 infections, 80907 patient days Rating SIR: 0.91	3 infections, 80907 patient days	0.91
Q1 2019 - Q4 2019 Result 0 infections, 78448 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 78448 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 66111 patient days Rating SIR: 0.82	2 infections, 66111 patient days	0.82
Q1 2017 - Q4 2017 Result 1 infections, 67852 patient days Rating SIR: 0.47	1 infections, 67852 patient days	0.47
Q1 2016 - Q4 2016 Result 0 infections, 72448 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 72448 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 37431 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 37431 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 2 infections, 64549 patient days Rating SIR: 0.70	2 infections, 64549 patient days	0.70
Q1 2013 - Q4 2013 Result 1 infections, 59816 patient days Rating SIR: 0.38	1 infections, 59816 patient days	0.38
Q1 2012 - Q4 2012 Result 0 infections, 58657 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 58657 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2012 - Q2 2012 Result 0 infections, 31498 patient days Rating SIR: 0.00	0 infections, 31498 patient days	0.00
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 10 infections, 86705 patient days Rating SIR: 0.13	10 infections, 86705 patient days	0.13
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 19 infections, 84012 patient days Rating SIR: 0.18	19 infections, 84012 patient days	0.18
Q1 2021 - Q4 2021 Result 17 infections, 81113 patient days Rating SIR: 0.15	17 infections, 81113 patient days	0.15
Q1 2020 - Q4 2020 Result 15 infections, 78847 patient days Rating SIR: 0.15	15 infections, 78847 patient days	0.15
Q1 2019 - Q4 2019 Result 20 infections, 74611 patient days Rating SIR: 0.25	20 infections, 74611 patient days	0.25
Q1 2018 - Q4 2018 Result 20 infections, 66111 patient days Rating SIR: 0.30	20 infections, 66111 patient days	0.30
Q1 2017 - Q4 2017 Result 41 infections, 67852 patient days Rating SIR: 0.77	41 infections, 67852 patient days	0.77
Q1 2016 - Q4 2016 Result 60 infections, 72448 patient days Rating SIR: 1.02	60 infections, 72448 patient days	1.02
Q1 2015 - Q4 2015 Result 29 infections, 21804 patient days ¹¹⁵ Rating SIR: 1.77 ¹¹⁵	29 infections, 21804 patient days ¹¹⁵	1.77 ¹¹⁵
Q1 2014 - Q4 2014 Result 49 infections, 60549 patient days Rating SIR: 1.39	49 infections, 60549 patient days	1.39
Q1 2013 - Q4 2013 Result 33 infections, 56420 patient days Rating SIR: 0.69	33 infections, 56420 patient days	0.69
Q1 2012 - Q4 2012 Result 35 infections, 49627 patient days Rating SIR: 0.84	35 infections, 49627 patient days	0.84

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 3459 central-line days Rating SIR: 0.33	1 infections, 3459 central-line days	0.33
Description Central Line-associated Bloodstream Infection data in the Adult Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 4399 central-line days Rating SIR: 1.05	4 infections, 4399 central-line days	1.05
Q1 2021 - Q4 2021 Result 1 infections, 4690 central-line days Rating SIR: 0.25	1 infections, 4690 central-line days	0.25
Q1 2020 - Q4 2020 Result 0 infections, 5094 central-line days Rating SIR: 0.00	0 infections, 5094 central-line days	0.00
Q1 2019 - Q4 2019 Result 2 infections, 4138 central-line days Rating SIR: 0.56	2 infections, 4138 central-line days	0.56
Q1 2018 - Q4 2018 Result 4 infections, 4514 central-line days Rating SIR: 1.02	4 infections, 4514 central-line days	1.02
Q1 2017 - Q4 2017 Result 1 infections, 3977 central-line days Rating SIR: 0.29	1 infections, 3977 central-line days	0.29
Q1 2016 - Q4 2016 Result 0 infections, 4031 central-line days Rating SIR: 0.00	0 infections, 4031 central-line days	0.00
Q1 2015 - Q4 2015 Result 0 infections, 3937 central-line days Rating SIR: 0.00	0 infections, 3937 central-line days	0.00
Q1 2014 - Q4 2014 Result 0 infections, 3781 central-line days Rating SIR: 0.00	0 infections, 3781 central-line days	0.00
Q1 2013 - Q4 2013 Result 1 infections, 3230 central-line days Rating SIR: 0.21	1 infections, 3230 central-line days	0.21
Q1 2012 - Q4 2012 Result 0 infections, 3033 central-line days Rating SIR: 0.00	0 infections, 3033 central-line days	0.00
Q1 2011 - Q4 2011 Result 5 infections, 3288 central-line days Rating SIR: 1.52	5 infections, 3288 central-line days	1.52
Q1 2010 - Q4 2010 Result 4 infections, 2303 central-line days Rating SIR: 1.16	4 infections, 2303 central-line days	1.16
Q1 2009 - Q4 2009 Result 3 infections, 2228 central-line days Rating SIR: 0.90	3 infections, 2228 central-line days	0.90
Q1 2009 - Q2 2009 Result 1 infections, 985 central-line days Rating SIR: 1.02	1 infections, 985 central-line days	1.02

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 55 central-line days Rating SIR: N/A	0 infections, 55 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, 40 central-line days ³³ Rating SIR: N/A ³³	0 infections, 40 central-line days ³³	N/A ³³
Q1 2021 - Q4 2021 Result 0 infections, 79 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 79 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 0 infections, 64 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 64 central-line days ⁴²	N/A ⁴²
Q1 2019 - Q4 2019 Result 0 infections, 108 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 108 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 0 infections, 48 central-line days ³³ Rating SIR: N/A ³³	0 infections, 48 central-line days ³³	N/A ³³
Q1 2017 - Q4 2017 Result 0 infections, 30 central-line days ³³ Rating SIR: N/A ³³	0 infections, 30 central-line days ³³	N/A ³³
Level III Neonatal ICU 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
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 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

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 0 infections, 847 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 847 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 1 infections, 791 procedures Rating SIR: 0.34	1 infections, 791 procedures	0.34
Q1 2018 - Q4 2018 Result 5 infections, 1135 procedures Rating SIR: 1.22	5 infections, 1135 procedures	1.22
Q1 2017 - Q4 2017 Result 1 infections, 862 procedures Rating SIR: 0.31	1 infections, 862 procedures	0.31
Q1 2016 - Q4 2016 Result 1 infections, 95 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 95 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2015 - Q4 2015 Result 2 infections, 226 procedures Rating SIR: 1.33	2 infections, 226 procedures	1.33
Q1 2014 - Q4 2014 Result 2 infections, 330 procedures Rating SIR: 0.87	2 infections, 330 procedures	0.87
Q3 2013 - Q2 2014 Result 2 infections, 395 procedures Rating SIR: 0.73	2 infections, 395 procedures	0.73
Q3 2012 - Q2 2013 Result 0 infections, 376 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 376 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 223 procedures Rating SIR: 0.62	1 infections, 223 procedures	0.62
Q3 2010 - Q2 2011 Result 0 infections, 247 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 247 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 0 infections, 25 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 25 procedures ¹¹⁸	N/A ¹¹⁸
Description Surgical Site Infections Associated with Coronary Artery Bypass Graft Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2019 - Q4 2019 Result 0 infections, 90 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 90 procedures ¹⁵³	N/A ¹⁵³
Q1 2018 - Q4 2018 Result 1 infections, 132 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 132 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2016 - Q4 2016 Result 0 infections, 30 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 30 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 1 infections, 55 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 55 procedures ¹⁵⁴	N/A ¹⁵⁴
Q1 2014 - Q4 2014 Result 0 infections, 54 procedures Rating SIR: N/A	0 infections, 54 procedures	N/A
Q3 2013 - Q2 2014 Result 0 infections, 43 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 43 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2012 - Q2 2013 Result 1 infections, 75 procedures Rating SIR: 0.79	1 infections, 75 procedures	0.79
Q3 2011 - Q2 2012 Result 1 infections, 67 procedures ⁴⁶ Rating SIR: 0.98 ⁴⁶	1 infections, 67 procedures ⁴⁶	0.98 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 77 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 77 procedures ⁴⁶	0.00 ⁴⁶