Advocate Lutheran General 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
42	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
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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

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
42	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
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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

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
42	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
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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

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 86.00 %	86.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 98.00 %	98.00 %
Q4 2020 - Q1 2021 Result 97.00 %	97.00 %
Q4 2019 - Q1 2020 Result 99.00 %	99.00 %
Q4 2018 - Q1 2019 Result 96.00 %	96.00 %
Q4 2017 - Q1 2018 Result 98.00 %	98.00 %

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
42	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
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 3.76	3.76
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: 3.64	3.64
Q4 2019 - Q3 2020 Rating SIR: 5.47	5.47
Q4 2018 - Q3 2019 Rating SIR: 3.88	3.88
Q2 2018 - Q1 2019 Rating SIR: 4.85	4.85
Q1 2015 - Q4 2015 Rating SIR: 10.55	10.55
Q4 2014 - Q3 2015 Rating SIR: 12.00	12.00
Q1 2014 - Q4 2014 Rating SIR: 11.88	11.88
Q4 2013 - Q3 2014 Rating SIR: 9.95	9.95
Q1 2013 - Q4 2013 Rating SIR: 6.91	6.91
Q3 2012 - Q2 2013 Rating SIR: 7.30	7.30
Q1 2012 - Q4 2012 Rating SIR: 10.39	10.39
Q4 2011 - Q3 2012 Rating SIR: 11.41	11.41
Q2 2011 - Q1 2012 Rating SIR: 1.25	1.25
Q1 2011 - Q4 2011 Rating SIR: 8.32	8.32
Q4 2010 - Q3 2011 Rating SIR: 10.45	10.45
Q1 2010 - Q4 2010 Rating SIR: 12.85	12.85
Q4 2009 - Q3 2010 Rating SIR: 12.64	12.64
Q1 2009 - Q4 2009 Rating SIR: 20.01	20.01
Q3 2008 - Q2 2009 Rating SIR: 26.60	26.60
Q1 2008 - Q4 2008 Rating SIR: 24.60	24.60
Wound Complications in Abdominal Wall Surgery Q4 2021 - Q3 2022 Rating SIR: 0.94	0.94
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: 0.56	0.56
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: 1.07	1.07
Q3 2012 - Q2 2013 Rating SIR: 1.01	1.01
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: 0.93	0.93
Q4 2010 - Q3 2011 Rating SIR: 0.48	0.48
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: 1.06	1.06
Q3 2008 - Q2 2009 Rating SIR: 0.09	0.09
Q1 2008 - Q4 2008 Rating SIR: 0.09	0.09
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 1.01	1.01
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: 1.18	1.18
Q4 2019 - Q3 2020 Rating SIR: 0.70	0.70
Q4 2018 - Q3 2019 Rating SIR: 0.25	0.25
Q2 2018 - Q1 2019 Rating SIR: 0.77	0.77
Q1 2015 - Q4 2015 Rating SIR: 0.36	0.36
Q4 2014 - Q3 2015 Rating SIR: 0.28	0.28
Q1 2014 - Q4 2014 Rating SIR: 0.99	0.99
Q4 2013 - Q3 2014 Rating SIR: 0.96	0.96
Q1 2013 - Q4 2013 Rating SIR: 0.54	0.54
Q3 2012 - Q2 2013 Rating SIR: 0.73	0.73
Q1 2012 - Q4 2012 Rating SIR: 0.71	0.71
Q4 2011 - Q3 2012 Rating SIR: 0.83	0.83
Q2 2011 - Q1 2012 Rating SIR: 0.08	0.08
Q1 2011 - Q4 2011 Rating SIR: 1.58	1.58
Q4 2010 - Q3 2011 Rating SIR: 1.39	1.39
Q1 2010 - Q4 2010 Rating SIR: 1.61	1.61
Q4 2009 - Q3 2010 Rating SIR: 1.96	1.96
Q1 2009 - Q4 2009 Rating SIR: 1.50	1.50
Q3 2008 - Q2 2009 Rating SIR: 1.10	1.10
Q1 2008 - Q4 2008 Rating SIR: 1.80	1.80
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.15	0.15
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: 0.22	0.22
Q4 2019 - Q3 2020 Rating SIR: 0.04	0.04
Q4 2018 - Q3 2019 Rating SIR: 0.12	0.12
Q2 2018 - Q1 2019 Rating SIR: 0.12	0.12
Q1 2015 - Q4 2015 Rating SIR: 0.22	0.22
Q4 2014 - Q3 2015 Rating SIR: 0.18	0.18
Q1 2014 - Q4 2014 Rating SIR: 0.28	0.28
Q4 2013 - Q3 2014 Rating SIR: 0.42	0.42
Q1 2013 - Q4 2013 Rating SIR: 0.29	0.29
Q3 2012 - Q2 2013 Rating SIR: 0.12	0.12
Q1 2012 - Q4 2012 Rating SIR: 0.30	0.30
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: 0.27	0.27
Q4 2010 - Q3 2011 Rating SIR: 0.09	0.09
Q1 2010 - Q4 2010 Rating SIR: 0.30	0.30
Q4 2009 - Q3 2010 Rating SIR: 0.57	0.57
Q1 2009 - Q4 2009 Rating SIR: 1.26	1.26
Q3 2008 - Q2 2009 Rating SIR: 0.50	0.50
Q1 2008 - Q4 2008 Rating SIR: 0.50	0.50
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.18	1.18
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: 1.95	1.95
Q4 2019 - Q3 2020 Rating SIR: 2.08	2.08
Q4 2018 - Q3 2019 Rating SIR: 2.32	2.32
Q2 2018 - Q1 2019 Rating SIR: 2.55	2.55
Q1 2015 - Q4 2015 Rating SIR: 1.80	1.80
Q4 2014 - Q3 2015 Rating SIR: 1.32	1.32
Q1 2014 - Q4 2014 Rating SIR: 2.41	2.41
Q4 2013 - Q3 2014 Rating SIR: 2.34	2.34
Q1 2013 - Q4 2013 Rating SIR: 1.81	1.81
Q3 2012 - Q2 2013 Rating SIR: 2.43	2.43
Q1 2012 - Q4 2012 Rating SIR: 2.85	2.85
Q4 2011 - Q3 2012 Rating SIR: 1.08	1.08
Q2 2011 - Q1 2012 Rating SIR: 0.87	0.87
Q1 2011 - Q4 2011 Rating SIR: 1.18	1.18
Q4 2010 - Q3 2011 Rating SIR: 0.88	0.88
Q1 2010 - Q4 2010 Rating SIR: 2.24	2.24
Q4 2009 - Q3 2010 Rating SIR: 2.39	2.39
Q1 2009 - Q4 2009 Rating SIR: 1.30	1.30
Q3 2008 - Q2 2009 Rating SIR: 0.10	0.10
Q1 2008 - Q4 2008 Rating SIR: 0.07	0.07
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 4.47	4.47
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: 8.03	8.03
Q4 2019 - Q3 2020 Rating SIR: 7.76	7.76
Q4 2018 - Q3 2019 Rating SIR: 4.88	4.88
Q2 2018 - Q1 2019 Rating SIR: 4.33	4.33
Q1 2015 - Q4 2015 Rating SIR: 4.27	4.27
Q4 2014 - Q3 2015 Rating SIR: 5.34	5.34
Q1 2014 - Q4 2014 Rating SIR: 3.31	3.31
Q4 2013 - Q3 2014 Rating SIR: 2.30	2.30
Q1 2013 - Q4 2013 Rating SIR: 3.04	3.04
Q3 2012 - Q2 2013 Rating SIR: 2.91	2.91
Q1 2012 - Q4 2012 Rating SIR: 3.46	3.46
Q4 2011 - Q3 2012 Rating SIR: 3.23	3.23
Q2 2011 - Q1 2012 Rating SIR: 3.27	3.27
Q1 2011 - Q4 2011 Rating SIR: 4.26	4.26
Q4 2010 - Q3 2011 Rating SIR: 4.54	4.54
Q1 2010 - Q4 2010 Rating SIR: 7.91	7.91
Q4 2009 - Q3 2010 Rating SIR: 14.40	14.40
Q1 2009 - Q4 2009 Rating SIR: 9.86	9.86
Q3 2008 - Q2 2009 Rating SIR: 0.87	0.87
Q1 2008 - Q4 2008 Rating SIR: 0.91	0.91
Postoperative Hip Fracture Q4 2021 - Q3 2022 Rating SIR: 0.04	0.04
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: 0.04	0.04
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.08	0.08
Q2 2018 - Q1 2019 Rating SIR: 0.17	0.17
Q1 2015 - Q4 2015 Rating SIR: 0.00	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: 0.41	0.41
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: 0.15	0.15
Q4 2019 - Q3 2020 Rating SIR: 0.26	0.26
Q4 2018 - Q3 2019 Rating SIR: 0.40	0.40
Q2 2018 - Q1 2019 Rating SIR: 0.36	0.36
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: 0.39	0.39
Q4 2013 - Q3 2014 Rating SIR: 0.40	0.40
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: 0.17	0.17
Q1 2011 - Q4 2011 Rating SIR: 0.54	0.54
Q4 2010 - Q3 2011 Rating SIR: 0.36	0.36
Q1 2010 - Q4 2010 Rating SIR: 0.61	0.61
Q4 2009 - Q3 2010 Rating SIR: 2.03	2.03
Q1 2009 - Q4 2009 Rating SIR: 1.40	1.40
Q3 2008 - Q2 2009 Rating SIR: 0.02	0.02
Q1 2008 - Q4 2008 Rating SIR: 0.14	0.14
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 6.08	6.08
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: 7.08	7.08
Q4 2019 - Q3 2020 Rating SIR: 7.72	7.72
Q4 2018 - Q3 2019 Rating SIR: 5.54	5.54
Q2 2018 - Q1 2019 Rating SIR: 7.09	7.09
Q1 2015 - Q4 2015 Rating SIR: 16.37	16.37
Q4 2014 - Q3 2015 Rating SIR: 18.45	18.45
Q1 2014 - Q4 2014 Rating SIR: 12.27	12.27
Q4 2013 - Q3 2014 Rating SIR: 9.99	9.99
Q1 2013 - Q4 2013 Rating SIR: 4.33	4.33
Q3 2012 - Q2 2013 Rating SIR: 3.37	3.37
Q1 2012 - Q4 2012 Rating SIR: 11.48	11.48
Q4 2011 - Q3 2012 Rating SIR: 11.03	11.03
Q2 2011 - Q1 2012 Rating SIR: 8.25	8.25
Q1 2011 - Q4 2011 Rating SIR: 6.79	6.79
Q4 2010 - Q3 2011 Rating SIR: 7.19	7.19
Q1 2010 - Q4 2010 Rating SIR: 8.92	8.92
Q4 2009 - Q3 2010 Rating SIR: 9.24	9.24
Q1 2009 - Q4 2009 Rating SIR: 9.02	9.02
Q3 2008 - Q2 2009 Rating SIR: 1.21	1.21
Q1 2008 - Q4 2008 Rating SIR: 1.12	1.12
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 0.28	0.28
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: 0.60	0.60
Q4 2019 - Q3 2020 Rating SIR: 0.96	0.96
Q4 2018 - Q3 2019 Rating SIR: 0.80	0.80
Q2 2018 - Q1 2019 Rating SIR: 1.13	1.13
Q1 2015 - Q4 2015 Rating SIR: 0.86	0.86
Q4 2014 - Q3 2015 Rating SIR: 1.35	1.35
Q1 2014 - Q4 2014 Rating SIR: 0.61	0.61
Q4 2013 - Q3 2014 Rating SIR: 0.29	0.29
Q1 2013 - Q4 2013 Rating SIR: 0.80	0.80
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: 0.29	0.29
Q2 2011 - Q1 2012 Rating SIR: 0.84	0.84
Q1 2011 - Q4 2011 Rating SIR: 0.79	0.79
Q4 2010 - Q3 2011 Rating SIR: 0.86	0.86
Q1 2010 - Q4 2010 Rating SIR: 0.93	0.93
Q4 2009 - Q3 2010 Rating SIR: 1.94	1.94
Q1 2009 - Q4 2009 Rating SIR: 0.67	0.67
Q3 2008 - Q2 2009 Rating SIR: 0.03	0.03
Q1 2008 - Q4 2008 Rating SIR: 0.03	0.03

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 9 infections, 202640 patient days Rating SIR: 0.59	9 infections, 202640 patient days	0.59
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 8 infections, 199570 patient days Rating SIR: 0.53	8 infections, 199570 patient days	0.53
Q1 2021 - Q4 2021 Result 9 infections, 182672 patient days Rating SIR: 0.65	9 infections, 182672 patient days	0.65
Q1 2020 - Q4 2020 Result 7 infections, 157349 patient days Rating SIR: 0.59	7 infections, 157349 patient days	0.59
Q1 2019 - Q4 2019 Result 7 infections, 165217 patient days Rating SIR: 0.71	7 infections, 165217 patient days	0.71
Q1 2018 - Q4 2018 Result 5 infections, 164449 patient days Rating SIR: 0.46	5 infections, 164449 patient days	0.46
Q1 2017 - Q4 2017 Result 5 infections, 146952 patient days Rating SIR: 0.82	5 infections, 146952 patient days	0.82
Q1 2016 - Q4 2016 Result 4 infections, 148079 patient days Rating SIR: 0.53	4 infections, 148079 patient days	0.53
Q1 2015 - Q4 2015 Result 5 infections, 157929 patient days Rating SIR: 0.60	5 infections, 157929 patient days	0.60
Q1 2014 - Q4 2014 Result 7 infections, 167202 patient days Rating SIR: 0.70	7 infections, 167202 patient days	0.70
Q1 2013 - Q4 2013 Result 0 infections, 165439 patient days Rating SIR: 0.00	0 infections, 165439 patient days	0.00
Q1 2012 - Q4 2012 Result 3 infections, 166624 patient days Rating SIR: 0.29	3 infections, 166624 patient days	0.29
Q1 2012 - Q2 2012 Result 1 infections, 86233 patient days Rating SIR: 0.12	1 infections, 86233 patient days	0.12
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 44 infections, 181009 patient days Rating SIR: 0.47	44 infections, 181009 patient days	0.47
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 67 infections, 178307 patient days Rating SIR: 0.73	67 infections, 178307 patient days	0.73
Q1 2021 - Q4 2021 Result 59 infections, 164661 patient days Rating SIR: 0.68	59 infections, 164661 patient days	0.68
Q1 2020 - Q4 2020 Result 44 infections, 139680 patient days Rating SIR: 0.61	44 infections, 139680 patient days	0.61
Q1 2019 - Q4 2019 Result 39 infections, 144855 patient days Rating SIR: 0.57	39 infections, 144855 patient days	0.57
Q1 2018 - Q4 2018 Result 120 infections, 144789 patient days Rating SIR: 1.25	120 infections, 144789 patient days	1.25
Q1 2017 - Q4 2017 Result 113 infections, 127160 patient days Rating SIR: 1.27	113 infections, 127160 patient days	1.27
Q1 2016 - Q4 2016 Result 126 infections, 127556 patient days Rating SIR: 1.39	126 infections, 127556 patient days	1.39
Q1 2015 - Q4 2015 Result 92 infections, 135835 patient days Rating SIR: 0.87	92 infections, 135835 patient days	0.87
Q1 2014 - Q4 2014 Result 88 infections, 144408 patient days Rating SIR: 0.74	88 infections, 144408 patient days	0.74
Q1 2013 - Q4 2013 Result 71 infections, 143427 patient days Rating SIR: 0.60	71 infections, 143427 patient days	0.60
Q1 2012 - Q4 2012 Result 99 infections, 144639 patient days Rating SIR: 0.84	99 infections, 144639 patient days	0.84

Adult CLABSI Measure	Result	SIR
Adult Neurologic ICU Q1 2023 - Q4 2023 Result 0 infections, 808 central-line days Rating SIR: N/A	0 infections, 808 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Adult Neurologic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 1 infections, 749 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 749 central-line days ⁴⁴	N/A ⁴⁴
Q1 2021 - Q4 2021 Result 0 infections, 827 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 827 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 1 infections, 785 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 785 central-line days ⁴⁴	N/A ⁴⁴
Adult Surgical ICU Q1 2023 - Q4 2023 Result 2 infections, 1708 central-line days Rating SIR: 1.04	2 infections, 1708 central-line days	1.04
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 0 infections, 1729 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1729 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 0 infections, 1707 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1707 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 4 infections, 1814 central-line days Rating SIR: 1.95	4 infections, 1814 central-line days	1.95
Q1 2019 - Q4 2019 Result 0 infections, 1917 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1917 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 2402 central-line days Rating SIR: 0.74	2 infections, 2402 central-line days	0.74
Q1 2017 - Q4 2017 Result 1 infections, 2117 central-line days Rating SIR: 0.47	1 infections, 2117 central-line days	0.47
Q1 2016 - Q4 2016 Result 0 infections, 2090 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2090 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 2320 central-line days Rating SIR: 0.00	0 infections, 2320 central-line days	0.00
Q1 2014 - Q4 2014 Result 0 infections, 2145 central-line days Rating SIR: 0.00	0 infections, 2145 central-line days	0.00
Q1 2013 - Q4 2013 Result 0 infections, 1910 central-line days Rating SIR: 0.00	0 infections, 1910 central-line days	0.00
Q1 2012 - Q4 2012 Result 2 infections, 2036 central-line days Rating SIR: 0.43	2 infections, 2036 central-line days	0.43
Q1 2011 - Q4 2011 Result 4 infections, 2557 central-line days Rating SIR: 0.68	4 infections, 2557 central-line days	0.68
Q1 2010 - Q4 2010 Result 0 infections, 2713 central-line days Rating SIR: 0.00	0 infections, 2713 central-line days	0.00
Q1 2009 - Q4 2009 Result 2 infections, 1429 central-line days Rating SIR: 0.61	2 infections, 1429 central-line days	0.61
Q1 2009 - Q2 2009 Result 0 infections, 759 central-line days Rating SIR: 0.00	0 infections, 759 central-line days	0.00
Adult Medical ICU Q1 2023 - Q4 2023 Result 3 infections, 3388 central-line days Rating SIR: 0.79	3 infections, 3388 central-line days	0.79
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 5 infections, 3601 central-line days Rating SIR: 1.23	5 infections, 3601 central-line days	1.23
Q1 2021 - Q4 2021 Result 3 infections, 3586 central-line days Rating SIR: 0.74	3 infections, 3586 central-line days	0.74
Q1 2020 - Q4 2020 Result 0 infections, 891 central-line days Rating SIR: 0.00	0 infections, 891 central-line days	0.00
Q1 2019 - Q4 2019 Result 0 infections, 3783 central-line days Rating SIR: 0.00	0 infections, 3783 central-line days	0.00
Q1 2018 - Q4 2018 Result 2 infections, 3741 central-line days Rating SIR: 0.47	2 infections, 3741 central-line days	0.47
Q1 2017 - Q4 2017 Result 7 infections, 3357 central-line days Rating SIR: 2.07	7 infections, 3357 central-line days	2.07
Q1 2016 - Q4 2016 Result 2 infections, 3591 central-line days Rating SIR: 0.55	2 infections, 3591 central-line days	0.55
Q1 2015 - Q4 2015 Result 1 infections, 3368 central-line days Rating SIR: 0.16	1 infections, 3368 central-line days	0.16
Q1 2014 - Q4 2014 Result 0 infections, 3127 central-line days Rating SIR: 0.00	0 infections, 3127 central-line days	0.00
Q1 2013 - Q4 2013 Result 0 infections, 3175 central-line days Rating SIR: 0.00	0 infections, 3175 central-line days	0.00
Q1 2012 - Q4 2012 Result 1 infections, 3232 central-line days Rating SIR: 0.16	1 infections, 3232 central-line days	0.16
Q1 2009 - Q4 2009 Result 0 infections, 1002 central-line days Rating SIR: 0.00	0 infections, 1002 central-line days	0.00
Q1 2009 - Q2 2009 Result 0 infections, 1002 central-line days Rating SIR: 0.00	0 infections, 1002 central-line days	0.00

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 1062 central-line days Rating SIR: 0.65	1 infections, 1062 central-line days	0.65
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 2 infections, 922 central-line days Rating SIR: 1.51	2 infections, 922 central-line days	1.51
Q1 2021 - Q4 2021 Result 0 infections, 796 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 796 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 0 infections, 829 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 829 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 2 infections, 1171 central-line days Rating SIR: 1.19	2 infections, 1171 central-line days	1.19
Q1 2018 - Q4 2018 Result 2 infections, 1052 central-line days Rating SIR: 1.32	2 infections, 1052 central-line days	1.32
Q1 2017 - Q4 2017 Result 2 infections, 1102 central-line days Rating SIR: 1.41	2 infections, 1102 central-line days	1.41
Q1 2016 - Q4 2016 Result 0 infections, 1161 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1161 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 1 infections, 890 central-line days Rating SIR: 0.38	1 infections, 890 central-line days	0.38
Q1 2014 - Q4 2014 Result 1 infections, 1192 central-line days Rating SIR: 0.28	1 infections, 1192 central-line days	0.28
Q1 2013 - Q4 2013 Result 0 infections, 1350 central-line days Rating SIR: 0.00	0 infections, 1350 central-line days	0.00
Q1 2012 - Q4 2012 Result 2 infections, 1232 central-line days Rating SIR: 0.54	2 infections, 1232 central-line days	0.54
Q1 2011 - Q4 2011 Result 3 infections, 1405 central-line days Rating SIR: 0.71	3 infections, 1405 central-line days	0.71
Q1 2010 - Q4 2010 Result 2 infections, 1178 central-line days Rating SIR: 0.57	2 infections, 1178 central-line days	0.57
Q1 2010 - Q2 2010 Result 2 infections, 710 central-line days Rating SIR: 0.94	2 infections, 710 central-line days	0.94

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2012 - Q4 2012 Result 2 infections, 4851 central-line days Rating SIR: 0.17	2 infections, 4851 central-line days	0.17
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 2011 - Q4 2011 Result 3 infections, 4270 central-line days Rating SIR: 0.27	3 infections, 4270 central-line days	0.27
Q1 2010 - Q4 2010 Result 8 infections, 5780 central-line days Rating SIR: 0.52	8 infections, 5780 central-line days	0.52
Q1 2010 - Q2 2010 Result 6 infections, 2788 central-line days Rating SIR: 0.76	6 infections, 2788 central-line days	0.76
Level III Neonatal ICU Q1 2022 - Q4 2022 Result 4 infections, 3407 central-line days Rating SIR: 0.99	4 infections, 3407 central-line days	0.99
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 2021 - Q4 2021 Result 2 infections, 2643 central-line days Rating SIR: 0.60	2 infections, 2643 central-line days	0.60
Q1 2020 - Q4 2020 Result 0 infections, 2226 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2226 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 4 infections, 3062 central-line days Rating SIR: 1.08	4 infections, 3062 central-line days	1.08
Q1 2018 - Q4 2018 Result 3 infections, 2763 central-line days Rating SIR: 0.88	3 infections, 2763 central-line days	0.88
Q1 2017 - Q4 2017 Result 1 infections, 2523 central-line days Rating SIR: 0.29	1 infections, 2523 central-line days	0.29
Q1 2016 - Q4 2016 Result 0 infections, 2656 central-line days Rating SIR: 0.00	0 infections, 2656 central-line days	0.00
Q1 2015 - Q4 2015 Result 8 infections, 3080 central-line days Rating SIR: 1.10	8 infections, 3080 central-line days	1.10
Q1 2014 - Q4 2014 Result 3 infections, 3635 central-line days Rating SIR: 0.33	3 infections, 3635 central-line days	0.33
Q1 2013 - Q4 2013 Result 3 infections, 3591 central-line days Rating SIR: 0.33	3 infections, 3591 central-line days	0.33

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 1 infections, 409 procedures Rating SIR: 0.73	1 infections, 409 procedures	0.73
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, 758 procedures Rating SIR: 1.20	3 infections, 758 procedures	1.20
Q1 2018 - Q4 2018 Result 3 infections, 740 procedures Rating SIR: 1.25	3 infections, 740 procedures	1.25
Q1 2017 - Q4 2017 Result 2 infections, 773 procedures Rating SIR: 0.91	2 infections, 773 procedures	0.91
Q1 2016 - Q4 2016 Result 3 infections, 916 procedures Rating SIR: 1.11	3 infections, 916 procedures	1.11
Q1 2015 - Q4 2015 Result 5 infections, 959 procedures Rating SIR: 0.83	5 infections, 959 procedures	0.83
Q1 2014 - Q4 2014 Result 3 infections, 947 procedures Rating SIR: 0.50	3 infections, 947 procedures	0.50
Q3 2013 - Q2 2014 Result 2 infections, 901 procedures Rating SIR: 0.35	2 infections, 901 procedures	0.35
Q3 2012 - Q2 2013 Result 2 infections, 933 procedures Rating SIR: 0.35	2 infections, 933 procedures	0.35
Q3 2011 - Q2 2012 Result 4 infections, 763 procedures Rating SIR: 0.89	4 infections, 763 procedures	0.89
Q3 2010 - Q2 2011 Result 0 infections, 521 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 521 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 0 infections, 123 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 123 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, 140 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 140 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 1 infections, 166 procedures Rating SIR: 0.70	1 infections, 166 procedures	0.70
Q1 2016 - Q4 2016 Result 0 infections, 138 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 138 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 1 infections, 142 procedures Rating SIR: 0.68	1 infections, 142 procedures	0.68
Q1 2014 - Q4 2014 Result 0 infections, 122 procedures Rating SIR: 0.00	0 infections, 122 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 132 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 132 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 1 infections, 74 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 74 procedures ¹¹⁴	N/A ¹¹⁴
Q3 2011 - Q2 2012 Result 1 infections, 81 procedures ⁴⁷ Rating SIR: N/A ⁴⁷	1 infections, 81 procedures ⁴⁷	N/A ⁴⁷
Q3 2010 - Q2 2011 Result 1 infections, 92 procedures ⁴⁷ Rating SIR: N/A ⁴⁷	1 infections, 92 procedures ⁴⁷	N/A ⁴⁷