Advocate Christ 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 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
44	Complete Reporting: Too few central line days to calculate a precise SIR
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
44	Complete Reporting: Too few central line days to calculate a precise SIR
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
44	Complete Reporting: Too few central line days to calculate a precise SIR
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 88.00 %	88.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 98.00 %	98.00 %
Q4 2020 - Q1 2021 Result 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 97.00 %	97.00 %

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2023 - Q4 2023 Result 8 infections, 245535 patient days Rating SIR: 0.39	8 infections, 245535 patient days	0.39
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 18 infections, 249815 patient days Rating SIR: 1.14	18 infections, 249815 patient days	1.14
Q1 2021 - Q4 2021 Result 21 infections, 233464 patient days Rating SIR: 1.27	21 infections, 233464 patient days	1.27
Q1 2020 - Q4 2020 Result 11 infections, 214574 patient days Rating SIR: 0.72	11 infections, 214574 patient days	0.72
Q1 2019 - Q4 2019 Result 8 infections, 231638 patient days Rating SIR: 0.41	8 infections, 231638 patient days	0.41
Q1 2018 - Q4 2018 Result 10 infections, 231514 patient days Rating SIR: 0.73	10 infections, 231514 patient days	0.73
Q1 2017 - Q4 2017 Result 3 infections, 227623 patient days Rating SIR: 0.25	3 infections, 227623 patient days	0.25
Q1 2016 - Q4 2016 Result 9 infections, 215359 patient days Rating SIR: 0.79	9 infections, 215359 patient days	0.79
Q1 2015 - Q4 2015 Result 3 infections, 197285 patient days Rating SIR: 0.20	3 infections, 197285 patient days	0.20
Q1 2014 - Q4 2014 Result 10 infections, 215443 patient days Rating SIR: 0.59	10 infections, 215443 patient days	0.59
Q1 2013 - Q4 2013 Result 12 infections, 213958 patient days Rating SIR: 0.67	12 infections, 213958 patient days	0.67
Q1 2012 - Q4 2012 Result 13 infections, 210084 patient days Rating SIR: 0.75	13 infections, 210084 patient days	0.75
Q1 2012 - Q2 2012 Result 10 infections, 105022 patient days Rating SIR: 0.95	10 infections, 105022 patient days	0.95
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 68 infections, 222368 patient days Rating SIR: 0.57	68 infections, 222368 patient days	0.57
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 83 infections, 224828 patient days Rating SIR: 0.68	83 infections, 224828 patient days	0.68
Q1 2021 - Q4 2021 Result 103 infections, 221078 patient days Rating SIR: 0.83	103 infections, 221078 patient days	0.83
Q1 2020 - Q4 2020 Result 73 infections, 201034 patient days Rating SIR: 0.67	73 infections, 201034 patient days	0.67
Q1 2019 - Q4 2019 Result 64 infections, 208017 patient days Rating SIR: 0.60	64 infections, 208017 patient days	0.60
Q1 2018 - Q4 2018 Result 154 infections, 206821 patient days Rating SIR: 1.03	154 infections, 206821 patient days	1.03
Q1 2017 - Q4 2017 Result 202 infections, 203863 patient days Rating SIR: 1.25	202 infections, 203863 patient days	1.25
Q1 2016 - Q4 2016 Result 177 infections, 192087 patient days Rating SIR: 1.13	177 infections, 192087 patient days	1.13
Q1 2015 - Q4 2015 Result 149 infections, 173929 patient days Rating SIR: 0.98	149 infections, 173929 patient days	0.98
Q1 2014 - Q4 2014 Result 216 infections, 192602 patient days Rating SIR: 1.32	216 infections, 192602 patient days	1.32
Q1 2013 - Q4 2013 Result 189 infections, 194602 patient days Rating SIR: 1.04	189 infections, 194602 patient days	1.04
Q1 2012 - Q4 2012 Result 213 infections, 185865 patient days Rating SIR: 1.17	213 infections, 185865 patient days	1.17

Adult CLABSI Measure	Result	SIR
Adult Neurologic ICU Q1 2023 - Q4 2023 Result 0 infections, 1267 central-line days Rating SIR: 0.00	0 infections, 1267 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Adult Neurologic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 0 infections, 1215 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1215 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 1 infections, 1243 central-line days Rating SIR: 0.71	1 infections, 1243 central-line days	0.71
Q1 2020 - Q4 2020 Result 0 infections, 1505 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1505 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 1 infections, 640 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 640 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 1 infections, 928 central-line days Rating SIR: 0.96	1 infections, 928 central-line days	0.96
Q1 2017 - Q4 2017 Result 0 infections, 1213 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1213 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 858 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 858 central-line days ⁴⁴	N/A ⁴⁴
Adult Surgical Cardiothoracic ICU Q1 2023 - Q4 2023 Result 2 infections, 5754 central-line days Rating SIR: 0.31	2 infections, 5754 central-line days	0.31
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 3 infections, 5799 central-line days Rating SIR: 0.46	3 infections, 5799 central-line days	0.46
Q1 2021 - Q4 2021 Result 1 infections, 5667 central-line days Rating SIR: 0.16	1 infections, 5667 central-line days	0.16
Q1 2020 - Q4 2020 Result 2 infections, 7334 central-line days Rating SIR: 0.24	2 infections, 7334 central-line days	0.24
Q1 2019 - Q4 2019 Result 2 infections, 6796 central-line days Rating SIR: 0.26	2 infections, 6796 central-line days	0.26
Q1 2018 - Q4 2018 Result 0 infections, 6668 central-line days Rating SIR: 0.00	0 infections, 6668 central-line days	0.00
Q1 2017 - Q4 2017 Result 4 infections, 6385 central-line days Rating SIR: 0.56	4 infections, 6385 central-line days	0.56
Q1 2016 - Q4 2016 Result 6 infections, 5861 central-line days Rating SIR: 0.91	6 infections, 5861 central-line days	0.91
Q1 2015 - Q4 2015 Result 6 infections, 6585 central-line days Rating SIR: 0.65	6 infections, 6585 central-line days	0.65
Q1 2014 - Q4 2014 Result 2 infections, 6210 central-line days Rating SIR: 0.23	2 infections, 6210 central-line days	0.23
Q1 2013 - Q4 2013 Result 4 infections, 6126 central-line days Rating SIR: 0.47	4 infections, 6126 central-line days	0.47
Q1 2012 - Q4 2012 Result 3 infections, 6507 central-line days Rating SIR: 0.33	3 infections, 6507 central-line days	0.33
Adult Trauma ICU Q1 2023 - Q4 2023 Result 0 infections, 1884 central-line days Rating SIR: 0.00	0 infections, 1884 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Adult Trauma ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 3 infections, 2150 central-line days Rating SIR: 0.91	3 infections, 2150 central-line days	0.91
Q1 2021 - Q4 2021 Result 0 infections, 1940 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1940 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 3 infections, 1803 central-line days Rating SIR: 1.09	3 infections, 1803 central-line days	1.09
Q1 2019 - Q4 2019 Result 0 infections, 1923 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1923 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 0 infections, 1679 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1679 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 1 infections, 2132 central-line days Rating SIR: 0.31	1 infections, 2132 central-line days	0.31
Q1 2016 - Q4 2016 Result 0 infections, 2184 central-line days Rating SIR: 0.00	0 infections, 2184 central-line days	0.00
Q1 2015 - Q4 2015 Result 5 infections, 2549 central-line days Rating SIR: 0.55	5 infections, 2549 central-line days	0.55
Adult Medical/Surgical ICU Q1 2019 - Q4 2019 Result 3 infections, 1435 central-line days Rating SIR: 1.85	3 infections, 1435 central-line days	1.85
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 2018 - Q4 2018 Result 0 infections, 1706 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1706 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 0 infections, 1900 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1900 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 2037 central-line days Rating SIR: 0.44	1 infections, 2037 central-line days	0.44
Q1 2015 - Q4 2015 Result 1 infections, 4054 central-line days Rating SIR: 0.12	1 infections, 4054 central-line days	0.12
Adult Medical/Surgical ICU, Second Unit Q1 2015 - Q4 2015 Result 5 infections, 2409 central-line days Rating SIR: 0.99	5 infections, 2409 central-line days	0.99
Description Central Line-associated Bloodstream Infection data in the Medical/Surgical ICU summarized as a Standardized Infection Ratio.
Adult Surgical ICU Q1 2023 - Q4 2023 Result 8 infections, 5597 central-line days Rating SIR: 1.27	8 infections, 5597 central-line days	1.27
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 2 infections, 2304 central-line days Rating SIR: 0.77	2 infections, 2304 central-line days	0.77
Q1 2021 - Q4 2021 Result 1 infections, 3501 central-line days Rating SIR: 0.25	1 infections, 3501 central-line days	0.25
Q1 2020 - Q4 2020 Result 2 infections, 2865 central-line days Rating SIR: 0.62	2 infections, 2865 central-line days	0.62
Q1 2019 - Q4 2019 Result 9 infections, 5117 central-line days Rating SIR: 1.56	9 infections, 5117 central-line days	1.56
Q1 2018 - Q4 2018 Result 3 infections, 2779 central-line days Rating SIR: 0.96	3 infections, 2779 central-line days	0.96
Q1 2017 - Q4 2017 Result 3 infections, 4671 central-line days Rating SIR: 0.57	3 infections, 4671 central-line days	0.57
Q1 2016 - Q4 2016 Result 2 infections, 4326 central-line days Rating SIR: 0.41	2 infections, 4326 central-line days	0.41
Adult Surgical ICU, Second Unit Q1 2022 - Q4 2022 Result 8 infections, 4938 central-line days Rating SIR: 1.44	8 infections, 4938 central-line days	1.44
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2021 - Q4 2021 Result 4 infections, 4702 central-line days Rating SIR: 0.75	4 infections, 4702 central-line days	0.75
Q1 2020 - Q4 2020 Result 4 infections, 3562 central-line days Rating SIR: 1.00	4 infections, 3562 central-line days	1.00
Q1 2019 - Q4 2019 Result 2 infections, 2920 central-line days Rating SIR: 0.61	2 infections, 2920 central-line days	0.61
Q1 2018 - Q4 2018 Result 2 infections, 5075 central-line days Rating SIR: 0.35	2 infections, 5075 central-line days	0.35
Q1 2017 - Q4 2017 Result 1 infections, 2481 central-line days Rating SIR: 0.36	1 infections, 2481 central-line days	0.36
Q1 2016 - Q4 2016 Result 0 infections, 2253 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2253 central-line days ¹¹⁷	0.00 ¹¹⁷
Adult Medical ICU Q1 2023 - Q4 2023 Result 0 infections, 3598 central-line days Rating SIR: 0.00	0 infections, 3598 central-line days	0.00
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, 4182 central-line days Rating SIR: 0.42	2 infections, 4182 central-line days	0.42
Q1 2021 - Q4 2021 Result 9 infections, 3673 central-line days Rating SIR: 2.17	9 infections, 3673 central-line days	2.17
Q1 2020 - Q4 2020 Result 0 infections, 992 central-line days Rating SIR: 0.00	0 infections, 992 central-line days	0.00
Q1 2019 - Q4 2019 Result 2 infections, 1187 central-line days Rating SIR: 1.49	2 infections, 1187 central-line days	1.49
Q1 2018 - Q4 2018 Result 3 infections, 1226 central-line days Rating SIR: 2.17	3 infections, 1226 central-line days	2.17
Q1 2017 - Q4 2017 Result 1 infections, 1057 central-line days Rating SIR: 0.84	1 infections, 1057 central-line days	0.84
Q1 2016 - Q4 2016 Result 3 infections, 4475 central-line days Rating SIR: 0.59	3 infections, 4475 central-line days	0.59
Q1 2015 - Q4 2015 Result 2 infections, 4325 central-line days Rating SIR: 0.18	2 infections, 4325 central-line days	0.18
Q1 2014 - Q4 2014 Result 1 infections, 3907 central-line days Rating SIR: 0.10	1 infections, 3907 central-line days	0.10
Q1 2013 - Q4 2013 Result 0 infections, 3956 central-line days Rating SIR: 0.00	0 infections, 3956 central-line days	0.00
Q1 2012 - Q4 2012 Result 3 infections, 3947 central-line days Rating SIR: 0.29	3 infections, 3947 central-line days	0.29
Q1 2011 - Q4 2011 Result 1 infections, 3886 central-line days Rating SIR: 0.10	1 infections, 3886 central-line days	0.10
Q1 2010 - Q4 2010 Result 4 infections, 3834 central-line days Rating SIR: 0.40	4 infections, 3834 central-line days	0.40
Q1 2009 - Q4 2009 Result 2 infections, 4182 central-line days Rating SIR: 0.18	2 infections, 4182 central-line days	0.18
Q1 2009 - Q2 2009 Result 0 infections, 2163 central-line days Rating SIR: 0.00	0 infections, 2163 central-line days	0.00
Adult Medical ICU, Second Unit Q1 2022 - Q4 2022 Result 2 infections, 1174 central-line days Rating SIR: 1.51	2 infections, 1174 central-line days	1.51
Description Central Line-associated Bloodstream Infection data in the Adult Medical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2021 - Q4 2021 Result 2 infections, 829 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	2 infections, 829 central-line days ⁴⁴	N/A ⁴⁴
Q1 2020 - Q4 2020 Result 0 infections, 251 central-line days Rating SIR: N/A	0 infections, 251 central-line days	N/A
Q1 2019 - Q4 2019 Result 2 infections, 4283 central-line days Rating SIR: 0.41	2 infections, 4283 central-line days	0.41
Q1 2018 - Q4 2018 Result 4 infections, 4327 central-line days Rating SIR: 0.82	4 infections, 4327 central-line days	0.82
Q1 2017 - Q4 2017 Result 1 infections, 4707 central-line days Rating SIR: 0.19	1 infections, 4707 central-line days	0.19
Q1 2016 - Q4 2016 Result 1 infections, 1316 central-line days Rating SIR: 0.67	1 infections, 1316 central-line days	0.67

Ped. CLABSI Measure	Result	SIR
Pediatric Medical ICU Q1 2023 - Q4 2023 Result 0 infections, 850 central-line days Rating SIR: 0.00	0 infections, 850 central-line days	0.00
Description Central Line-associated Bloodstream Infection data in the Medical Pediatric ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 1767 central-line days Rating SIR: 1.57	4 infections, 1767 central-line days	1.57
Q1 2021 - Q4 2021 Result 7 infections, 1642 central-line days Rating SIR: 2.96	7 infections, 1642 central-line days	2.96
Q1 2020 - Q4 2020 Result 1 infections, 1773 central-line days Rating SIR: 0.39	1 infections, 1773 central-line days	0.39
Q1 2019 - Q4 2019 Result 1 infections, 1412 central-line days Rating SIR: 0.49	1 infections, 1412 central-line days	0.49
Q1 2018 - Q4 2018 Result 2 infections, 1537 central-line days Rating SIR: 0.90	2 infections, 1537 central-line days	0.90
Q1 2017 - Q4 2017 Result 4 infections, 1965 central-line days Rating SIR: 1.41	4 infections, 1965 central-line days	1.41
Q1 2016 - Q4 2016 Result 6 infections, 1948 central-line days Rating SIR: 2.14	6 infections, 1948 central-line days	2.14
Q1 2015 - Q4 2015 Result 2 infections, 2268 central-line days Rating SIR: 0.68	2 infections, 2268 central-line days	0.68
Q1 2014 - Q4 2014 Result 1 infections, 1673 central-line days Rating SIR: 0.46	1 infections, 1673 central-line days	0.46
Q1 2013 - Q4 2013 Result 1 infections, 1779 central-line days Rating SIR: 0.43	1 infections, 1779 central-line days	0.43
Q1 2012 - Q4 2012 Result 1 infections, 1891 central-line days Rating SIR: 0.41	1 infections, 1891 central-line days	0.41
Q1 2011 - Q4 2011 Result 3 infections, 1816 central-line days Rating SIR: 1.27	3 infections, 1816 central-line days	1.27
Q1 2010 - Q4 2010 Result 9 infections, 2509 central-line days Rating SIR: 2.76	9 infections, 2509 central-line days	2.76
Q1 2010 - Q2 2010 Result 3 infections, 1230 central-line days Rating SIR: 1.88	3 infections, 1230 central-line days	1.88
Pediatric Cardiothoracic ICU Q1 2023 - Q4 2023 Result 3 infections, 2962 central-line days Rating SIR: 0.70	3 infections, 2962 central-line days	0.70
Description Central Line-associated Bloodstream Infection data in the Pediatric Cardiothoracic ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 5 infections, 3095 central-line days Rating SIR: 1.12	5 infections, 3095 central-line days	1.12
Q1 2021 - Q4 2021 Result 5 infections, 3621 central-line days Rating SIR: 0.96	5 infections, 3621 central-line days	0.96
Q1 2020 - Q4 2020 Result 6 infections, 4053 central-line days Rating SIR: 1.03	6 infections, 4053 central-line days	1.03
Q1 2018 - Q4 2018 Result 2 infections, 2243 central-line days Rating SIR: 0.62	2 infections, 2243 central-line days	0.62
Q1 2017 - Q4 2017 Result 1 infections, 2208 central-line days Rating SIR: 0.32	1 infections, 2208 central-line days	0.32
Q1 2016 - Q4 2016 Result 1 infections, 2241 central-line days Rating SIR: 0.31	1 infections, 2241 central-line days	0.31
Q1 2015 - Q4 2015 Result 4 infections, 1958 central-line days Rating SIR: 0.62	4 infections, 1958 central-line days	0.62
Q1 2014 - Q4 2014 Result 1 infections, 1979 central-line days Rating SIR: 0.15	1 infections, 1979 central-line days	0.15
Q1 2013 - Q4 2013 Result 1 infections, 2085 central-line days Rating SIR: 0.15	1 infections, 2085 central-line days	0.15
Q1 2012 - Q4 2012 Result 0 infections, 1911 central-line days Rating SIR: 0.00	0 infections, 1911 central-line days	0.00
Q1 2011 - Q4 2011 Result 7 infections, 2384 central-line days Rating SIR: 0.89	7 infections, 2384 central-line days	0.89
Q1 2010 - Q4 2010 Result 14 infections, 2596 central-line days Rating SIR: 1.63	14 infections, 2596 central-line days	1.63
Q1 2010 - Q2 2010 Result 5 infections, 1187 central-line days Rating SIR: 1.28	5 infections, 1187 central-line days	1.28

NICU CLABSI Measure	Result	SIR
Level III Neonatal ICU Q1 2022 - Q4 2022 Result 8 infections, 3312 central-line days Rating SIR: 1.84	8 infections, 3312 central-line days	1.84
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 2021 - Q4 2021 Result 5 infections, 3516 central-line days Rating SIR: 1.13	5 infections, 3516 central-line days	1.13
Q1 2020 - Q4 2020 Result 3 infections, 2986 central-line days Rating SIR: 0.75	3 infections, 2986 central-line days	0.75
Q1 2019 - Q4 2019 Result 5 infections, 3404 central-line days Rating SIR: 1.09	5 infections, 3404 central-line days	1.09
Q1 2018 - Q4 2018 Result 2 infections, 3147 central-line days Rating SIR: 0.47	2 infections, 3147 central-line days	0.47
Q1 2017 - Q4 2017 Result 5 infections, 3462 central-line days Rating SIR: 1.14	5 infections, 3462 central-line days	1.14
Q1 2016 - Q4 2016 Result 3 infections, 3448 central-line days Rating SIR: 0.65	3 infections, 3448 central-line days	0.65
Q1 2015 - Q4 2015 Result 8 infections, 4759 central-line days Rating SIR: 0.74	8 infections, 4759 central-line days	0.74
Q1 2014 - Q4 2014 Result 6 infections, 5106 central-line days Rating SIR: 0.50	6 infections, 5106 central-line days	0.50
Q1 2013 - Q4 2013 Result 2 infections, 4643 central-line days Rating SIR: 0.19	2 infections, 4643 central-line days	0.19
Q1 2012 - Q4 2012 Result 4 infections, 6872 central-line days Rating SIR: 0.26	4 infections, 6872 central-line days	0.26
Q1 2011 - Q4 2011 Result 3 infections, 7544 central-line days Rating SIR: 0.17	3 infections, 7544 central-line days	0.17
Q1 2010 - Q4 2010 Result 3 infections, 8141 central-line days Rating SIR: 0.17	3 infections, 8141 central-line days	0.17
Q1 2010 - Q2 2010 Result 1 infections, 2416 central-line days Rating SIR: 0.15	1 infections, 2416 central-line days	0.15

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 2 infections, 346 procedures Rating SIR: 1.51	2 infections, 346 procedures	1.51
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 4 infections, 871 procedures Rating SIR: 1.16	4 infections, 871 procedures	1.16
Q1 2018 - Q4 2018 Result 4 infections, 732 procedures Rating SIR: 1.39	4 infections, 732 procedures	1.39
Q1 2017 - Q4 2017 Result 3 infections, 784 procedures Rating SIR: 1.03	3 infections, 784 procedures	1.03
Q1 2016 - Q4 2016 Result 3 infections, 824 procedures Rating SIR: 0.95	3 infections, 824 procedures	0.95
Q1 2015 - Q4 2015 Result 7 infections, 734 procedures Rating SIR: 1.25	7 infections, 734 procedures	1.25
Q1 2014 - Q4 2014 Result 5 infections, 627 procedures Rating SIR: 0.97	5 infections, 627 procedures	0.97
Q3 2013 - Q2 2014 Result 3 infections, 655 procedures Rating SIR: 0.59	3 infections, 655 procedures	0.59
Q3 2012 - Q2 2013 Result 4 infections, 706 procedures Rating SIR: 0.74	4 infections, 706 procedures	0.74
Q3 2011 - Q2 2012 Result 6 infections, 649 procedures Rating SIR: 1.18	6 infections, 649 procedures	1.18
Q3 2010 - Q2 2011 Result 1 infections, 591 procedures Rating SIR: 0.21	1 infections, 591 procedures	0.21
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 1 infections, 354 procedures Rating SIR: 0.28	1 infections, 354 procedures	0.28
Description Surgical Site Infections Associated with Coronary Artery Bypass Graft Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2019 - Q4 2019 Result 3 infections, 426 procedures Rating SIR: 0.64	3 infections, 426 procedures	0.64
Q1 2018 - Q4 2018 Result 6 infections, 448 procedures Rating SIR: 1.29	6 infections, 448 procedures	1.29
Q1 2016 - Q4 2016 Result 2 infections, 403 procedures Rating SIR: 0.50	2 infections, 403 procedures	0.50
Q1 2015 - Q4 2015 Result 2 infections, 388 procedures Rating SIR: 0.39	2 infections, 388 procedures	0.39
Q1 2014 - Q4 2014 Result 5 infections, 424 procedures Rating SIR: 0.86	5 infections, 424 procedures	0.86
Q3 2013 - Q2 2014 Result 4 infections, 405 procedures Rating SIR: 0.76	4 infections, 405 procedures	0.76
Q3 2012 - Q2 2013 Result 6 infections, 429 procedures Rating SIR: 1.13	6 infections, 429 procedures	1.13
Q3 2011 - Q2 2012 Result 4 infections, 392 procedures Rating SIR: 0.78	4 infections, 392 procedures	0.78
Q3 2010 - Q2 2011 Result 3 infections, 414 procedures Rating SIR: 0.61	3 infections, 414 procedures	0.61