John H Stroger Jr Hospital of Cook County

Patient Safety - All

Healthcare-Associated Infections

Hospitals in Illinois are participating in programs to reduce the number of infections acquired during hospital stays. While it is difficult to reduce infections to zero, following specific protocols can greatly reduce the risk.

The Hospital Report Card Act (Illinois Public Act 93-563) requires Illinois hospitals to report central line associated bloodstream infections (CLABSIs) as well as surgical site infections (SSIs). As of January 1, 2012, hospitals are also mandated to report Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections and Clostridioides difficileinfections. Infections are reported through the CDC’s National Healthcare Safety Network (NHSN) surveillance system. The Standardized Infection Ratio (SIR) , a summary measure used to determine whether infection data are statistically different from the national average, is presented for each type of infection shown below. Read more about healthcare-associated infections in Illinois . To learn more about the data collection methods using the CDC's National Health Safety Network (NHSN) surveillance system, read the Report Card methodology .

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

Facility-wide Healthcare Facility Onset Incidence Rates for CDI and MRSA are presented below. These rates are based on results of laboratory tests that were obtained on or after day four of an inpatient stay and do not consider presence or timing of clinical signs or symptoms. The Standardized Infection Ratio (SIR) is presented, which is a summary measure used to determine if rates of CDI and MRSA bloodstream infections are statistically different from the national average. Statewide summaries of CDI and MRSA data arranged by hospital are also included. Note: Starting with 2016 data, new methods for risk adjustment were used.

Statistical Significance

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

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
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
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed

Central Line Associated Bloodstream Infections (CLABSIs)

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

Statistical Significance

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

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
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
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed

Adult CLABSI

Pediatric CLABSI

NICU CLABSI

Surgical Site Infections (SSIs)

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

Statistical Significance

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

Not statistically significantly better or worse than the national average

Statistically significantly worse than the national average

Key	Description
42	Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
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
48	No Target Procedures Performed
49	Complete Reporting: 20 or Fewer Procedures Performed
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
118	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
153	Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
155	Complete Reporting: 20 or Fewer Procedures Performed

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 85.00 %	85.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 92.00 %	92.00 %
Q4 2020 - Q1 2021 Result 90.00 %	90.00 %
Q4 2019 - Q1 2020 Result N/A %	N/A %
Q4 2018 - Q1 2019 Result 97.00 %	97.00 %
Q4 2017 - Q1 2018 Result 94.00 %	94.00 %

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2024 - Q4 2024 Result 7 infections, 113034 patient days Rating SIR: 0.95	7 infections, 113034 patient days	0.95
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 3 infections, 106416 patient days Rating SIR: 0.39	3 infections, 106416 patient days	0.39
Q1 2022 - Q4 2022 Result 5 infections, 98946 patient days Rating SIR: 0.79	5 infections, 98946 patient days	0.79
Q1 2021 - Q4 2021 Result 5 infections, 95808 patient days Rating SIR: 1.06	5 infections, 95808 patient days	1.06
Q1 2020 - Q4 2020 Result 9 infections, 91922 patient days Rating SIR: 1.52	9 infections, 91922 patient days	1.52
Q1 2019 - Q4 2019 Result 7 infections, 104953 patient days Rating SIR: 1.06	7 infections, 104953 patient days	1.06
Q1 2018 - Q4 2018 Result 6 infections, 102049 patient days Rating SIR: 1.04	6 infections, 102049 patient days	1.04
Q1 2017 - Q4 2017 Result 4 infections, 107411 patient days Rating SIR: 0.55	4 infections, 107411 patient days	0.55
Q1 2016 - Q4 2016 Result 8 infections, 109464 patient days Rating SIR: 1.14	8 infections, 109464 patient days	1.14
Q1 2015 - Q4 2015 Result 14 infections, 109072 patient days Rating SIR: 1.56	14 infections, 109072 patient days	1.56
Q1 2014 - Q4 2014 Result 8 infections, 105711 patient days Rating SIR: 0.87	8 infections, 105711 patient days	0.87
Q1 2013 - Q4 2013 Result 13 infections, 105806 patient days Rating SIR: 1.33	13 infections, 105806 patient days	1.33
Q1 2012 - Q4 2012 Result 11 infections, 104678 patient days Rating SIR: 1.09	11 infections, 104678 patient days	1.09
Q1 2012 - Q2 2012 Result 1 infections, 54595 patient days Rating SIR: 0.18	1 infections, 54595 patient days	0.18
Clostridioides difficile infections (CDI) Q1 2024 - Q4 2024 Result 37 infections, 106061 patient days Rating SIR: 0.49	37 infections, 106061 patient days	0.49
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 27 infections, 100942 patient days Rating SIR: 0.38	27 infections, 100942 patient days	0.38
Q1 2022 - Q4 2022 Result 43 infections, 94692 patient days Rating SIR: 0.64	43 infections, 94692 patient days	0.64
Q1 2021 - Q4 2021 Result 43 infections, 90362 patient days Rating SIR: 0.69	43 infections, 90362 patient days	0.69
Q1 2020 - Q4 2020 Result 53 infections, 85204 patient days Rating SIR: 0.89	53 infections, 85204 patient days	0.89
Q1 2019 - Q4 2019 Result 64 infections, 96590 patient days Rating SIR: 0.91	64 infections, 96590 patient days	0.91
Q1 2018 - Q4 2018 Result 63 infections, 93308 patient days Rating SIR: 0.87	63 infections, 93308 patient days	0.87
Q1 2017 - Q4 2017 Result 60 infections, 97142 patient days Rating SIR: 0.82	60 infections, 97142 patient days	0.82
Q1 2016 - Q4 2016 Result 54 infections, 99266 patient days Rating SIR: 0.86	54 infections, 99266 patient days	0.86
Q1 2015 - Q4 2015 Result 59 infections, 98043 patient days Rating SIR: 0.73	59 infections, 98043 patient days	0.73
Q1 2014 - Q4 2014 Result 29 infections, 94112 patient days Rating SIR: 0.46	29 infections, 94112 patient days	0.46
Q1 2013 - Q4 2013 Result 30 infections, 95128 patient days Rating SIR: 0.47	30 infections, 95128 patient days	0.47
Q1 2012 - Q4 2012 Result 46 infections, 93358 patient days Rating SIR: 0.73	46 infections, 93358 patient days	0.73

Adult CLABSI Measure	Result	SIR
Adult Neurosurgical ICU Q1 2024 - Q4 2024 Result 0 infections, 435 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 435 central-line days ⁴²	N/A ⁴²
Description Central Line-associated Bloodstream Infection data in the Adult Neurosurgical ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 0 infections, 275 central-line days Rating SIR: N/A	0 infections, 275 central-line days	N/A
Q1 2022 - Q4 2022 Result 0 infections, 284 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 284 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 1 infections, 406 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 406 central-line days ⁴⁴	N/A ⁴⁴
Q1 2020 - Q4 2020 Result 1 infections, 417 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 417 central-line days ⁴⁴	N/A ⁴⁴
Q1 2019 - Q4 2019 Result 0 infections, 149 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 149 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 0 infections, 202 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 202 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 0 infections, 274 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 274 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 0 infections, 466 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 466 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 2 infections, 508 central-line days Rating SIR: 1.58	2 infections, 508 central-line days	1.58
Q1 2014 - Q4 2014 Result 1 infections, 828 central-line days Rating SIR: 0.48	1 infections, 828 central-line days	0.48
Q1 2013 - Q4 2013 Result 0 infections, 609 central-line days ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 609 central-line days ⁴⁶	0.00 ⁴⁶
Q1 2012 - Q4 2012 Result 2 infections, 571 central-line days Rating SIR: 1.40	2 infections, 571 central-line days	1.40
Adult Medical Cardiac ICU Q1 2024 - Q4 2024 Result 0 infections, 542 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 542 central-line days ⁴²	N/A ⁴²
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 2023 - Q4 2023 Result 0 infections, 726 central-line days Rating SIR: N/A	0 infections, 726 central-line days	N/A
Q1 2022 - Q4 2022 Result 0 infections, 645 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 645 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 621 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 621 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 3 infections, 824 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	3 infections, 824 central-line days ⁴⁴	N/A ⁴⁴
Q1 2019 - Q4 2019 Result 3 infections, 503 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	3 infections, 503 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 0 infections, 382 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 382 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 0 infections, 330 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 330 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 0 infections, 374 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 374 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 483 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 483 central-line days ⁴²	N/A ⁴²
Q1 2014 - Q4 2014 Result 0 infections, 310 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 310 central-line days ⁴²	N/A ⁴²
Q1 2013 - Q4 2013 Result 0 infections, 240 central-line days ⁴³ Rating SIR: N/A ⁴³	0 infections, 240 central-line days ⁴³	N/A ⁴³
Q1 2012 - Q4 2012 Result 0 infections, 410 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 410 central-line days ⁴²	N/A ⁴²
Adult Trauma ICU Q1 2024 - Q4 2024 Result 0 infections, 849 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 849 central-line days ¹¹⁷	0.00 ¹¹⁷
Description Central Line-associated Bloodstream Infection data in the Adult Trauma ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 0 infections, 1073 central-line days Rating SIR: 0.00	0 infections, 1073 central-line days	0.00
Q1 2022 - Q4 2022 Result 1 infections, 1191 central-line days Rating SIR: 0.55	1 infections, 1191 central-line days	0.55
Q1 2021 - Q4 2021 Result 0 infections, 1075 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1075 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 0 infections, 789 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 789 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 0 infections, 781 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 781 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 943 central-line days Rating SIR: 1.39	2 infections, 943 central-line days	1.39
Q1 2017 - Q4 2017 Result 2 infections, 1365 central-line days Rating SIR: 0.96	2 infections, 1365 central-line days	0.96
Q1 2016 - Q4 2016 Result 2 infections, 877 central-line days Rating SIR: 1.49	2 infections, 877 central-line days	1.49
Q1 2015 - Q4 2015 Result 0 infections, 652 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 652 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 0 infections, 839 central-line days Rating SIR: 0.00	0 infections, 839 central-line days	0.00
Q1 2013 - Q4 2013 Result 1 infections, 897 central-line days Rating SIR: 0.31	1 infections, 897 central-line days	0.31
Q1 2012 - Q4 2012 Result 6 infections, 1058 central-line days Rating SIR: 1.57	6 infections, 1058 central-line days	1.57
Adult Burn ICU Q1 2024 - Q4 2024 Result 1 infections, 655 central-line days Rating SIR: 0.45	1 infections, 655 central-line days	0.45
Description Central Line-associated Bloodstream Infection data in the Adult Burn ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 1 infections, 492 central-line days Rating SIR: 0.60	1 infections, 492 central-line days	0.60
Q1 2022 - Q4 2022 Result 0 infections, 578 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 578 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 0 infections, 474 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 474 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 266 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 266 central-line days ⁴⁴	N/A ⁴⁴
Q1 2019 - Q4 2019 Result 1 infections, 464 central-line days Rating SIR: 0.64	1 infections, 464 central-line days	0.64
Q1 2018 - Q4 2018 Result 1 infections, 536 central-line days Rating SIR: 0.55	1 infections, 536 central-line days	0.55
Q1 2017 - Q4 2017 Result 1 infections, 484 central-line days Rating SIR: 0.61	1 infections, 484 central-line days	0.61
Q1 2016 - Q4 2016 Result 0 infections, 804 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 804 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 1 infections, 629 central-line days Rating SIR: 0.29	1 infections, 629 central-line days	0.29
Q1 2014 - Q4 2014 Result 3 infections, 655 central-line days Rating SIR: 0.83	3 infections, 655 central-line days	0.83
Q1 2013 - Q4 2013 Result 0 infections, 618 central-line days Rating SIR: 0.00	0 infections, 618 central-line days	0.00
Q1 2012 - Q4 2012 Result 0 infections, 667 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 667 central-line days ⁴³	0.00 ⁴³
Adult Surgical ICU Q1 2024 - Q4 2024 Result 0 infections, 1695 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1695 central-line days ¹¹⁷	0.00 ¹¹⁷
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 1 infections, 1294 central-line days Rating SIR: 0.69	1 infections, 1294 central-line days	0.69
Q1 2022 - Q4 2022 Result 0 infections, 1611 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1611 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 0 infections, 1388 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1388 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 0 infections, 1599 central-line days Rating SIR: 0.00	0 infections, 1599 central-line days	0.00
Q1 2019 - Q4 2019 Result 1 infections, 1599 central-line days Rating SIR: 0.55	1 infections, 1599 central-line days	0.55
Q1 2018 - Q4 2018 Result 3 infections, 1514 central-line days Rating SIR: 1.76	3 infections, 1514 central-line days	1.76
Q1 2017 - Q4 2017 Result 0 infections, 1386 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1386 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 1252 central-line days Rating SIR: 0.71	1 infections, 1252 central-line days	0.71
Q1 2015 - Q4 2015 Result 2 infections, 1534 central-line days Rating SIR: 0.57	2 infections, 1534 central-line days	0.57
Q1 2014 - Q4 2014 Result 4 infections, 1751 central-line days Rating SIR: 0.99	4 infections, 1751 central-line days	0.99
Q1 2013 - Q4 2013 Result 0 infections, 1622 central-line days Rating SIR: 0.00	0 infections, 1622 central-line days	0.00
Q1 2012 - Q4 2012 Result 3 infections, 1979 central-line days Rating SIR: 0.66	3 infections, 1979 central-line days	0.66
Q1 2011 - Q4 2011 Result 9 infections, 1910 central-line days Rating SIR: 2.05	9 infections, 1910 central-line days	2.05
Q1 2010 - Q4 2010 Result 5 infections, 1952 central-line days Rating SIR: 1.11	5 infections, 1952 central-line days	1.11
Q1 2009 - Q4 2009 Result 3 infections, 1939 central-line days Rating SIR: 0.67	3 infections, 1939 central-line days	0.67
Q1 2009 - Q2 2009 Result 1 infections, 898 central-line days Rating SIR: 1.11	1 infections, 898 central-line days	1.11
Adult Medical ICU Q1 2024 - Q4 2024 Result 3 infections, 1779 central-line days Rating SIR: 1.50	3 infections, 1779 central-line days	1.50
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 2 infections, 1813 central-line days Rating SIR: 0.98	2 infections, 1813 central-line days	0.98
Q1 2022 - Q4 2022 Result 2 infections, 1854 central-line days Rating SIR: 0.96	2 infections, 1854 central-line days	0.96
Q1 2021 - Q4 2021 Result 3 infections, 2469 central-line days Rating SIR: 1.08	3 infections, 2469 central-line days	1.08
Q1 2020 - Q4 2020 Result 8 infections, 3166 central-line days Rating SIR: 2.24	8 infections, 3166 central-line days	2.24
Q1 2019 - Q4 2019 Result 5 infections, 2355 central-line days Rating SIR: 1.88	5 infections, 2355 central-line days	1.88
Q1 2018 - Q4 2018 Result 2 infections, 2255 central-line days Rating SIR: 0.79	2 infections, 2255 central-line days	0.79
Q1 2017 - Q4 2017 Result 1 infections, 2486 central-line days Rating SIR: 0.36	1 infections, 2486 central-line days	0.36
Q1 2016 - Q4 2016 Result 1 infections, 2587 central-line days Rating SIR: 0.34	1 infections, 2587 central-line days	0.34
Q1 2015 - Q4 2015 Result 1 infections, 2085 central-line days Rating SIR: 0.18	1 infections, 2085 central-line days	0.18
Q1 2014 - Q4 2014 Result 1 infections, 1983 central-line days Rating SIR: 0.19	1 infections, 1983 central-line days	0.19
Q1 2013 - Q4 2013 Result 5 infections, 2750 central-line days Rating SIR: 0.70	5 infections, 2750 central-line days	0.70
Q1 2012 - Q4 2012 Result 2 infections, 2802 central-line days Rating SIR: 0.28	2 infections, 2802 central-line days	0.28
Q1 2011 - Q4 2011 Result 7 infections, 3941 central-line days Rating SIR: 0.94	7 infections, 3941 central-line days	0.94
Q1 2010 - Q4 2010 Result 6 infections, 3894 central-line days Rating SIR: 0.81	6 infections, 3894 central-line days	0.81

Ped. CLABSI Measure	Result	SIR
Pediatric Medical-Surgical ICU Q1 2023 - Q4 2023 Result 0 infections, 143 central-line days Rating SIR: N/A	0 infections, 143 central-line days	N/A
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 0 infections, 78 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 78 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 72 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 72 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 0 infections, 127 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 127 central-line days ⁴²	N/A ⁴²
Q1 2019 - Q4 2019 Result 0 infections, 263 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 263 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 0 infections, 271 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 271 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 0 infections, 303 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 303 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 0 infections, 330 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 330 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 246 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 246 central-line days ⁴²	N/A ⁴²
Q1 2014 - Q4 2014 Result 1 infections, 224 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 224 central-line days ⁴⁴	N/A ⁴⁴
Q1 2013 - Q4 2013 Result 0 infections, 233 central-line days ⁴³ Rating SIR: N/A ⁴³	0 infections, 233 central-line days ⁴³	N/A ⁴³
Q1 2012 - Q4 2012 Result 0 infections, 197 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 197 central-line days ⁴²	N/A ⁴²
Q1 2011 - Q4 2011 Result 0 infections, 177 central-line days Rating SIR: N/A	0 infections, 177 central-line days	N/A
Q1 2010 - Q4 2010 Result 2 infections, 270 central-line days ⁴⁴ Rating SIR: 0.00 ⁴⁴	2 infections, 270 central-line days ⁴⁴	0.00 ⁴⁴
Q1 2010 - Q2 2010 Result 0 infections, 84 central-line days Rating SIR: 0.00	0 infections, 84 central-line days	0.00

NICU CLABSI Measure	Result	SIR
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 1147 central-line days Rating SIR: 0.00	0 infections, 1147 central-line days	0.00
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 1 infections, 823 central-line days Rating SIR: 0.91	1 infections, 823 central-line days	0.91
Q1 2021 - Q4 2021 Result 0 infections, 1204 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1204 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 0 infections, 1473 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1473 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 0 infections, 2143 central-line days Rating SIR: 0.00	0 infections, 2143 central-line days	0.00
Q1 2018 - Q4 2018 Result 0 infections, 1914 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1914 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 2267 central-line days Rating SIR: 0.00	0 infections, 2267 central-line days	0.00
Q1 2016 - Q4 2016 Result 1 infections, 2228 central-line days Rating SIR: 0.29	1 infections, 2228 central-line days	0.29
Q1 2015 - Q4 2015 Result 5 infections, 2832 central-line days Rating SIR: 0.72	5 infections, 2832 central-line days	0.72
Q1 2014 - Q4 2014 Result 2 infections, 2961 central-line days Rating SIR: 0.28	2 infections, 2961 central-line days	0.28
Q1 2013 - Q4 2013 Result 2 infections, 2795 central-line days Rating SIR: 0.33	2 infections, 2795 central-line days	0.33
Q1 2012 - Q4 2012 Result 1 infections, 3567 central-line days Rating SIR: 0.13	1 infections, 3567 central-line days	0.13
Q1 2011 - Q4 2011 Result 2 infections, 4439 central-line days Rating SIR: 0.21	2 infections, 4439 central-line days	0.21
Q1 2010 - Q4 2010 Result 2 infections, 3918 central-line days Rating SIR: 0.22	2 infections, 3918 central-line days	0.22
Q1 2010 - Q2 2010 Result 0 infections, 1463 central-line days Rating SIR: 0.00	0 infections, 1463 central-line days	0.00

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2024 - Q4 2024 Result 0 infections, 13 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 13 procedures ⁴⁹	N/A ⁴⁹
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 0 infections, 3 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 3 procedures ⁴⁹	N/A ⁴⁹
Q1 2022 - Q4 2022 Result 0 infections, 6 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 6 procedures ⁴⁹	N/A ⁴⁹
Q1 2021 - Q4 2021 Result 0 infections, 7 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 7 procedures ⁴⁹	N/A ⁴⁹
Q1 2020 - Q4 2020 Result 0 infections, 8 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 8 procedures ⁴⁹	N/A ⁴⁹
Q1 2019 - Q4 2019 Result 0 infections, 23 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 23 procedures ¹⁵³	N/A ¹⁵³
Q1 2018 - Q4 2018 Result 0 infections, 23 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 23 procedures ¹⁵³	N/A ¹⁵³
Q1 2017 - Q4 2017 Result 0 infections, 18 procedures ¹⁵⁵ Rating SIR: N/A ¹⁵⁵	0 infections, 18 procedures ¹⁵⁵	N/A ¹⁵⁵
Q1 2016 - Q4 2016 Result 0 infections, 13 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 13 procedures ⁴⁹	N/A ⁴⁹
Q1 2015 - Q4 2015 Result N/A infections, N/A procedures ¹⁵⁵ Rating SIR: N/A ¹⁵⁵	N/A infections, N/A procedures ¹⁵⁵	N/A ¹⁵⁵
Q1 2014 - Q4 2014 Result 0 infections, 2 procedures Rating SIR: N/A	0 infections, 2 procedures	N/A
Q3 2013 - Q2 2014 Result 0 infections, 3 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 3 procedures ⁴⁹	N/A ⁴⁹
Q3 2012 - Q2 2013 Result 0 infections, 2 procedures ⁴⁹ Rating SIR: N/A ⁴⁹	0 infections, 2 procedures ⁴⁹	N/A ⁴⁹
Q3 2011 - Q2 2012 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q3 2010 - Q2 2011 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Coronary Artery Bypass Graft Surgery Q1 2024 - Q4 2024 Result 0 infections, 110 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 110 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 2023 - Q4 2023 Result 0 infections, 94 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 94 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2022 - Q4 2022 Result 0 infections, 88 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 88 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 0 infections, 70 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 70 procedures ¹¹⁸	N/A ¹¹⁸
Q1 2020 - Q4 2020 Result 0 infections, 74 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 74 procedures ¹¹⁸	N/A ¹¹⁸
Q1 2019 - Q4 2019 Result 0 infections, 94 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 94 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 0 infections, 111 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 111 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 60 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 60 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 0 infections, 68 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 68 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 0 infections, 59 procedures Rating SIR: N/A	0 infections, 59 procedures	N/A
Q3 2013 - Q2 2014 Result 0 infections, 76 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 76 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 0 infections, 81 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 81 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 86 procedures Rating SIR: 0.94	1 infections, 86 procedures	0.94
Q3 2010 - Q2 2011 Result 0 infections, 83 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 83 procedures ⁴⁶	0.00 ⁴⁶