Endeavor Edward 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
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
169	Exempt: No Licensed ICU Beds

Central Line Associated Bloodstream Infections (CLABSIs)

Presented below are annual central line-associated bloodstream infections (CLABSIs) occurring in critical care units, also known as intensive care units (ICUs). ICU-specific summary data for CLABSI are provided using the Standardized Infection Ratio(SIR) . Statewide summaries of CLABSI data arranged by ICU type and hospital are also included.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
169	Exempt: No Licensed ICU Beds

Adult CLABSI

Pediatric CLABSI

NICU CLABSI

Surgical Site Infections (SSIs)

Presented below are data for surgical site infections associated with coronary artery bypass graft surgery (CABG) and total knee replacement surgery (KPROs) using the Standardized Infection Ratio (SIR) . Superficial and secondary surgical site infections are not included in the summary data below. Statewide summaries of surgical site infection data arranged by surgical procedure ( CABG , KPRO ) and hospital are also included.

Statistical Significance

Statistically significantly better than the national average or performing at the best possible rate

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
169	Exempt: No Licensed ICU Beds

Immunization Practices

Illinois hospitals are focusing their efforts on boosting immunization treatments and strengthening patient safety protocols. The objective is not merely achieving statistical success, but also enhancing the quality of care and patient well-being.

Data on immunization measures in Illinois hospitals is available through the Medicare comparison tool at medicare.gov/hospitalcompare . This tool provides valuable insights, allowing patients and their families to gauge the quality of care and safety practices at local hospitals, helping them make informed healthcare decisions.

In the realm of Patient Safety, a host of measures are assessed, with risk-adjusted rates available for each. These measures encompass various aspects of patient care and treatment outcomes. However, interpreting these metrics requires an understanding of the complexity and context-specific nature of healthcare.

Immunization

These indicators are used to measure immunization treatments at hospitals. This data comes from medicare.gov/hospitalcompare .

Measure	Result
Healthcare workers given influenza vaccination Q4 2017 - Q1 2018 Result 91.00 %	91.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel

Measure

Healthcare workers given influenza vaccination

Q4 2017 - Q1 2018

Result: 91.00 %

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
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 5.10	5.10
Description The number of cases of deep vein thrombosis or pulmonary embolism per 1,000 surgical discharges (PSI 12). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 5.71	5.71
Q4 2019 - Q3 2020 Rating SIR: 4.44	4.44
Q4 2018 - Q3 2019 Rating SIR: 5.33	5.33
Q2 2018 - Q1 2019 Rating SIR: 4.79	4.79
Q1 2015 - Q4 2015 Rating SIR: 5.36	5.36
Q4 2014 - Q3 2015 Rating SIR: 8.37	8.37
Q1 2014 - Q4 2014 Rating SIR: 10.06	10.06
Q4 2013 - Q3 2014 Rating SIR: 8.27	8.27
Q1 2013 - Q4 2013 Rating SIR: 9.22	9.22
Q3 2012 - Q2 2013 Rating SIR: 7.90	7.90
Q1 2012 - Q4 2012 Rating SIR: 7.29	7.29
Q4 2011 - Q3 2012 Rating SIR: 7.05	7.05
Q2 2011 - Q1 2012 Rating SIR: 0.99	0.99
Q1 2011 - Q4 2011 Rating SIR: 10.21	10.21
Q4 2010 - Q3 2011 Rating SIR: 8.92	8.92
Q1 2010 - Q4 2010 Rating SIR: 10.45	10.45
Q4 2009 - Q3 2010 Rating SIR: 8.45	8.45
Q1 2009 - Q4 2009 Rating SIR: 11.16	11.16
Q1 2008 - Q4 2008 Rating SIR: 11.20	11.20
Wound Complications in Abdominal Wall Surgery Q4 2021 - Q3 2022 Rating SIR: 2.23	2.23
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: 4.08	4.08
Q4 2019 - Q3 2020 Rating SIR: 0.62	0.62
Q4 2018 - Q3 2019 Rating SIR: 1.28	1.28
Q2 2018 - Q1 2019 Rating SIR: 1.24	1.24
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: 1.20	1.20
Q1 2013 - Q4 2013 Rating SIR: 1.19	1.19
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 4.57	4.57
Q4 2011 - Q3 2012 Rating SIR: 2.13	2.13
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 1.27	1.27
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 1.31	1.31
Q4 2009 - Q3 2010 Rating SIR: 2.86	2.86
Q1 2009 - Q4 2009 Rating SIR: 2.84	2.84
Q1 2008 - Q4 2008 Rating SIR: 0.12	0.12
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 1.71	1.71
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: 1.70	1.70
Q4 2019 - Q3 2020 Rating SIR: 1.57	1.57
Q4 2018 - Q3 2019 Rating SIR: 2.13	2.13
Q2 2018 - Q1 2019 Rating SIR: 2.41	2.41
Q1 2015 - Q4 2015 Rating SIR: 2.27	2.27
Q4 2014 - Q3 2015 Rating SIR: 2.96	2.96
Q1 2014 - Q4 2014 Rating SIR: 2.59	2.59
Q4 2013 - Q3 2014 Rating SIR: 1.98	1.98
Q1 2013 - Q4 2013 Rating SIR: 1.83	1.83
Q3 2012 - Q2 2013 Rating SIR: 1.46	1.46
Q1 2012 - Q4 2012 Rating SIR: 1.45	1.45
Q4 2011 - Q3 2012 Rating SIR: 1.62	1.62
Q2 2011 - Q1 2012 Rating SIR: 0.21	0.21
Q1 2011 - Q4 2011 Rating SIR: 3.10	3.10
Q4 2010 - Q3 2011 Rating SIR: 2.69	2.69
Q1 2010 - Q4 2010 Rating SIR: 2.66	2.66
Q4 2009 - Q3 2010 Rating SIR: 3.41	3.41
Q1 2009 - Q4 2009 Rating SIR: 4.09	4.09
Q1 2008 - Q4 2008 Rating SIR: 2.90	2.90
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.19	0.19
Description This measure is used to assess the number of cases of collapsed lung caused by medical care per 1,000 patients. (PSI 06) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.19	0.19
Q4 2018 - Q3 2019 Rating SIR: 0.21	0.21
Q2 2018 - Q1 2019 Rating SIR: 0.22	0.22
Q1 2015 - Q4 2015 Rating SIR: 0.65	0.65
Q4 2014 - Q3 2015 Rating SIR: 0.70	0.70
Q1 2014 - Q4 2014 Rating SIR: 0.83	0.83
Q4 2013 - Q3 2014 Rating SIR: 0.88	0.88
Q1 2013 - Q4 2013 Rating SIR: 0.72	0.72
Q3 2012 - Q2 2013 Rating SIR: 0.31	0.31
Q1 2012 - Q4 2012 Rating SIR: 0.55	0.55
Q4 2011 - Q3 2012 Rating SIR: 0.31	0.31
Q2 2011 - Q1 2012 Rating SIR: 0.04	0.04
Q1 2011 - Q4 2011 Rating SIR: 2.42	2.42
Q4 2010 - Q3 2011 Rating SIR: 0.49	0.49
Q1 2010 - Q4 2010 Rating SIR: 0.70	0.70
Q4 2009 - Q3 2010 Rating SIR: 1.47	1.47
Q1 2009 - Q4 2009 Rating SIR: 0.35	0.35
Q1 2008 - Q4 2008 Rating SIR: 0.40	0.40
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 3.91	3.91
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: 3.57	3.57
Q4 2019 - Q3 2020 Rating SIR: 5.72	5.72
Q4 2018 - Q3 2019 Rating SIR: 4.35	4.35
Q2 2018 - Q1 2019 Rating SIR: 5.39	5.39
Q1 2015 - Q4 2015 Rating SIR: 6.97	6.97
Q4 2014 - Q3 2015 Rating SIR: 10.43	10.43
Q1 2014 - Q4 2014 Rating SIR: 10.11	10.11
Q4 2013 - Q3 2014 Rating SIR: 8.64	8.64
Q1 2013 - Q4 2013 Rating SIR: 6.02	6.02
Q3 2012 - Q2 2013 Rating SIR: 5.65	5.65
Q1 2012 - Q4 2012 Rating SIR: 6.89	6.89
Q4 2011 - Q3 2012 Rating SIR: 2.19	2.19
Q2 2011 - Q1 2012 Rating SIR: 3.32	3.32
Q1 2011 - Q4 2011 Rating SIR: 2.69	2.69
Q4 2010 - Q3 2011 Rating SIR: 2.48	2.48
Q1 2010 - Q4 2010 Rating SIR: 1.64	1.64
Q4 2009 - Q3 2010 Rating SIR: 1.72	1.72
Q1 2009 - Q4 2009 Rating SIR: 2.93	2.93
Q1 2008 - Q4 2008 Rating SIR: 0.23	0.23
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 8.38	8.38
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: 5.21	5.21
Q4 2019 - Q3 2020 Rating SIR: 1.72	1.72
Q4 2018 - Q3 2019 Rating SIR: 1.88	1.88
Q2 2018 - Q1 2019 Rating SIR: 2.17	2.17
Q1 2015 - Q4 2015 Rating SIR: 5.35	5.35
Q4 2014 - Q3 2015 Rating SIR: 7.95	7.95
Q1 2014 - Q4 2014 Rating SIR: 12.64	12.64
Q4 2013 - Q3 2014 Rating SIR: 12.72	12.72
Q1 2013 - Q4 2013 Rating SIR: 13.16	13.16
Q3 2012 - Q2 2013 Rating SIR: 8.80	8.80
Q1 2012 - Q4 2012 Rating SIR: 7.31	7.31
Q4 2011 - Q3 2012 Rating SIR: 7.88	7.88
Q2 2011 - Q1 2012 Rating SIR: 8.05	8.05
Q1 2011 - Q4 2011 Rating SIR: 8.44	8.44
Q4 2010 - Q3 2011 Rating SIR: 12.10	12.10
Q1 2010 - Q4 2010 Rating SIR: 8.47	8.47
Q4 2009 - Q3 2010 Rating SIR: 11.33	11.33
Q1 2009 - Q4 2009 Rating SIR: 6.37	6.37
Q1 2008 - Q4 2008 Rating SIR: 0.92	0.92
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: 0.31	0.31
Q2 2018 - Q1 2019 Rating SIR: 0.24	0.24
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
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 0.13	0.13
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: 0.13	0.13
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.28	0.28
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: 0.28	0.28
Q1 2014 - Q4 2014 Rating SIR: 0.48	0.48
Q4 2013 - Q3 2014 Rating SIR: 0.96	0.96
Q1 2013 - Q4 2013 Rating SIR: 0.78	0.78
Q3 2012 - Q2 2013 Rating SIR: 0.27	0.27
Q1 2012 - Q4 2012 Rating SIR: 0.27	0.27
Q4 2011 - Q3 2012 Rating SIR: 0.24	0.24
Q2 2011 - Q1 2012 Rating SIR: 0.26	0.26
Q1 2011 - Q4 2011 Rating SIR: 0.81	0.81
Q4 2010 - Q3 2011 Rating SIR: 0.27	0.27
Q1 2010 - Q4 2010 Rating SIR: 4.47	4.47
Q4 2009 - Q3 2010 Rating SIR: 1.04	1.04
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.24	0.24
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 4.53	4.53
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: 3.34	3.34
Q4 2019 - Q3 2020 Rating SIR: 2.56	2.56
Q4 2018 - Q3 2019 Rating SIR: 4.03	4.03
Q2 2018 - Q1 2019 Rating SIR: 4.49	4.49
Q1 2015 - Q4 2015 Rating SIR: 6.52	6.52
Q4 2014 - Q3 2015 Rating SIR: 6.18	6.18
Q1 2014 - Q4 2014 Rating SIR: 9.76	9.76
Q4 2013 - Q3 2014 Rating SIR: 12.09	12.09
Q1 2013 - Q4 2013 Rating SIR: 11.44	11.44
Q3 2012 - Q2 2013 Rating SIR: 8.59	8.59
Q1 2012 - Q4 2012 Rating SIR: 7.44	7.44
Q4 2011 - Q3 2012 Rating SIR: 5.07	5.07
Q2 2011 - Q1 2012 Rating SIR: 7.83	7.83
Q1 2011 - Q4 2011 Rating SIR: 7.23	7.23
Q4 2010 - Q3 2011 Rating SIR: 5.44	5.44
Q1 2010 - Q4 2010 Rating SIR: 6.82	6.82
Q4 2009 - Q3 2010 Rating SIR: 6.52	6.52
Q1 2009 - Q4 2009 Rating SIR: 4.70	4.70
Q1 2008 - Q4 2008 Rating SIR: 1.17	1.17
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 1.03	1.03
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: 1.22	1.22
Q4 2019 - Q3 2020 Rating SIR: 0.91	0.91
Q4 2018 - Q3 2019 Rating SIR: 0.64	0.64
Q2 2018 - Q1 2019 Rating SIR: 0.62	0.62
Q1 2015 - Q4 2015 Rating SIR: 0.70	0.70
Q4 2014 - Q3 2015 Rating SIR: 0.82	0.82
Q1 2014 - Q4 2014 Rating SIR: 0.47	0.47
Q4 2013 - Q3 2014 Rating SIR: 0.00	0.00
Q1 2013 - Q4 2013 Rating SIR: 0.50	0.50
Q3 2012 - Q2 2013 Rating SIR: 0.26	0.26
Q1 2012 - Q4 2012 Rating SIR: 0.28	0.28
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.80	0.80
Q1 2011 - Q4 2011 Rating SIR: 0.37	0.37
Q4 2010 - Q3 2011 Rating SIR: 1.21	1.21
Q1 2010 - Q4 2010 Rating SIR: 1.44	1.44
Q4 2009 - Q3 2010 Rating SIR: 0.37	0.37
Q1 2009 - Q4 2009 Rating SIR: 0.76	0.76
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 0 infections, 114361 patient days Rating SIR: 0.00	0 infections, 114361 patient days	0.00
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 3 infections, 111758 patient days Rating SIR: 0.62	3 infections, 111758 patient days	0.62
Q1 2021 - Q4 2021 Result 2 infections, 111419 patient days Rating SIR: 0.46	2 infections, 111419 patient days	0.46
Q1 2020 - Q4 2020 Result 5 infections, 104961 patient days Rating SIR: 0.98	5 infections, 104961 patient days	0.98
Q1 2019 - Q4 2019 Result 6 infections, 109385 patient days Rating SIR: 1.16	6 infections, 109385 patient days	1.16
Q1 2018 - Q4 2018 Result 4 infections, 107010 patient days Rating SIR: 0.96	4 infections, 107010 patient days	0.96
Q1 2017 - Q4 2017 Result 1 infections, 105590 patient days Rating SIR: 0.24	1 infections, 105590 patient days	0.24
Q1 2016 - Q4 2016 Result 4 infections, 103229 patient days Rating SIR: 1.00	4 infections, 103229 patient days	1.00
Q1 2015 - Q4 2015 Result 2 infections, 103552 patient days Rating SIR: 0.36	2 infections, 103552 patient days	0.36
Q1 2014 - Q4 2014 Result 7 infections, 100450 patient days Rating SIR: 1.18	7 infections, 100450 patient days	1.18
Q1 2013 - Q4 2013 Result 4 infections, 92567 patient days Rating SIR: 1.02	4 infections, 92567 patient days	1.02
Q1 2012 - Q4 2012 Result 3 infections, 95978 patient days Rating SIR: 0.70	3 infections, 95978 patient days	0.70
Q1 2012 - Q2 2012 Result 0 infections, 48164 patient days Rating SIR: 0.00	0 infections, 48164 patient days	0.00
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 31 infections, 100558 patient days Rating SIR: 0.41	31 infections, 100558 patient days	0.41
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 67 infections, 97831 patient days Rating SIR: 0.72	67 infections, 97831 patient days	0.72
Q1 2021 - Q4 2021 Result 47 infections, 97701 patient days Rating SIR: 0.51	47 infections, 97701 patient days	0.51
Q1 2020 - Q4 2020 Result 62 infections, 92931 patient days Rating SIR: 0.66	62 infections, 92931 patient days	0.66
Q1 2019 - Q4 2019 Result 51 infections, 95116 patient days Rating SIR: 0.57	51 infections, 95116 patient days	0.57
Q1 2018 - Q4 2018 Result 66 infections, 93116 patient days Rating SIR: 0.82	66 infections, 93116 patient days	0.82
Q1 2017 - Q4 2017 Result 80 infections, 91498 patient days Rating SIR: 0.95	80 infections, 91498 patient days	0.95
Q1 2016 - Q4 2016 Result 83 infections, 90380 patient days Rating SIR: 0.91	83 infections, 90380 patient days	0.91
Q1 2015 - Q4 2015 Result 80 infections, 91178 patient days Rating SIR: 1.06	80 infections, 91178 patient days	1.06
Q1 2014 - Q4 2014 Result 94 infections, 86907 patient days Rating SIR: 1.24	94 infections, 86907 patient days	1.24
Q1 2013 - Q4 2013 Result 92 infections, 81207 patient days Rating SIR: 1.29	92 infections, 81207 patient days	1.29
Q1 2012 - Q4 2012 Result 65 infections, 82117 patient days Rating SIR: 0.92	65 infections, 82117 patient days	0.92

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 0 infections, 1377 central-line days Rating SIR: 0.00	0 infections, 1377 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Adult Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 1 infections, 1873 central-line days Rating SIR: 0.62	1 infections, 1873 central-line days	0.62
Q1 2021 - Q4 2021 Result 1 infections, 2088 central-line days Rating SIR: 0.55	1 infections, 2088 central-line days	0.55
Q1 2020 - Q4 2020 Result 1 infections, 1921 central-line days Rating SIR: 0.60	1 infections, 1921 central-line days	0.60
Q1 2019 - Q4 2019 Result 2 infections, 1849 central-line days Rating SIR: 1.25	2 infections, 1849 central-line days	1.25
Q1 2018 - Q4 2018 Result 0 infections, 1981 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1981 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 1854 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1854 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 2148 central-line days Rating SIR: 0.54	1 infections, 2148 central-line days	0.54
Q1 2015 - Q4 2015 Result 2 infections, 2129 central-line days Rating SIR: 0.63	2 infections, 2129 central-line days	0.63
Q1 2014 - Q4 2014 Result 2 infections, 2437 central-line days Rating SIR: 0.55	2 infections, 2437 central-line days	0.55
Q1 2013 - Q4 2013 Result 0 infections, 2210 central-line days Rating SIR: 0.00	0 infections, 2210 central-line days	0.00
Q1 2012 - Q4 2012 Result 1 infections, 2088 central-line days Rating SIR: 0.32	1 infections, 2088 central-line days	0.32
Q1 2011 - Q4 2011 Result 2 infections, 2069 central-line days Rating SIR: 0.64	2 infections, 2069 central-line days	0.64
Q1 2010 - Q4 2010 Result 2 infections, 1861 central-line days Rating SIR: 0.72	2 infections, 1861 central-line days	0.72
Q1 2009 - Q4 2009 Result 4 infections, 1874 central-line days Rating SIR: 1.42	4 infections, 1874 central-line days	1.42
Q1 2009 - Q2 2009 Result 3 infections, 1037 central-line days Rating SIR: 2.89	3 infections, 1037 central-line days	2.89
Adult Medical/Surgical ICU, Second Unit Q1 2023 - Q4 2023 Result 0 infections, 2 central-line days Rating SIR: N/A	0 infections, 2 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 1 central-line days ³³ Rating SIR: N/A ³³	0 infections, 1 central-line days ³³	N/A ³³
Q1 2021 - Q4 2021 Result 0 infections, 1 central-line days ³³ Rating SIR: N/A ³³	0 infections, 1 central-line days ³³	N/A ³³
Q1 2012 - Q4 2012 Result 0 infections, 1862 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 1862 central-line days ⁴³	0.00 ⁴³
Q1 2011 - Q4 2011 Result 0 infections, 1602 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 1602 central-line days ⁴³	0.00 ⁴³
Q1 2010 - Q4 2010 Result 2 infections, 1396 central-line days Rating SIR: 0.96	2 infections, 1396 central-line days	0.96
Adult Medical ICU Q1 2023 - Q4 2023 Result 3 infections, 1851 central-line days Rating SIR: 1.87	3 infections, 1851 central-line days	1.87
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 1 infections, 2349 central-line days Rating SIR: 0.49	1 infections, 2349 central-line days	0.49
Q1 2021 - Q4 2021 Result 6 infections, 3042 central-line days Rating SIR: 2.27	6 infections, 3042 central-line days	2.27
Q1 2020 - Q4 2020 Result 5 infections, 2193 central-line days Rating SIR: 2.63	5 infections, 2193 central-line days	2.63
Q1 2019 - Q4 2019 Result 0 infections, 2399 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2399 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 0 infections, 2322 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2322 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 2484 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2484 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 2665 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2665 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 1 infections, 2958 central-line days Rating SIR: 0.18	1 infections, 2958 central-line days	0.18
Q1 2014 - Q4 2014 Result 4 infections, 2523 central-line days Rating SIR: 0.83	4 infections, 2523 central-line days	0.83
Q1 2013 - Q4 2013 Result 2 infections, 2178 central-line days Rating SIR: 0.48	2 infections, 2178 central-line days	0.48

Ped. CLABSI Measure	Result	SIR
Pediatric Medical ICU Q1 2014 - Q4 2014 Result 0 infections, 20 central-line days ³³ Rating SIR: N/A ³³	0 infections, 20 central-line days ³³	N/A ³³
Description Central Line-associated Bloodstream Infection data in the Medical Pediatric ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2013 - Q4 2013 Result 0 infections, 58 central-line days ⁴³ Rating SIR: N/A ⁴³	0 infections, 58 central-line days ⁴³	N/A ⁴³
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 2012 - Q4 2012 Result 0 infections, 21 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 21 central-line days ³³	0.00 ³³
Q1 2011 - Q4 2011 Result 0 infections, 21 central-line days ³³ Rating SIR: N/A ³³	0 infections, 21 central-line days ³³	N/A ³³
Q1 2010 - Q4 2010 Result 0 infections, 45 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 45 central-line days ³³	0.00 ³³
Q1 2010 - Q2 2010 Result 0 infections, 25 central-line days ³³ Rating SIR: N/A ³³	0 infections, 25 central-line days ³³	N/A ³³

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 1 infections, 1536 central-line days Rating SIR: 0.42	1 infections, 1536 central-line days	0.42
Description Central Line-associated Bloodstream Infection data in the Level II/III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 1 infections, 1187 central-line days Rating SIR: 0.58	1 infections, 1187 central-line days	0.58
Q1 2021 - Q4 2021 Result 2 infections, 1577 central-line days Rating SIR: 0.87	2 infections, 1577 central-line days	0.87
Q1 2020 - Q4 2020 Result 2 infections, 1526 central-line days Rating SIR: 0.89	2 infections, 1526 central-line days	0.89
Q1 2019 - Q4 2019 Result 1 infections, 1540 central-line days Rating SIR: 0.47	1 infections, 1540 central-line days	0.47
Q1 2018 - Q4 2018 Result 0 infections, 1263 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1263 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 1 infections, 1393 central-line days Rating SIR: 0.54	1 infections, 1393 central-line days	0.54
Q1 2016 - Q4 2016 Result 1 infections, 1144 central-line days Rating SIR: 0.58	1 infections, 1144 central-line days	0.58
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 2 infections, 925 central-line days Rating SIR: 0.78	2 infections, 925 central-line days	0.78
Q1 2013 - Q4 2013 Result 1 infections, 626 central-line days Rating SIR: 0.62	1 infections, 626 central-line days	0.62
Q1 2012 - Q4 2012 Result 0 infections, 1474 central-line days Rating SIR: 0.00	0 infections, 1474 central-line days	0.00
Q1 2011 - Q4 2011 Result 1 infections, 893 central-line days Rating SIR: 0.40	1 infections, 893 central-line days	0.40
Q1 2010 - Q4 2010 Result 1 infections, 979 central-line days Rating SIR: 0.37	1 infections, 979 central-line days	0.37
Q1 2010 - Q2 2010 Result 0 infections, 289 central-line days Rating SIR: 0.00	0 infections, 289 central-line days	0.00

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 1 infections, 615 procedures Rating SIR: 0.62	1 infections, 615 procedures	0.62
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 6 infections, 796 procedures Rating SIR: 3.45	6 infections, 796 procedures	3.45
Q1 2018 - Q4 2018 Result 5 infections, 821 procedures Rating SIR: 2.61	5 infections, 821 procedures	2.61
Q1 2017 - Q4 2017 Result 1 infections, 740 procedures Rating SIR: 0.56	1 infections, 740 procedures	0.56
Q1 2016 - Q4 2016 Result 4 infections, 723 procedures Rating SIR: 2.28	4 infections, 723 procedures	2.28
Q1 2015 - Q4 2015 Result 0 infections, 658 procedures Rating SIR: 0.00	0 infections, 658 procedures	0.00
Q1 2014 - Q4 2014 Result 0 infections, 556 procedures Rating SIR: 0.00	0 infections, 556 procedures	0.00
Q3 2013 - Q2 2014 Result 1 infections, 581 procedures Rating SIR: 0.33	1 infections, 581 procedures	0.33
Q3 2012 - Q2 2013 Result 0 infections, 496 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 496 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 4 infections, 553 procedures Rating SIR: 1.41	4 infections, 553 procedures	1.41
Q3 2010 - Q2 2011 Result 2 infections, 569 procedures Rating SIR: 0.68	2 infections, 569 procedures	0.68
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 0 infections, 176 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 176 procedures ¹¹⁷	0.00 ¹¹⁷
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, 189 procedures Rating SIR: 0.78	1 infections, 189 procedures	0.78
Q1 2018 - Q4 2018 Result 0 infections, 219 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 219 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 197 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 197 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 2 infections, 170 procedures Rating SIR: 1.13	2 infections, 170 procedures	1.13
Q1 2014 - Q4 2014 Result 0 infections, 193 procedures Rating SIR: 0.00	0 infections, 193 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 189 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 189 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 170 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 170 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 0 infections, 168 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 168 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 163 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 163 procedures ⁴⁶	0.00 ⁴⁶