Advocate Good Samaritan 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
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
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
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
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
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
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
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
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
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 83.00 %	83.00 %
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 98.00 %	98.00 %
Q4 2018 - Q1 2019 Result 96.00 %	96.00 %
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
36	Incomplete Reporting
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
43	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44	Complete Reporting: Too few central line days to calculate a precise SIR
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
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 4.94	4.94
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: 5.13	5.13
Q4 2019 - Q3 2020 Rating SIR: 5.23	5.23
Q4 2018 - Q3 2019 Rating SIR: 5.63	5.63
Q2 2018 - Q1 2019 Rating SIR: 4.47	4.47
Q1 2015 - Q4 2015 Rating SIR: 11.05	11.05
Q4 2014 - Q3 2015 Rating SIR: 9.14	9.14
Q1 2014 - Q4 2014 Rating SIR: 10.38	10.38
Q4 2013 - Q3 2014 Rating SIR: 11.23	11.23
Q1 2013 - Q4 2013 Rating SIR: 10.84	10.84
Q3 2012 - Q2 2013 Rating SIR: 8.73	8.73
Q1 2012 - Q4 2012 Rating SIR: 9.48	9.48
Q4 2011 - Q3 2012 Rating SIR: 7.13	7.13
Q2 2011 - Q1 2012 Rating SIR: 0.73	0.73
Q1 2011 - Q4 2011 Rating SIR: 6.40	6.40
Q4 2010 - Q3 2011 Rating SIR: 7.48	7.48
Q1 2010 - Q4 2010 Rating SIR: 9.57	9.57
Q4 2009 - Q3 2010 Rating SIR: 9.84	9.84
Q1 2009 - Q4 2009 Rating SIR: 14.80	14.80
Q3 2008 - Q2 2009 Rating SIR: 13.50	13.50
Q1 2008 - Q4 2008 Rating SIR: 13.70	13.70
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: 2.97	2.97
Q4 2019 - Q3 2020 Rating SIR: 2.40	2.40
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: 1.99	1.99
Q4 2013 - Q3 2014 Rating SIR: 3.88	3.88
Q1 2013 - Q4 2013 Rating SIR: 1.84	1.84
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: 1.01	1.01
Q4 2009 - Q3 2010 Rating SIR: 2.21	2.21
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.34	0.34
Q1 2008 - Q4 2008 Rating SIR: 0.61	0.61
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 2.14	2.14
Description The number of cases of accidental cut, puncture, perforation, or laceration during procedure per 1,000 discharges. (PSI 15) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.40	0.40
Q4 2019 - Q3 2020 Rating SIR: 0.48	0.48
Q4 2018 - Q3 2019 Rating SIR: 0.45	0.45
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.62	0.62
Q4 2014 - Q3 2015 Rating SIR: 0.38	0.38
Q1 2014 - Q4 2014 Rating SIR: 0.31	0.31
Q4 2013 - Q3 2014 Rating SIR: 0.25	0.25
Q1 2013 - Q4 2013 Rating SIR: 0.67	0.67
Q3 2012 - Q2 2013 Rating SIR: 0.74	0.74
Q1 2012 - Q4 2012 Rating SIR: 0.52	0.52
Q4 2011 - Q3 2012 Rating SIR: 0.37	0.37
Q2 2011 - Q1 2012 Rating SIR: 0.04	0.04
Q1 2011 - Q4 2011 Rating SIR: 1.74	1.74
Q4 2010 - Q3 2011 Rating SIR: 1.83	1.83
Q1 2010 - Q4 2010 Rating SIR: 1.97	1.97
Q4 2009 - Q3 2010 Rating SIR: 1.93	1.93
Q1 2009 - Q4 2009 Rating SIR: 1.05	1.05
Q3 2008 - Q2 2009 Rating SIR: 1.20	1.20
Q1 2008 - Q4 2008 Rating SIR: 1.80	1.80
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.30	0.30
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: 0.24	0.24
Q4 2019 - Q3 2020 Rating SIR: 0.42	0.42
Q4 2018 - Q3 2019 Rating SIR: 0.21	0.21
Q2 2018 - Q1 2019 Rating SIR: 0.13	0.13
Q1 2015 - Q4 2015 Rating SIR: 0.08	0.08
Q4 2014 - Q3 2015 Rating SIR: 0.09	0.09
Q1 2014 - Q4 2014 Rating SIR: 0.17	0.17
Q4 2013 - Q3 2014 Rating SIR: 0.19	0.19
Q1 2013 - Q4 2013 Rating SIR: 0.18	0.18
Q3 2012 - Q2 2013 Rating SIR: 0.27	0.27
Q1 2012 - Q4 2012 Rating SIR: 0.19	0.19
Q4 2011 - Q3 2012 Rating SIR: 0.11	0.11
Q2 2011 - Q1 2012 Rating SIR: 0.01	0.01
Q1 2011 - Q4 2011 Rating SIR: 0.76	0.76
Q4 2010 - Q3 2011 Rating SIR: 0.14	0.14
Q1 2010 - Q4 2010 Rating SIR: 0.06	0.06
Q4 2009 - Q3 2010 Rating SIR: 0.29	0.29
Q1 2009 - Q4 2009 Rating SIR: 0.81	0.81
Q3 2008 - Q2 2009 Rating SIR: 0.30	0.30
Q1 2008 - Q4 2008 Rating SIR: 0.30	0.30
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 1.57	1.57
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: 0.91	0.91
Q4 2019 - Q3 2020 Rating SIR: 3.08	3.08
Q4 2018 - Q3 2019 Rating SIR: 0.90	0.90
Q2 2018 - Q1 2019 Rating SIR: 1.85	1.85
Q1 2015 - Q4 2015 Rating SIR: 3.39	3.39
Q4 2014 - Q3 2015 Rating SIR: 5.35	5.35
Q1 2014 - Q4 2014 Rating SIR: 5.26	5.26
Q4 2013 - Q3 2014 Rating SIR: 3.23	3.23
Q1 2013 - Q4 2013 Rating SIR: 5.44	5.44
Q3 2012 - Q2 2013 Rating SIR: 3.78	3.78
Q1 2012 - Q4 2012 Rating SIR: 2.99	2.99
Q4 2011 - Q3 2012 Rating SIR: 1.96	1.96
Q2 2011 - Q1 2012 Rating SIR: 2.66	2.66
Q1 2011 - Q4 2011 Rating SIR: 3.00	3.00
Q4 2010 - Q3 2011 Rating SIR: 3.35	3.35
Q1 2010 - Q4 2010 Rating SIR: 2.79	2.79
Q4 2009 - Q3 2010 Rating SIR: 2.84	2.84
Q1 2009 - Q4 2009 Rating SIR: 2.61	2.61
Q3 2008 - Q2 2009 Rating SIR: 0.21	0.21
Q1 2008 - Q4 2008 Rating SIR: 0.13	0.13
Postoperative Respiratory Failure Q4 2021 - Q3 2022 Rating SIR: 28.23	28.23
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: 33.54	33.54
Q4 2019 - Q3 2020 Rating SIR: 24.32	24.32
Q4 2018 - Q3 2019 Rating SIR: 14.48	14.48
Q2 2018 - Q1 2019 Rating SIR: 12.58	12.58
Q1 2015 - Q4 2015 Rating SIR: 10.93	10.93
Q4 2014 - Q3 2015 Rating SIR: 9.86	9.86
Q1 2014 - Q4 2014 Rating SIR: 3.47	3.47
Q4 2013 - Q3 2014 Rating SIR: 3.44	3.44
Q1 2013 - Q4 2013 Rating SIR: 4.01	4.01
Q3 2012 - Q2 2013 Rating SIR: 4.64	4.64
Q1 2012 - Q4 2012 Rating SIR: 8.82	8.82
Q4 2011 - Q3 2012 Rating SIR: 10.79	10.79
Q2 2011 - Q1 2012 Rating SIR: 8.17	8.17
Q1 2011 - Q4 2011 Rating SIR: 8.49	8.49
Q4 2010 - Q3 2011 Rating SIR: 8.80	8.80
Q1 2010 - Q4 2010 Rating SIR: 8.58	8.58
Q4 2009 - Q3 2010 Rating SIR: 13.43	13.43
Q1 2009 - Q4 2009 Rating SIR: 10.44	10.44
Q3 2008 - Q2 2009 Rating SIR: 0.46	0.46
Q1 2008 - Q4 2008 Rating SIR: 0.47	0.47
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: 0.07	0.07
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: 0.40	0.40
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: 0.26	0.26
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.12	0.12
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: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.34	0.34
Q1 2013 - Q4 2013 Rating SIR: 0.31	0.31
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: 0.31	0.31
Q1 2011 - Q4 2011 Rating SIR: 0.85	0.85
Q4 2010 - Q3 2011 Rating SIR: 0.57	0.57
Q1 2010 - Q4 2010 Rating SIR: 0.26	0.26
Q4 2009 - Q3 2010 Rating SIR: 0.86	0.86
Q1 2009 - Q4 2009 Rating SIR: 0.88	0.88
Q3 2008 - Q2 2009 Rating SIR: 0.05	0.05
Q1 2008 - Q4 2008 Rating SIR: 0.27	0.27
Postoperative Sepsis Q4 2021 - Q3 2022 Rating SIR: 5.58	5.58
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: 5.06	5.06
Q4 2019 - Q3 2020 Rating SIR: 0.77	0.77
Q4 2018 - Q3 2019 Rating SIR: 2.57	2.57
Q2 2018 - Q1 2019 Rating SIR: 4.38	4.38
Q1 2015 - Q4 2015 Rating SIR: 16.25	16.25
Q4 2014 - Q3 2015 Rating SIR: 15.73	15.73
Q1 2014 - Q4 2014 Rating SIR: 5.17	5.17
Q4 2013 - Q3 2014 Rating SIR: 9.90	9.90
Q1 2013 - Q4 2013 Rating SIR: 13.57	13.57
Q3 2012 - Q2 2013 Rating SIR: 8.20	8.20
Q1 2012 - Q4 2012 Rating SIR: 4.02	4.02
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 6.82	6.82
Q1 2011 - Q4 2011 Rating SIR: 7.20	7.20
Q4 2010 - Q3 2011 Rating SIR: 11.57	11.57
Q1 2010 - Q4 2010 Rating SIR: 15.87	15.87
Q4 2009 - Q3 2010 Rating SIR: 18.43	18.43
Q1 2009 - Q4 2009 Rating SIR: 12.35	12.35
Q3 2008 - Q2 2009 Rating SIR: 1.25	1.25
Q1 2008 - Q4 2008 Rating SIR: 1.17	1.17
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2021 - Q3 2022 Rating SIR: 0.71	0.71
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: 1.01	1.01
Q4 2019 - Q3 2020 Rating SIR: 0.65	0.65
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.41	0.41
Q1 2015 - Q4 2015 Rating SIR: 0.42	0.42
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: 0.40	0.40
Q1 2012 - Q4 2012 Rating SIR: 0.37	0.37
Q4 2011 - Q3 2012 Rating SIR: 0.39	0.39
Q2 2011 - Q1 2012 Rating SIR: 0.38	0.38
Q1 2011 - Q4 2011 Rating SIR: 0.37	0.37
Q4 2010 - Q3 2011 Rating SIR: 0.39	0.39
Q1 2010 - Q4 2010 Rating SIR: 0.37	0.37
Q4 2009 - Q3 2010 Rating SIR: 0.37	0.37
Q1 2009 - Q4 2009 Rating SIR: 1.47	1.47
Q3 2008 - Q2 2009 Rating SIR: 0.18	0.18
Q1 2008 - Q4 2008 Rating SIR: 0.04	0.04

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 2 infections, 86851 patient days Rating SIR: 0.49	2 infections, 86851 patient days	0.49
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 2 infections, 88257 patient days Rating SIR: 0.42	2 infections, 88257 patient days	0.42
Q1 2021 - Q4 2021 Result 2 infections, 82013 patient days Rating SIR: 0.45	2 infections, 82013 patient days	0.45
Q1 2020 - Q4 2020 Result 1 infections, 66889 patient days Rating SIR: 0.23	1 infections, 66889 patient days	0.23
Q1 2019 - Q4 2019 Result 1 infections, 75055 patient days Rating SIR: 0.22	1 infections, 75055 patient days	0.22
Q1 2018 - Q4 2018 Result 1 infections, 77438 patient days Rating SIR: 0.33	1 infections, 77438 patient days	0.33
Q1 2017 - Q4 2017 Result 2 infections, 79961 patient days Rating SIR: 0.71	2 infections, 79961 patient days	0.71
Q1 2016 - Q4 2016 Result 1 infections, 79718 patient days Rating SIR: 0.31	1 infections, 79718 patient days	0.31
Q1 2015 - Q4 2015 Result 0 infections, 80141 patient days Rating SIR: 0.00	0 infections, 80141 patient days	0.00
Q1 2014 - Q4 2014 Result 3 infections, 80340 patient days Rating SIR: 0.98	3 infections, 80340 patient days	0.98
Q1 2013 - Q4 2013 Result 1 infections, 81830 patient days Rating SIR: 0.28	1 infections, 81830 patient days	0.28
Q1 2012 - Q4 2012 Result 0 infections, 79142 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 79142 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2012 - Q2 2012 Result 0 infections, 40777 patient days Rating SIR: 0.00	0 infections, 40777 patient days	0.00
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 4 infections, 80138 patient days Rating SIR: 0.11	4 infections, 80138 patient days	0.11
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 18 infections, 82007 patient days Rating SIR: 0.49	18 infections, 82007 patient days	0.49
Q1 2021 - Q4 2021 Result 17 infections, 79132 patient days Rating SIR: 0.46	17 infections, 79132 patient days	0.46
Q1 2020 - Q4 2020 Result 12 infections, 63307 patient days Rating SIR: 0.40	12 infections, 63307 patient days	0.40
Q1 2019 - Q4 2019 Result 15 infections, 68555 patient days Rating SIR: 0.50	15 infections, 68555 patient days	0.50
Q1 2018 - Q4 2018 Result 42 infections, 71844 patient days Rating SIR: 1.03	42 infections, 71844 patient days	1.03
Q1 2017 - Q4 2017 Result 65 infections, 71878 patient days Rating SIR: 1.54	65 infections, 71878 patient days	1.54
Q1 2016 - Q4 2016 Result 52 infections, 71830 patient days Rating SIR: 1.27	52 infections, 71830 patient days	1.27
Q1 2015 - Q4 2015 Result 65 infections, 68147 patient days Rating SIR: 1.28	65 infections, 68147 patient days	1.28
Q1 2014 - Q4 2014 Result 51 infections, 68351 patient days Rating SIR: 0.96	51 infections, 68351 patient days	0.96
Q1 2013 - Q4 2013 Result 35 infections, 74037 patient days Rating SIR: 0.62	35 infections, 74037 patient days	0.62
Q1 2012 - Q4 2012 Result 47 infections, 70765 patient days Rating SIR: 0.86	47 infections, 70765 patient days	0.86

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 1 infections, 2839 central-line days Rating SIR: 0.41	1 infections, 2839 central-line days	0.41
Description Central Line-associated Bloodstream Infection data in the Adult Medical/Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 5 infections, 3016 central-line days Rating SIR: 1.47	5 infections, 3016 central-line days	1.47
Q1 2021 - Q4 2021 Result 1 infections, 3098 central-line days Rating SIR: 0.29	1 infections, 3098 central-line days	0.29
Q1 2019 - Q4 2019 Result 3 infections, 2822 central-line days Rating SIR: 0.94	3 infections, 2822 central-line days	0.94
Q1 2018 - Q4 2018 Result 3 infections, 3465 central-line days Rating SIR: 1.00	3 infections, 3465 central-line days	1.00
Q1 2017 - Q4 2017 Result 2 infections, 3624 central-line days Rating SIR: 0.64	2 infections, 3624 central-line days	0.64
Q1 2016 - Q4 2016 Result 2 infections, 3334 central-line days Rating SIR: 0.69	2 infections, 3334 central-line days	0.69
Q1 2015 - Q4 2015 Result 0 infections, 3366 central-line days Rating SIR: 0.00	0 infections, 3366 central-line days	0.00
Q1 2014 - Q4 2014 Result 1 infections, 3394 central-line days Rating SIR: 0.20	1 infections, 3394 central-line days	0.20
Q1 2013 - Q4 2013 Result 0 infections, 3376 central-line days Rating SIR: 0.00	0 infections, 3376 central-line days	0.00
Q1 2012 - Q4 2012 Result 1 infections, 3815 central-line days Rating SIR: 0.18	1 infections, 3815 central-line days	0.18
Q1 2011 - Q4 2011 Result 2 infections, 5233 central-line days Rating SIR: 0.26	2 infections, 5233 central-line days	0.26
Q1 2010 - Q4 2010 Result 5 infections, 6650 central-line days Rating SIR: 0.50	5 infections, 6650 central-line days	0.50
Q1 2009 - Q4 2009 Result 4 infections, 6162 central-line days Rating SIR: 0.43	4 infections, 6162 central-line days	0.43
Q1 2009 - Q2 2009 Result 1 infections, 3206 central-line days Rating SIR: 0.31	1 infections, 3206 central-line days	0.31

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2017 - Q4 2017 Result 0 infections, 210 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 210 central-line days ⁴²	N/A 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 2016 - Q4 2016 Result 0 infections, 400 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 400 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 1 infections, 512 central-line days Rating SIR: 0.74	1 infections, 512 central-line days	0.74
Q1 2014 - Q4 2014 Result 2 infections, 509 central-line days Rating SIR: 1.33	2 infections, 509 central-line days	1.33
Q1 2013 - Q4 2013 Result 1 infections, 651 central-line days Rating SIR: 0.59	1 infections, 651 central-line days	0.59
Q1 2012 - Q4 2012 Result 0 infections, 566 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 566 central-line days ⁴³	0.00 ⁴³
Q1 2011 - Q4 2011 Result 3 infections, 549 central-line days Rating SIR: 2.67	3 infections, 549 central-line days	2.67
Q1 2010 - Q4 2010 Result 0 infections, 506 central-line days ³⁶ Rating SIR: 0.00 ³⁶	0 infections, 506 central-line days ³⁶	0.00 ³⁶
Q1 2010 - Q2 2010 Result 0 infections, 130 central-line days Rating SIR: 0.00	0 infections, 130 central-line days	0.00
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 308 central-line days Rating SIR: N/A	0 infections, 308 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Level III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 390 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 390 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 163 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 163 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 0 infections, 288 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 288 central-line days ⁴²	N/A ⁴²
Q1 2019 - Q4 2019 Result 1 infections, 370 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 370 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 0 infections, 390 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 390 central-line days ⁴²	N/A ⁴²

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 0 infections, 243 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 243 procedures ¹¹⁸	N/A ¹¹⁸
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 2 infections, 383 procedures Rating SIR: 1.38	2 infections, 383 procedures	1.38
Q1 2018 - Q4 2018 Result 2 infections, 352 procedures Rating SIR: 1.76	2 infections, 352 procedures	1.76
Q1 2017 - Q4 2017 Result 3 infections, 351 procedures Rating SIR: 2.69	3 infections, 351 procedures	2.69
Q1 2016 - Q4 2016 Result 4 infections, 319 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	4 infections, 319 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2015 - Q4 2015 Result 2 infections, 341 procedures Rating SIR: 1.01	2 infections, 341 procedures	1.01
Q1 2014 - Q4 2014 Result 2 infections, 343 procedures Rating SIR: 0.94	2 infections, 343 procedures	0.94
Q3 2013 - Q2 2014 Result 1 infections, 335 procedures Rating SIR: 0.47	1 infections, 335 procedures	0.47
Q3 2012 - Q2 2013 Result 0 infections, 327 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 327 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 289 procedures Rating SIR: 0.59	1 infections, 289 procedures	0.59
Q3 2010 - Q2 2011 Result 3 infections, 285 procedures Rating SIR: 1.91	3 infections, 285 procedures	1.91
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 1 infections, 136 procedures Rating SIR: 0.86	1 infections, 136 procedures	0.86
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 3 infections, 126 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	3 infections, 126 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2018 - Q4 2018 Result 1 infections, 134 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 134 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2016 - Q4 2016 Result 1 infections, 136 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 136 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2015 - Q4 2015 Result 0 infections, 145 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 145 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 0 infections, 145 procedures Rating SIR: 0.00	0 infections, 145 procedures	0.00
Q3 2013 - Q2 2014 Result 1 infections, 145 procedures Rating SIR: 0.62	1 infections, 145 procedures	0.62
Q3 2012 - Q2 2013 Result 0 infections, 139 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 139 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 155 procedures Rating SIR: 0.62	1 infections, 155 procedures	0.62
Q3 2010 - Q2 2011 Result 3 infections, 142 procedures Rating SIR: 1.99	3 infections, 142 procedures	1.99