UChicago Medicine

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 state average or performing at the best possible rate

Not statistically significantly better or worse than state average

Statistically significantly worse than state average

Footnotes

Key	Description
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
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

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 state average or performing at the best possible rate

Not statistically significantly better or worse than state average

Statistically significantly worse than state average

Footnotes

Key	Description
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
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

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 state average or performing at the best possible rate

Not statistically significantly better or worse than state average

Statistically significantly worse than state average

Footnotes

Key	Description
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
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

Immunization Practices

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

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

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

Immunization

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

Measure	Result
Healthcare workers given influenza vaccination Q4 2022 - Q1 2023 Result 96.00 %	96.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 95.00 %	95.00 %
Q4 2020 - Q1 2021 Result 95.00 %	95.00 %
Q4 2019 - Q1 2020 Result 95.00 %	95.00 %
Q4 2018 - Q1 2019 Result 95.00 %	95.00 %
Q4 2017 - Q1 2018 Result 92.00 %	92.00 %

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 15 infections, 233430 patient days Rating SIR: 0.83	15 infections, 233430 patient days	0.83
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 15 infections, 238141 patient days Rating SIR: 0.81	15 infections, 238141 patient days	0.81
Q1 2021 - Q4 2021 Result 20 infections, 238817 patient days Rating SIR: 0.97	20 infections, 238817 patient days	0.97
Q1 2020 - Q4 2020 Result 16 infections, 217337 patient days Rating SIR: 0.94	16 infections, 217337 patient days	0.94
Q1 2019 - Q4 2019 Result 17 infections, 215998 patient days Rating SIR: 0.94	17 infections, 215998 patient days	0.94
Q1 2018 - Q4 2018 Result 9 infections, 206561 patient days Rating SIR: 0.40	9 infections, 206561 patient days	0.40
Q1 2017 - Q4 2017 Result 6 infections, 202075 patient days Rating SIR: 0.45	6 infections, 202075 patient days	0.45
Q1 2016 - Q4 2016 Result 7 infections, 197279 patient days Rating SIR: 0.42	7 infections, 197279 patient days	0.42
Q1 2015 - Q4 2015 Result 16 infections, 185216 patient days Rating SIR: 0.92	16 infections, 185216 patient days	0.92
Q1 2014 - Q4 2014 Result 10 infections, 176765 patient days Rating SIR: 0.55	10 infections, 176765 patient days	0.55
Q1 2013 - Q4 2013 Result 23 infections, 163834 patient days Rating SIR: 1.35	23 infections, 163834 patient days	1.35
Q1 2012 - Q4 2012 Result 20 infections, 154403 patient days Rating SIR: 1.19	20 infections, 154403 patient days	1.19
Q1 2012 - Q2 2012 Result 8 infections, 76102 patient days Rating SIR: 1.05	8 infections, 76102 patient days	1.05
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 120 infections, 213222 patient days Rating SIR: 0.63	120 infections, 213222 patient days	0.63
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 99 infections, 216685 patient days Rating SIR: 0.54	99 infections, 216685 patient days	0.54
Q1 2021 - Q4 2021 Result 114 infections, 217871 patient days Rating SIR: 0.61	114 infections, 217871 patient days	0.61
Q1 2020 - Q4 2020 Result 113 infections, 195196 patient days Rating SIR: 0.65	113 infections, 195196 patient days	0.65
Q1 2019 - Q4 2019 Result 113 infections, 197687 patient days Rating SIR: 0.57	113 infections, 197687 patient days	0.57
Q1 2018 - Q4 2018 Result 181 infections, 185769 patient days Rating SIR: 0.96	181 infections, 185769 patient days	0.96
Q1 2017 - Q4 2017 Result 211 infections, 179872 patient days Rating SIR: 1.10	211 infections, 179872 patient days	1.10
Q1 2016 - Q4 2016 Result 189 infections, 171434 patient days Rating SIR: 1.01	189 infections, 171434 patient days	1.01
Q1 2015 - Q4 2015 Result 203 infections, 168125 patient days Rating SIR: 1.20	203 infections, 168125 patient days	1.20
Q1 2014 - Q4 2014 Result 213 infections, 154366 patient days Rating SIR: 2.00	213 infections, 154366 patient days	2.00
Q1 2013 - Q4 2013 Result 195 infections, 141442 patient days Rating SIR: 1.37	195 infections, 141442 patient days	1.37
Q1 2012 - Q4 2012 Result 174 infections, 136014 patient days Rating SIR: 1.33	174 infections, 136014 patient days	1.33

Adult CLABSI Measure	Result	SIR
Adult Neurosurgical ICU Q1 2023 - Q4 2023 Result 0 infections, 1031 central-line days Rating SIR: 0.00	0 infections, 1031 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Adult Neurosurgical ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 1 infections, 1109 central-line days Rating SIR: 0.80	1 infections, 1109 central-line days	0.80
Q1 2021 - Q4 2021 Result 1 infections, 1201 central-line days Rating SIR: 0.74	1 infections, 1201 central-line days	0.74
Q1 2020 - Q4 2020 Result 1 infections, 1245 central-line days Rating SIR: 0.71	1 infections, 1245 central-line days	0.71
Q1 2019 - Q4 2019 Result 0 infections, 1114 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1114 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 1257 central-line days Rating SIR: 1.41	2 infections, 1257 central-line days	1.41
Q1 2017 - Q4 2017 Result 2 infections, 1076 central-line days Rating SIR: 1.65	2 infections, 1076 central-line days	1.65
Q1 2016 - Q4 2016 Result 1 infections, 1110 central-line days Rating SIR: 0.80	1 infections, 1110 central-line days	0.80
Q1 2015 - Q4 2015 Result 1 infections, 1378 central-line days Rating SIR: 0.29	1 infections, 1378 central-line days	0.29
Q1 2014 - Q4 2014 Result 1 infections, 1538 central-line days Rating SIR: 0.26	1 infections, 1538 central-line days	0.26
Q1 2013 - Q4 2013 Result 0 infections, 1469 central-line days Rating SIR: 0.00	0 infections, 1469 central-line days	0.00
Q1 2012 - Q4 2012 Result 0 infections, 1370 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 1370 central-line days ⁴³	0.00 ⁴³
Adult Surgical Cardiothoracic ICU Q1 2023 - Q4 2023 Result 9 infections, 6904 central-line days Rating SIR: 1.16	9 infections, 6904 central-line days	1.16
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 2022 - Q4 2022 Result 6 infections, 7487 central-line days Rating SIR: 0.71	6 infections, 7487 central-line days	0.71
Q1 2021 - Q4 2021 Result 5 infections, 7093 central-line days Rating SIR: 0.63	5 infections, 7093 central-line days	0.63
Q1 2020 - Q4 2020 Result 5 infections, 6199 central-line days Rating SIR: 0.72	5 infections, 6199 central-line days	0.72
Q1 2019 - Q4 2019 Result 10 infections, 7634 central-line days Rating SIR: 1.16	10 infections, 7634 central-line days	1.16
Q1 2018 - Q4 2018 Result 4 infections, 6881 central-line days Rating SIR: 0.52	4 infections, 6881 central-line days	0.52
Q1 2017 - Q4 2017 Result 9 infections, 6731 central-line days Rating SIR: 1.19	9 infections, 6731 central-line days	1.19
Q1 2016 - Q4 2016 Result 7 infections, 4329 central-line days Rating SIR: 1.43	7 infections, 4329 central-line days	1.43
Q1 2015 - Q4 2015 Result 2 infections, 3209 central-line days Rating SIR: 0.45	2 infections, 3209 central-line days	0.45
Q1 2014 - Q4 2014 Result 0 infections, 3468 central-line days Rating SIR: 0.00	0 infections, 3468 central-line days	0.00
Q1 2013 - Q4 2013 Result 1 infections, 3042 central-line days Rating SIR: 0.24	1 infections, 3042 central-line days	0.24
Q1 2012 - Q4 2012 Result 1 infections, 2559 central-line days Rating SIR: 0.28	1 infections, 2559 central-line days	0.28
Adult Medical Cardiac ICU Q1 2016 - Q4 2016 Result 1 infections, 1290 central-line days Rating SIR: 0.69	1 infections, 1290 central-line days	0.69
Description Central Line-associated Bloodstream Infection data in the Adult Medical Cardiac ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2015 - Q4 2015 Result 3 infections, 1736 central-line days Rating SIR: 0.86	3 infections, 1736 central-line days	0.86
Q1 2014 - Q4 2014 Result 3 infections, 2847 central-line days Rating SIR: 0.53	3 infections, 2847 central-line days	0.53
Q1 2013 - Q4 2013 Result 1 infections, 1756 central-line days Rating SIR: 0.29	1 infections, 1756 central-line days	0.29
Q1 2012 - Q4 2012 Result 3 infections, 2023 central-line days Rating SIR: 0.74	3 infections, 2023 central-line days	0.74
Adult Burn ICU Q1 2023 - Q4 2023 Result 0 infections, 715 central-line days Rating SIR: 0.00	0 infections, 715 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Adult Burn ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 863 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 863 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 2 infections, 1015 central-line days Rating SIR: 0.58	2 infections, 1015 central-line days	0.58
Q1 2020 - Q4 2020 Result 0 infections, 699 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 699 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 1 infections, 899 central-line days Rating SIR: 0.33	1 infections, 899 central-line days	0.33
Q1 2018 - Q4 2018 Result 1 infections, 585 central-line days Rating SIR: 0.50	1 infections, 585 central-line days	0.50
Q1 2017 - Q4 2017 Result 1 infections, 840 central-line days Rating SIR: 0.35	1 infections, 840 central-line days	0.35
Q1 2016 - Q4 2016 Result 0 infections, 696 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 696 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 561 central-line days Rating SIR: 0.00	0 infections, 561 central-line days	0.00
Q1 2014 - Q4 2014 Result 0 infections, 548 central-line days Rating SIR: 0.00	0 infections, 548 central-line days	0.00
Q1 2013 - Q4 2013 Result 0 infections, 531 central-line days ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 531 central-line days ⁴⁶	0.00 ⁴⁶
Q1 2012 - Q4 2012 Result 0 infections, 535 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 535 central-line days ⁴³	0.00 ⁴³
Adult Surgical ICU Q1 2023 - Q4 2023 Result 3 infections, 2773 central-line days Rating SIR: 0.96	3 infections, 2773 central-line days	0.96
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 3 infections, 2982 central-line days Rating SIR: 0.89	3 infections, 2982 central-line days	0.89
Q1 2021 - Q4 2021 Result 1 infections, 2408 central-line days Rating SIR: 0.37	1 infections, 2408 central-line days	0.37
Q1 2020 - Q4 2020 Result 2 infections, 2370 central-line days Rating SIR: 0.75	2 infections, 2370 central-line days	0.75
Q1 2016 - Q4 2016 Result 1 infections, 1857 central-line days Rating SIR: 0.50	1 infections, 1857 central-line days	0.50
Q1 2015 - Q4 2015 Result 1 infections, 1538 central-line days Rating SIR: 0.28	1 infections, 1538 central-line days	0.28
Q1 2014 - Q4 2014 Result 2 infections, 2038 central-line days Rating SIR: 0.43	2 infections, 2038 central-line days	0.43
Q1 2013 - Q4 2013 Result 1 infections, 1863 central-line days Rating SIR: 0.23	1 infections, 1863 central-line days	0.23
Q1 2012 - Q4 2012 Result 0 infections, 1768 central-line days Rating SIR: 0.00	0 infections, 1768 central-line days	0.00
Q1 2011 - Q4 2011 Result 2 infections, 1672 central-line days Rating SIR: 0.52	2 infections, 1672 central-line days	0.52
Q1 2010 - Q4 2010 Result 1 infections, 2006 central-line days Rating SIR: 0.22	1 infections, 2006 central-line days	0.22
Q1 2009 - Q4 2009 Result 1 infections, 1812 central-line days Rating SIR: 0.24	1 infections, 1812 central-line days	0.24
Q1 2009 - Q2 2009 Result 1 infections, 900 central-line days Rating SIR: 1.11	1 infections, 900 central-line days	1.11
Adult Medical ICU Q1 2023 - Q4 2023 Result 2 infections, 1074 central-line days Rating SIR: 1.65	2 infections, 1074 central-line days	1.65
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 2 infections, 1386 central-line days Rating SIR: 1.28	2 infections, 1386 central-line days	1.28
Q1 2021 - Q4 2021 Result 0 infections, 997 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 997 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 835 central-line days Rating SIR: N/A	1 infections, 835 central-line days	N/A
Q1 2019 - Q4 2019 Result 4 infections, 2202 central-line days Rating SIR: 1.61	4 infections, 2202 central-line days	1.61
Q1 2018 - Q4 2018 Result 5 infections, 2199 central-line days Rating SIR: 2.02	5 infections, 2199 central-line days	2.02
Q1 2017 - Q4 2017 Result 3 infections, 1962 central-line days Rating SIR: 1.36	3 infections, 1962 central-line days	1.36
Q1 2016 - Q4 2016 Result 3 infections, 4427 central-line days Rating SIR: 0.60	3 infections, 4427 central-line days	0.60
Q1 2015 - Q4 2015 Result 3 infections, 2792 central-line days Rating SIR: 0.41	3 infections, 2792 central-line days	0.41
Q1 2014 - Q4 2014 Result 3 infections, 3072 central-line days Rating SIR: 0.38	3 infections, 3072 central-line days	0.38
Q1 2013 - Q4 2013 Result 1 infections, 3259 central-line days Rating SIR: 0.12	1 infections, 3259 central-line days	0.12
Q1 2012 - Q4 2012 Result 0 infections, 3317 central-line days Rating SIR: 0.00	0 infections, 3317 central-line days	0.00
Q1 2011 - Q4 2011 Result 2 infections, 2901 central-line days Rating SIR: 0.27	2 infections, 2901 central-line days	0.27
Q1 2010 - Q4 2010 Result 3 infections, 3077 central-line days Rating SIR: 0.38	3 infections, 3077 central-line days	0.38
Q1 2009 - Q4 2009 Result 12 infections, 2910 central-line days Rating SIR: 1.59	12 infections, 2910 central-line days	1.59
Q1 2009 - Q2 2009 Result 4 infections, 1562 central-line days Rating SIR: 2.56	4 infections, 1562 central-line days	2.56
Adult Medical ICU, Second Unit Q1 2023 - Q4 2023 Result 4 infections, 1808 central-line days Rating SIR: 1.96	4 infections, 1808 central-line days	1.96
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 2 infections, 2106 central-line days Rating SIR: 0.84	2 infections, 2106 central-line days	0.84
Q1 2021 - Q4 2021 Result 1 infections, 2299 central-line days Rating SIR: 0.39	1 infections, 2299 central-line days	0.39
Q1 2020 - Q4 2020 Result 1 infections, 1761 central-line days Rating SIR: 0.50	1 infections, 1761 central-line days	0.50
Q1 2019 - Q4 2019 Result 3 infections, 1959 central-line days Rating SIR: 1.36	3 infections, 1959 central-line days	1.36
Q1 2018 - Q4 2018 Result 1 infections, 1760 central-line days Rating SIR: 0.50	1 infections, 1760 central-line days	0.50
Q1 2017 - Q4 2017 Result 1 infections, 1751 central-line days Rating SIR: 0.51	1 infections, 1751 central-line days	0.51
Q1 2015 - Q4 2015 Result 2 infections, 1865 central-line days Rating SIR: 0.41	2 infections, 1865 central-line days	0.41
Adult Medical ICU, Third Unit Q1 2023 - Q4 2023 Result 1 infections, 1723 central-line days Rating SIR: 0.51	1 infections, 1723 central-line days	0.51
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 2 infections, 2229 central-line days Rating SIR: 0.80	2 infections, 2229 central-line days	0.80
Q1 2021 - Q4 2021 Result 0 infections, 2053 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2053 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 2003 central-line days Rating SIR: 0.44	1 infections, 2003 central-line days	0.44
Q1 2017 - Q4 2017 Result 0 infections, 184 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 184 central-line days ⁴²	N/A ⁴²

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2023 - Q4 2023 Result 6 infections, 3545 central-line days Rating SIR: 1.18	6 infections, 3545 central-line days	1.18
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, 3477 central-line days Rating SIR: 1.20	6 infections, 3477 central-line days	1.20
Q1 2021 - Q4 2021 Result 4 infections, 3557 central-line days Rating SIR: 0.78	4 infections, 3557 central-line days	0.78
Q1 2020 - Q4 2020 Result 3 infections, 2432 central-line days Rating SIR: 0.86	3 infections, 2432 central-line days	0.86
Q1 2019 - Q4 2019 Result 2 infections, 2275 central-line days Rating SIR: 0.61	2 infections, 2275 central-line days	0.61
Q1 2018 - Q4 2018 Result 5 infections, 2001 central-line days Rating SIR: 1.74	5 infections, 2001 central-line days	1.74
Q1 2017 - Q4 2017 Result 1 infections, 2107 central-line days Rating SIR: 0.33	1 infections, 2107 central-line days	0.33
Q1 2016 - Q4 2016 Result 3 infections, 2899 central-line days Rating SIR: 0.72	3 infections, 2899 central-line days	0.72
Q1 2015 - Q4 2015 Result 5 infections, 3029 central-line days Rating SIR: 0.55	5 infections, 3029 central-line days	0.55
Q1 2014 - Q4 2014 Result 0 infections, 2337 central-line days Rating SIR: 0.00	0 infections, 2337 central-line days	0.00
Q1 2013 - Q4 2013 Result 2 infections, 2575 central-line days Rating SIR: 0.26	2 infections, 2575 central-line days	0.26
Q1 2012 - Q4 2012 Result 4 infections, 2548 central-line days Rating SIR: 0.52	4 infections, 2548 central-line days	0.52
Q1 2011 - Q4 2011 Result 4 infections, 2624 central-line days Rating SIR: 0.51	4 infections, 2624 central-line days	0.51
Q1 2010 - Q4 2010 Result 0 infections, 2249 central-line days Rating SIR: 0.00	0 infections, 2249 central-line days	0.00
Q1 2010 - Q2 2010 Result 0 infections, 1248 central-line days Rating SIR: 0.00	0 infections, 1248 central-line days	0.00
Pediatric Cardiothoracic ICU Q1 2019 - Q4 2019 Result 1 infections, 861 central-line days Rating SIR: 0.81	1 infections, 861 central-line days	0.81
Description Central Line-associated Bloodstream Infection data in the Pediatric Cardiothoracic ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result 1 infections, 804 central-line days Rating SIR: 0.86	1 infections, 804 central-line days	0.86
Q1 2017 - Q4 2017 Result 0 infections, 797 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 797 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 348 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 348 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 287 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 287 central-line days ⁴²	N/A ⁴²
Q1 2014 - Q4 2014 Result 0 infections, 181 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 181 central-line days ⁴²	N/A ⁴²
Q1 2013 - Q4 2013 Result 2 infections, 318 central-line days Rating SIR: 1.91	2 infections, 318 central-line days	1.91
Q1 2012 - Q4 2012 Result 0 infections, 374 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 374 central-line days ⁴³	0.00 ⁴³
Q1 2011 - Q4 2011 Result 0 infections, 429 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 429 central-line days ⁴³	0.00 ⁴³
Q1 2010 - Q4 2010 Result 1 infections, 334 central-line days Rating SIR: 0.91	1 infections, 334 central-line days	0.91
Q1 2010 - Q2 2010 Result 0 infections, 209 central-line days Rating SIR: 0.00	0 infections, 209 central-line days	0.00

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 53 central-line days Rating SIR: N/A	0 infections, 53 central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Level II/III Neonatal ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 151 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 151 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 64 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 64 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 0 infections, 101 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 101 central-line days ⁴²	N/A ⁴²
Q1 2019 - Q4 2019 Result 0 infections, 125 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 125 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 0 infections, 133 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 133 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 0 infections, 575 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 575 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 0 infections, 562 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 562 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 110 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 110 central-line days ⁴²	N/A ⁴²
Q1 2014 - Q4 2014 Result 0 infections, 185 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 185 central-line days ⁴²	N/A ⁴²
Q1 2013 - Q4 2013 Result 0 infections, 129 central-line days ⁴³ Rating SIR: N/A ⁴³	0 infections, 129 central-line days ⁴³	N/A ⁴³
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 2 infections, 4413 central-line days Rating SIR: 0.31	2 infections, 4413 central-line days	0.31
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 4 infections, 6925 central-line days Rating SIR: 0.41	4 infections, 6925 central-line days	0.41
Q1 2021 - Q4 2021 Result 3 infections, 6525 central-line days Rating SIR: 0.34	3 infections, 6525 central-line days	0.34
Q1 2020 - Q4 2020 Result 7 infections, 7026 central-line days Rating SIR: 0.67	7 infections, 7026 central-line days	0.67
Q1 2019 - Q4 2019 Result 4 infections, 5313 central-line days Rating SIR: 0.59	4 infections, 5313 central-line days	0.59
Q1 2018 - Q4 2018 Result 6 infections, 5692 central-line days Rating SIR: 0.88	6 infections, 5692 central-line days	0.88
Q1 2017 - Q4 2017 Result 3 infections, 7494 central-line days Rating SIR: 0.25	3 infections, 7494 central-line days	0.25
Q1 2016 - Q4 2016 Result 6 infections, 9094 central-line days Rating SIR: 0.47	6 infections, 9094 central-line days	0.47
Q1 2015 - Q4 2015 Result 4 infections, 6729 central-line days Rating SIR: 0.24	4 infections, 6729 central-line days	0.24
Q1 2014 - Q4 2014 Result 4 infections, 6716 central-line days Rating SIR: 0.26	4 infections, 6716 central-line days	0.26
Q1 2013 - Q4 2013 Result 4 infections, 6987 central-line days Rating SIR: 0.25	4 infections, 6987 central-line days	0.25
Q1 2012 - Q4 2012 Result 6 infections, 7117 central-line days Rating SIR: 0.38	6 infections, 7117 central-line days	0.38
Q1 2011 - Q4 2011 Result 8 infections, 6891 central-line days Rating SIR: 0.45	8 infections, 6891 central-line days	0.45
Q1 2010 - Q4 2010 Result 9 infections, 7559 central-line days Rating SIR: 0.50	9 infections, 7559 central-line days	0.50
Q1 2010 - Q2 2010 Result 4 infections, 2997 central-line days Rating SIR: 0.49	4 infections, 2997 central-line days	0.49

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 1 infections, 326 procedures Rating SIR: 0.50	1 infections, 326 procedures	0.50
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, 412 procedures Rating SIR: 0.83	2 infections, 412 procedures	0.83
Q1 2018 - Q4 2018 Result 3 infections, 370 procedures Rating SIR: 1.39	3 infections, 370 procedures	1.39
Q1 2017 - Q4 2017 Result 1 infections, 314 procedures Rating SIR: 0.47	1 infections, 314 procedures	0.47
Q1 2016 - Q4 2016 Result 1 infections, 285 procedures Rating SIR: 0.54	1 infections, 285 procedures	0.54
Q1 2015 - Q4 2015 Result 2 infections, 281 procedures Rating SIR: 0.73	2 infections, 281 procedures	0.73
Q1 2014 - Q4 2014 Result 0 infections, 275 procedures Rating SIR: 0.00	0 infections, 275 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 226 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 226 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 182 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 182 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 244 procedures Rating SIR: 0.41	1 infections, 244 procedures	0.41
Q3 2010 - Q2 2011 Result 0 infections, 242 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 242 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 0 infections, 220 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 220 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 0 infections, 210 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 210 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 237 procedures Rating SIR: 0.78	2 infections, 237 procedures	0.78
Q1 2016 - Q4 2016 Result 1 infections, 174 procedures Rating SIR: 0.40	1 infections, 174 procedures	0.40
Q1 2015 - Q4 2015 Result 1 infections, 147 procedures Rating SIR: 0.39	1 infections, 147 procedures	0.39
Q1 2014 - Q4 2014 Result 0 infections, 152 procedures Rating SIR: 0.00	0 infections, 152 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 149 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 149 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 114 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 114 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 2 infections, 124 procedures Rating SIR: 0.98	2 infections, 124 procedures	0.98
Q3 2010 - Q2 2011 Result 0 infections, 155 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 155 procedures ⁴⁶	0.00 ⁴⁶