OSF Saint Francis Medical Center

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
39	Exempt: No Licensed NICU Beds
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
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: 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
39	Exempt: No Licensed NICU Beds
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
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: 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
39	Exempt: No Licensed NICU Beds
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
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
154	Complete Reporting: 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 82.00 %	82.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 86.00 %	86.00 %
Q4 2020 - Q1 2021 Result 88.00 %	88.00 %
Q4 2019 - Q1 2020 Result 92.00 %	92.00 %
Q4 2018 - Q1 2019 Result 96.00 %	96.00 %
Q4 2017 - Q1 2018 Result 93.00 %	93.00 %

Illinois Hospital Report Card

and Consumer Guide to Health Care

OSF Saint Francis Medical Center

Patient Safety - All

Healthcare-Associated Infections

Clostridioides difficile infections (CDI) and Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections

Statistical Significance

Description

Historical Data

Description

Historical Data

Central Line Associated Bloodstream Infections (CLABSIs)

Statistical Significance

Adult CLABSI

Description

Historical Data

Description

Historical Data

Description

Historical Data

Description

Historical Data

Pediatric CLABSI

Description

Historical Data

NICU CLABSI

Description

Historical Data

Surgical Site Infections (SSIs)

Statistical Significance

Description

Historical Data

Description

Historical Data

Immunization Practices

Immunization

Description

Historical Data

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2024 - Q4 2024 Result 10 infections, 208514 patient days Rating SIR: 0.44	10 infections, 208514 patient days	0.44
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 9 infections, 204788 patient days Rating SIR: 0.44	9 infections, 204788 patient days	0.44
Q1 2022 - Q4 2022 Result 13 infections, 198239 patient days Rating SIR: 0.60	13 infections, 198239 patient days	0.60
Q1 2021 - Q4 2021 Result 11 infections, 187346 patient days Rating SIR: 0.64	11 infections, 187346 patient days	0.64
Q1 2020 - Q4 2020 Result 10 infections, 176098 patient days Rating SIR: 0.55	10 infections, 176098 patient days	0.55
Q1 2019 - Q4 2019 Result 2 infections, 198563 patient days Rating SIR: 0.11	2 infections, 198563 patient days	0.11
Q1 2018 - Q4 2018 Result 5 infections, 196979 patient days Rating SIR: 0.25	5 infections, 196979 patient days	0.25
Q1 2017 - Q4 2017 Result 11 infections, 191847 patient days Rating SIR: 0.56	11 infections, 191847 patient days	0.56
Q1 2016 - Q4 2016 Result 9 infections, 175603 patient days Rating SIR: 0.68	9 infections, 175603 patient days	0.68
Q1 2015 - Q4 2015 Result 19 infections, 178346 patient days Rating SIR: 1.19	19 infections, 178346 patient days	1.19
Q1 2014 - Q4 2014 Result 5 infections, 178517 patient days Rating SIR: 0.27	5 infections, 178517 patient days	0.27
Q1 2013 - Q4 2013 Result 14 infections, 183528 patient days Rating SIR: 0.73	14 infections, 183528 patient days	0.73
Q1 2012 - Q4 2012 Result 16 infections, 184511 patient days Rating SIR: 0.82	16 infections, 184511 patient days	0.82
Q1 2012 - Q2 2012 Result 8 infections, 92601 patient days Rating SIR: 0.86	8 infections, 92601 patient days	0.86
Clostridioides difficile infections (CDI) Q1 2024 - Q4 2024 Result 41 infections, 187015 patient days Rating SIR: 0.43	41 infections, 187015 patient days	0.43
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 51 infections, 183751 patient days Rating SIR: 0.50	51 infections, 183751 patient days	0.50
Q1 2022 - Q4 2022 Result 41 infections, 175999 patient days Rating SIR: 0.36	41 infections, 175999 patient days	0.36
Q1 2021 - Q4 2021 Result 35 infections, 166146 patient days Rating SIR: 0.31	35 infections, 166146 patient days	0.31
Q1 2020 - Q4 2020 Result 49 infections, 156771 patient days Rating SIR: 0.38	49 infections, 156771 patient days	0.38
Q1 2019 - Q4 2019 Result 90 infections, 175246 patient days Rating SIR: 0.58	90 infections, 175246 patient days	0.58
Q1 2018 - Q4 2018 Result 148 infections, 174803 patient days Rating SIR: 0.95	148 infections, 174803 patient days	0.95
Q1 2017 - Q4 2017 Result 200 infections, 169448 patient days Rating SIR: 1.21	200 infections, 169448 patient days	1.21
Q1 2016 - Q4 2016 Result 203 infections, 157414 patient days Rating SIR: 1.25	203 infections, 157414 patient days	1.25
Q1 2015 - Q4 2015 Result 162 infections, 155972 patient days Rating SIR: 1.05	162 infections, 155972 patient days	1.05
Q1 2014 - Q4 2014 Result 177 infections, 157362 patient days Rating SIR: 1.19	177 infections, 157362 patient days	1.19
Q1 2013 - Q4 2013 Result 192 infections, 159467 patient days Rating SIR: 1.23	192 infections, 159467 patient days	1.23
Q1 2012 - Q4 2012 Result 201 infections, 163692 patient days Rating SIR: 1.31	201 infections, 163692 patient days	1.31

Adult CLABSI Measure	Result	SIR
Adult Neurologic ICU Q1 2024 - Q4 2024 Result 0 infections, 493 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 493 central-line days ⁴²	N/A ⁴²
Description Central Line-associated Bloodstream Infection data in the Adult Neurologic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 0 infections, 600 central-line days Rating SIR: N/A	0 infections, 600 central-line days	N/A
Q1 2022 - Q4 2022 Result 1 infections, 559 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 559 central-line days ⁴⁴	N/A ⁴⁴
Q1 2021 - Q4 2021 Result 0 infections, 612 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 612 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 2 infections, 827 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	2 infections, 827 central-line days ⁴⁴	N/A ⁴⁴
Q1 2019 - Q4 2019 Result 0 infections, 579 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 579 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 2 infections, 795 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	2 infections, 795 central-line days ⁴⁴	N/A ⁴⁴
Q1 2017 - Q4 2017 Result 1 infections, 877 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 877 central-line days ⁴⁴	N/A ⁴⁴
Q1 2016 - Q4 2016 Result 0 infections, 753 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 753 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 2 infections, 1127 central-line days Rating SIR: 1.27	2 infections, 1127 central-line days	1.27
Q1 2014 - Q4 2014 Result 1 infections, 1232 central-line days Rating SIR: 0.58	1 infections, 1232 central-line days	0.58
Adult Surgical Cardiothoracic ICU Q1 2024 - Q4 2024 Result 1 infections, 2669 central-line days Rating SIR: 0.33	1 infections, 2669 central-line days	0.33
Description Central Line-associated Bloodstream Infection data in the Adult Surgical Cardiothoracic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 1 infections, 2813 central-line days Rating SIR: 0.32	1 infections, 2813 central-line days	0.32
Q1 2022 - Q4 2022 Result 6 infections, 2646 central-line days Rating SIR: 2.01	6 infections, 2646 central-line days	2.01
Q1 2021 - Q4 2021 Result 9 infections, 2987 central-line days Rating SIR: 2.67	9 infections, 2987 central-line days	2.67
Q1 2020 - Q4 2020 Result 3 infections, 2628 central-line days Rating SIR: 1.01	3 infections, 2628 central-line days	1.01
Q1 2019 - Q4 2019 Result 6 infections, 2478 central-line days Rating SIR: 2.15	6 infections, 2478 central-line days	2.15
Q1 2018 - Q4 2018 Result 2 infections, 2522 central-line days Rating SIR: 0.70	2 infections, 2522 central-line days	0.70
Q1 2017 - Q4 2017 Result 2 infections, 2583 central-line days Rating SIR: 0.69	2 infections, 2583 central-line days	0.69
Q1 2016 - Q4 2016 Result 3 infections, 2786 central-line days Rating SIR: 0.95	3 infections, 2786 central-line days	0.95
Q1 2015 - Q4 2015 Result 4 infections, 3070 central-line days Rating SIR: 0.93	4 infections, 3070 central-line days	0.93
Q1 2013 - Q4 2013 Result 12 infections, 3736 central-line days Rating SIR: 2.29	12 infections, 3736 central-line days	2.29
Q1 2012 - Q4 2012 Result 9 infections, 4553 central-line days Rating SIR: 1.41	9 infections, 4553 central-line days	1.41
Adult Surgical ICU Q1 2024 - Q4 2024 Result 2 infections, 1142 central-line days Rating SIR: 1.55	2 infections, 1142 central-line days	1.55
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 3 infections, 1336 central-line days Rating SIR: 1.99	3 infections, 1336 central-line days	1.99
Q1 2022 - Q4 2022 Result 3 infections, 926 central-line days Rating SIR: 2.87	3 infections, 926 central-line days	2.87
Q1 2021 - Q4 2021 Result 1 infections, 1143 central-line days Rating SIR: 0.78	1 infections, 1143 central-line days	0.78
Q1 2020 - Q4 2020 Result 3 infections, 1093 central-line days Rating SIR: 2.43	3 infections, 1093 central-line days	2.43
Q1 2019 - Q4 2019 Result 1 infections, 1236 central-line days Rating SIR: 0.72	1 infections, 1236 central-line days	0.72
Q1 2018 - Q4 2018 Result 2 infections, 1361 central-line days Rating SIR: 1.30	2 infections, 1361 central-line days	1.30
Q1 2017 - Q4 2017 Result 3 infections, 1329 central-line days Rating SIR: 2.00	3 infections, 1329 central-line days	2.00
Q1 2016 - Q4 2016 Result 7 infections, 1711 central-line days Rating SIR: 3.63	7 infections, 1711 central-line days	3.63
Q1 2015 - Q4 2015 Result 4 infections, 2036 central-line days Rating SIR: 0.85	4 infections, 2036 central-line days	0.85
Q1 2013 - Q4 2013 Result 2 infections, 1665 central-line days Rating SIR: 0.52	2 infections, 1665 central-line days	0.52
Q1 2012 - Q4 2012 Result 4 infections, 1863 central-line days Rating SIR: 0.93	4 infections, 1863 central-line days	0.93
Q1 2011 - Q4 2011 Result 4 infections, 2460 central-line days Rating SIR: 0.71	4 infections, 2460 central-line days	0.71
Q1 2010 - Q4 2010 Result 3 infections, 1710 central-line days Rating SIR: 0.76	3 infections, 1710 central-line days	0.76
Q1 2009 - Q4 2009 Result 1 infections, 2034 central-line days Rating SIR: 0.21	1 infections, 2034 central-line days	0.21
Q1 2009 - Q2 2009 Result 1 infections, 975 central-line days Rating SIR: 1.03	1 infections, 975 central-line days	1.03
Adult Medical ICU Q1 2024 - Q4 2024 Result 2 infections, 1940 central-line days Rating SIR: 0.91	2 infections, 1940 central-line days	0.91
Description Central Line-associated Bloodstream Infection data in the Adult Medical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 5 infections, 1811 central-line days Rating SIR: 2.45	5 infections, 1811 central-line days	2.45
Q1 2022 - Q4 2022 Result 5 infections, 1722 central-line days Rating SIR: 2.57	5 infections, 1722 central-line days	2.57
Q1 2021 - Q4 2021 Result 0 infections, 1614 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1614 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 1548 central-line days Rating SIR: 0.57	1 infections, 1548 central-line days	0.57
Q1 2019 - Q4 2019 Result 1 infections, 1563 central-line days Rating SIR: 0.57	1 infections, 1563 central-line days	0.57
Q1 2018 - Q4 2018 Result 3 infections, 1613 central-line days Rating SIR: 1.65	3 infections, 1613 central-line days	1.65
Q1 2017 - Q4 2017 Result 2 infections, 1841 central-line days Rating SIR: 0.96	2 infections, 1841 central-line days	0.96
Q1 2016 - Q4 2016 Result 3 infections, 2366 central-line days Rating SIR: 1.12	3 infections, 2366 central-line days	1.12
Q1 2015 - Q4 2015 Result 4 infections, 2931 central-line days Rating SIR: 0.53	4 infections, 2931 central-line days	0.53
Q1 2014 - Q4 2014 Result 1 infections, 2891 central-line days Rating SIR: 0.13	1 infections, 2891 central-line days	0.13
Q1 2013 - Q4 2013 Result 1 infections, 3135 central-line days Rating SIR: 0.12	1 infections, 3135 central-line days	0.12
Q1 2012 - Q4 2012 Result 0 infections, 4055 central-line days Rating SIR: 0.00	0 infections, 4055 central-line days	0.00
Q1 2011 - Q4 2011 Result 4 infections, 3592 central-line days Rating SIR: 0.43	4 infections, 3592 central-line days	0.43
Q1 2010 - Q4 2010 Result 2 infections, 2158 central-line days Rating SIR: 0.36	2 infections, 2158 central-line days	0.36
Q1 2009 - Q4 2009 Result 2 infections, 1520 central-line days Rating SIR: 0.51	2 infections, 1520 central-line days	0.51
Q1 2009 - Q2 2009 Result 2 infections, 712 central-line days Rating SIR: 2.81	2 infections, 712 central-line days	2.81

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2023 - Q4 2023 Result 6 infections, 2865 central-line days Rating SIR: 1.45	6 infections, 2865 central-line days	1.45
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 6 infections, 1948 central-line days Rating SIR: 2.14	6 infections, 1948 central-line days	2.14
Q1 2021 - Q4 2021 Result 2 infections, 1868 central-line days Rating SIR: 0.74	2 infections, 1868 central-line days	0.74
Q1 2020 - Q4 2020 Result 1 infections, 2785 central-line days Rating SIR: 0.25	1 infections, 2785 central-line days	0.25
Q1 2019 - Q4 2019 Result 1 infections, 2857 central-line days Rating SIR: 0.24	1 infections, 2857 central-line days	0.24
Q1 2018 - Q4 2018 Result 3 infections, 3345 central-line days Rating SIR: 0.62	3 infections, 3345 central-line days	0.62
Q1 2017 - Q4 2017 Result 1 infections, 3102 central-line days Rating SIR: 0.22	1 infections, 3102 central-line days	0.22
Q1 2016 - Q4 2016 Result 4 infections, 3377 central-line days Rating SIR: 0.82	4 infections, 3377 central-line days	0.82
Q1 2015 - Q4 2015 Result 4 infections, 3151 central-line days Rating SIR: 0.42	4 infections, 3151 central-line days	0.42
Q1 2014 - Q4 2014 Result 2 infections, 3307 central-line days Rating SIR: 0.20	2 infections, 3307 central-line days	0.20
Q1 2013 - Q4 2013 Result 4 infections, 4005 central-line days Rating SIR: 0.33	4 infections, 4005 central-line days	0.33
Q1 2012 - Q4 2012 Result 2 infections, 3707 central-line days Rating SIR: 0.18	2 infections, 3707 central-line days	0.18
Q1 2011 - Q4 2011 Result 3 infections, 3230 central-line days Rating SIR: 0.31	3 infections, 3230 central-line days	0.31
Q1 2010 - Q4 2010 Result 5 infections, 2902 central-line days Rating SIR: 0.57	5 infections, 2902 central-line days	0.57
Q1 2010 - Q2 2010 Result 1 infections, 1233 central-line days Rating SIR: 0.27	1 infections, 1233 central-line days	0.27

NICU CLABSI Measure	Result	SIR
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 7 infections, 3117 central-line days Rating SIR: 1.41	7 infections, 3117 central-line days	1.41
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 16 infections, 3631 central-line days Rating SIR: 2.74	16 infections, 3631 central-line days	2.74
Q1 2021 - Q4 2021 Result 5 infections, 3223 central-line days Rating SIR: 1.02	5 infections, 3223 central-line days	1.02
Q1 2020 - Q4 2020 Result 5 infections, 2508 central-line days Rating SIR: 1.37	5 infections, 2508 central-line days	1.37
Q1 2019 - Q4 2019 Result 11 infections, 3262 central-line days Rating SIR: 2.30	11 infections, 3262 central-line days	2.30
Q1 2018 - Q4 2018 Result 5 infections, 3616 central-line days Rating SIR: 1.03	5 infections, 3616 central-line days	1.03
Q1 2017 - Q4 2017 Result 5 infections, 4325 central-line days Rating SIR: 0.84	5 infections, 4325 central-line days	0.84
Q1 2016 - Q4 2016 Result 3 infections, 3559 central-line days Rating SIR: 0.64	3 infections, 3559 central-line days	0.64
Q1 2015 - Q4 2015 Result 3 infections, 4075 central-line days Rating SIR: 0.33	3 infections, 4075 central-line days	0.33
Q1 2014 - Q4 2014 Result 3 infections, 3561 central-line days Rating SIR: 0.37	3 infections, 3561 central-line days	0.37
Q1 2013 - Q4 2013 Result N/A infections, N/A central-line days ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2012 - Q4 2012 Result 4 infections, 4166 central-line days Rating SIR: 0.40	4 infections, 4166 central-line days	0.40
Q1 2011 - Q4 2011 Result 9 infections, 5317 central-line days Rating SIR: 0.74	9 infections, 5317 central-line days	0.74
Q1 2010 - Q4 2010 Result 10 infections, 5369 central-line days Rating SIR: 0.78	10 infections, 5369 central-line days	0.78
Q1 2010 - Q2 2010 Result 2 infections, 1939 central-line days Rating SIR: 0.36	2 infections, 1939 central-line days	0.36

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2024 - Q4 2024 Result 1 infections, 302 procedures Rating SIR: 0.81	1 infections, 302 procedures	0.81
Description Surgical Site Infections Associated with Total Knee Replacement Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 5 infections, 306 procedures Rating SIR: 3.42	5 infections, 306 procedures	3.42
Q1 2022 - Q4 2022 Result 1 infections, 270 procedures Rating SIR: 0.93	1 infections, 270 procedures	0.93
Q1 2021 - Q4 2021 Result 0 infections, 310 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 310 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 306 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 306 procedures ¹⁵⁴	N/A ¹⁵⁴
Q1 2019 - Q4 2019 Result 3 infections, 774 procedures Rating SIR: 1.30	3 infections, 774 procedures	1.30
Q1 2018 - Q4 2018 Result 3 infections, 871 procedures Rating SIR: 1.24	3 infections, 871 procedures	1.24
Q1 2017 - Q4 2017 Result 4 infections, 828 procedures Rating SIR: 1.68	4 infections, 828 procedures	1.68
Q1 2016 - Q4 2016 Result 1 infections, 641 procedures Rating SIR: 0.53	1 infections, 641 procedures	0.53
Q1 2015 - Q4 2015 Result 0 infections, 553 procedures Rating SIR: 0.00	0 infections, 553 procedures	0.00
Q1 2014 - Q4 2014 Result 0 infections, 503 procedures Rating SIR: 0.00	0 infections, 503 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 508 procedures Rating SIR: 0.00	0 infections, 508 procedures	0.00
Q3 2012 - Q2 2013 Result 2 infections, 435 procedures Rating SIR: 0.68	2 infections, 435 procedures	0.68
Q3 2011 - Q2 2012 Result 0 infections, 425 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 425 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 3 infections, 388 procedures Rating SIR: 1.20	3 infections, 388 procedures	1.20
Coronary Artery Bypass Graft Surgery Q1 2024 - Q4 2024 Result 1 infections, 183 procedures Rating SIR: 0.57	1 infections, 183 procedures	0.57
Description Surgical Site Infections Associated with Coronary Artery Bypass Graft Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 3 infections, 243 procedures Rating SIR: 1.38	3 infections, 243 procedures	1.38
Q1 2022 - Q4 2022 Result 1 infections, 184 procedures Rating SIR: 0.61	1 infections, 184 procedures	0.61
Q1 2021 - Q4 2021 Result 3 infections, 174 procedures Rating SIR: 1.81	3 infections, 174 procedures	1.81
Q1 2020 - Q4 2020 Result 2 infections, 187 procedures Rating SIR: 1.19	2 infections, 187 procedures	1.19
Q1 2019 - Q4 2019 Result 1 infections, 220 procedures Rating SIR: 0.50	1 infections, 220 procedures	0.50
Q1 2018 - Q4 2018 Result 3 infections, 227 procedures Rating SIR: 1.52	3 infections, 227 procedures	1.52
Q1 2016 - Q4 2016 Result 3 infections, 185 procedures Rating SIR: 1.68	3 infections, 185 procedures	1.68
Q1 2015 - Q4 2015 Result 0 infections, 194 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 194 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 0 infections, 217 procedures Rating SIR: 0.00	0 infections, 217 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 192 procedures Rating SIR: 0.00	0 infections, 192 procedures	0.00
Q3 2012 - Q2 2013 Result 0 infections, 177 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 177 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 0 infections, 203 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 203 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 1 infections, 213 procedures Rating SIR: 0.31	1 infections, 213 procedures	0.31