St. Margaret's Health - Spring Valley

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
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
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
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: 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 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
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
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
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: 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

NICU CLABSI Measure	Result	SIR
Level III Neonatal 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 data in the Level III Neonatal 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 ³⁹ Rating SIR: N/A ³⁹	N/A infections, N/A central-line days ³⁹	N/A ³⁹
Q1 2015 - Q4 2015 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 2014 - Q4 2014 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 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 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 2011 - Q4 2011 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 2010 - Q4 2010 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 2010 - Q2 2010 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

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
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
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
45	Complete Reporting: Zero infections. Number of predicted LabID events too low to calculate a precise SIR
47	Complete Reporting: Number of predicted LabID events too low to calculate a precise SIR
48	No Target Procedures Performed
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
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
154	Complete Reporting: 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 2021 - Q1 2022 Result 96.00 %	96.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2020 - Q1 2021 Result 98.00 %	98.00 %
Q4 2019 - Q1 2020 Result 98.00 %	98.00 %
Q4 2018 - Q1 2019 Result 95.00 %	95.00 %
Q4 2017 - Q1 2018 Result 90.00 %	90.00 %

Illinois Hospital Report Card

and Consumer Guide to Health Care

St. Margaret's Health - Spring Valley

Patient Safety - All

Healthcare-Associated Infections

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

Statistical Significance

Footnotes

Description

Historical Data

Description

Historical Data

Central Line Associated Bloodstream Infections (CLABSIs)

Statistical Significance

Footnotes

Adult CLABSI

Description

Historical Data

Pediatric CLABSI

Description

Historical Data

NICU CLABSI

Description

Historical Data

Surgical Site Infections (SSIs)

Statistical Significance

Footnotes

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 2022 - Q4 2022 Result 1 infections, 5437 patient days ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 5437 patient days ¹⁵⁴	N/A ¹⁵⁴
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2021 - Q4 2021 Result 0 infections, 5763 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 5763 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2020 - Q4 2020 Result 0 infections, 6123 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 6123 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2019 - Q4 2019 Result 2 infections, 7240 patient days ⁴⁷ Rating SIR: N/A ⁴⁷	2 infections, 7240 patient days ⁴⁷	N/A ⁴⁷
Q1 2018 - Q4 2018 Result 0 infections, 6968 patient days ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 6968 patient days ⁴⁵	N/A ⁴⁵
Q1 2017 - Q4 2017 Result 0 infections, 7160 patient days ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 7160 patient days ⁴⁵	N/A ⁴⁵
Q1 2016 - Q4 2016 Result 1 infections, 6839 patient days ⁴⁷ Rating SIR: N/A ⁴⁷	1 infections, 6839 patient days ⁴⁷	N/A ⁴⁷
Q1 2015 - Q4 2015 Result 1 infections, 6374 patient days ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 6374 patient days ¹¹⁴	N/A ¹¹⁴
Q1 2014 - Q4 2014 Result 0 infections, 7233 patient days ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 7233 patient days ⁴⁵	N/A ⁴⁵
Q1 2013 - Q4 2013 Result 0 infections, 7558 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 7558 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2012 - Q4 2012 Result 0 infections, 8349 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 8349 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2012 - Q2 2012 Result 0 infections, 4808 patient days Rating SIR: 0.00	0 infections, 4808 patient days	0.00
Clostridioides difficile infections (CDI) Q1 2022 - Q4 2022 Result 6 infections, 5369 patient days Rating SIR: 1.25	6 infections, 5369 patient days	1.25
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2021 - Q4 2021 Result 5 infections, 5340 patient days Rating SIR: 1.61	5 infections, 5340 patient days	1.61
Q1 2020 - Q4 2020 Result 2 infections, 5687 patient days Rating SIR: 0.83	2 infections, 5687 patient days	0.83
Q1 2019 - Q4 2019 Result 4 infections, 6656 patient days Rating SIR: 1.15	4 infections, 6656 patient days	1.15
Q1 2018 - Q4 2018 Result 6 infections, 6329 patient days Rating SIR: 1.51	6 infections, 6329 patient days	1.51
Q1 2017 - Q4 2017 Result 8 infections, 6490 patient days Rating SIR: 1.10	8 infections, 6490 patient days	1.10
Q1 2016 - Q4 2016 Result 6 infections, 6158 patient days Rating SIR: 1.05	6 infections, 6158 patient days	1.05
Q1 2015 - Q4 2015 Result 5 infections, 5923 patient days Rating SIR: 1.13	5 infections, 5923 patient days	1.13
Q1 2014 - Q4 2014 Result 7 infections, 6595 patient days Rating SIR: 1.57	7 infections, 6595 patient days	1.57
Q1 2013 - Q4 2013 Result 5 infections, 7016 patient days Rating SIR: 1.76	5 infections, 7016 patient days	1.76
Q1 2012 - Q4 2012 Result 2 infections, 7795 patient days Rating SIR: 0.64	2 infections, 7795 patient days	0.64

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2022 - Q4 2022 Result 0 infections, 38 central-line days ³³ Rating SIR: N/A ³³	0 infections, 38 central-line days ³³	N/A ³³
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 2021 - Q4 2021 Result 0 infections, 143 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 143 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 0 infections, 105 central-line days Rating SIR: N/A	0 infections, 105 central-line days	N/A
Q1 2019 - Q4 2019 Result 1 infections, 97 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 97 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 0 infections, 28 central-line days ³³ Rating SIR: N/A ³³	0 infections, 28 central-line days ³³	N/A ³³
Q1 2017 - Q4 2017 Result 0 infections, 44 central-line days ³³ Rating SIR: N/A ³³	0 infections, 44 central-line days ³³	N/A ³³
Q1 2016 - Q4 2016 Result 0 infections, 59 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 59 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 34 central-line days ³³ Rating SIR: N/A ³³	0 infections, 34 central-line days ³³	N/A ³³
Q1 2014 - Q4 2014 Result N/A infections, 37 central-line days ³³ Rating SIR: N/A ³³	N/A infections, 37 central-line days ³³	N/A ³³
Q1 2013 - Q4 2013 Result 0 infections, 39 central-line days ³³ Rating SIR: N/A ³³	0 infections, 39 central-line days ³³	N/A ³³
Q1 2012 - Q4 2012 Result 0 infections, 15 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 15 central-line days ³³	0.00 ³³
Q1 2011 - Q4 2011 Result 0 infections, 38 central-line days ³³ Rating SIR: N/A ³³	0 infections, 38 central-line days ³³	N/A ³³
Q1 2010 - Q4 2010 Result 0 infections, 13 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 13 central-line days ³³	0.00 ³³
Q1 2009 - Q4 2009 Result 0 infections, 83 central-line days Rating SIR: 0.00	0 infections, 83 central-line days	0.00

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 0 infections, 119 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 119 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 0 infections, 193 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 193 procedures ¹⁵³	N/A ¹⁵³
Q1 2018 - Q4 2018 Result 0 infections, 155 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 155 procedures ¹⁵³	N/A ¹⁵³
Q1 2017 - Q4 2017 Result 1 infections, 147 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 147 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2016 - Q4 2016 Result 0 infections, 136 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 136 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 1 infections, 173 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 173 procedures ¹⁵⁴	N/A ¹⁵⁴
Q1 2014 - Q4 2014 Result 0 infections, 146 procedures Rating SIR: N/A	0 infections, 146 procedures	N/A
Q3 2013 - Q2 2014 Result 0 infections, 161 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 161 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2012 - Q2 2013 Result 1 infections, 127 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 127 procedures ¹¹⁴	N/A ¹¹⁴
Q3 2011 - Q2 2012 Result 0 infections, 160 procedures ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 160 procedures ⁴⁵	N/A ⁴⁵
Q3 2010 - Q2 2011 Result 1 infections, 146 procedures ⁴⁷ Rating SIR: N/A ⁴⁷	1 infections, 146 procedures ⁴⁷	N/A ⁴⁷
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
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 N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2018 - Q4 2018 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2016 - Q4 2016 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2015 - Q4 2015 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2014 - Q4 2014 Result N/A infections, N/A procedures Rating SIR: N/A	N/A infections, N/A procedures	N/A
Q3 2013 - Q2 2014 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q3 2012 - Q2 2013 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
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