UW Health SwedishAmerican Hospital

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
32	Complete Reporting: Unit Operational Limited Time
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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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
32	Complete Reporting: Unit Operational Limited Time
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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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

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
32	Complete Reporting: Unit Operational Limited Time
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
46	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
114	Complete Reporting: Number of predicted events too low to calculate a precise SIR
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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 2022 - Q1 2023 Result 67.00 %	67.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 85.00 %	85.00 %
Q4 2020 - Q1 2021 Result 94.00 %	94.00 %
Q4 2019 - Q1 2020 Result 96.00 %	96.00 %
Q4 2018 - Q1 2019 Result 95.00 %	95.00 %
Q4 2017 - Q1 2018 Result 94.00 %	94.00 %

Illinois Hospital Report Card

and Consumer Guide to Health Care

UW Health SwedishAmerican Hospital

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

Description

Historical Data

Pediatric CLABSI

Description

Historical Data

NICU CLABSI

Description

Historical Data

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 2023 - Q4 2023 Result 1 infections, 79508 patient days Rating SIR: 0.26	1 infections, 79508 patient days	0.26
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 5 infections, 86334 patient days Rating SIR: 0.87	5 infections, 86334 patient days	0.87
Q1 2021 - Q4 2021 Result 4 infections, 75497 patient days Rating SIR: 1.18	4 infections, 75497 patient days	1.18
Q1 2020 - Q4 2020 Result 0 infections, 61410 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 61410 patient days ¹¹⁷	0.00 ¹¹⁷
Q1 2019 - Q4 2019 Result 2 infections, 57664 patient days Rating SIR: 0.84	2 infections, 57664 patient days	0.84
Q1 2018 - Q4 2018 Result 1 infections, 56992 patient days Rating SIR: 0.36	1 infections, 56992 patient days	0.36
Q1 2017 - Q4 2017 Result 1 infections, 56962 patient days Rating SIR: 0.37	1 infections, 56962 patient days	0.37
Q1 2016 - Q4 2016 Result 4 infections, 62231 patient days Rating SIR: 1.49	4 infections, 62231 patient days	1.49
Q1 2015 - Q4 2015 Result 3 infections, 69106 patient days Rating SIR: 0.95	3 infections, 69106 patient days	0.95
Q1 2014 - Q4 2014 Result 1 infections, 67320 patient days Rating SIR: 0.33	1 infections, 67320 patient days	0.33
Q1 2013 - Q4 2013 Result 1 infections, 69396 patient days Rating SIR: 0.34	1 infections, 69396 patient days	0.34
Q1 2012 - Q4 2012 Result 3 infections, 72172 patient days Rating SIR: 0.98	3 infections, 72172 patient days	0.98
Q1 2012 - Q2 2012 Result 2 infections, 36729 patient days Rating SIR: 0.54	2 infections, 36729 patient days	0.54
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 17 infections, 72956 patient days Rating SIR: 0.47	17 infections, 72956 patient days	0.47
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 53 infections, 79378 patient days Rating SIR: 1.22	53 infections, 79378 patient days	1.22
Q1 2021 - Q4 2021 Result 33 infections, 68617 patient days Rating SIR: 0.76	33 infections, 68617 patient days	0.76
Q1 2020 - Q4 2020 Result 41 infections, 58041 patient days Rating SIR: 0.93	41 infections, 58041 patient days	0.93
Q1 2019 - Q4 2019 Result 41 infections, 54896 patient days Rating SIR: 0.83	41 infections, 54896 patient days	0.83
Q1 2018 - Q4 2018 Result 37 infections, 53846 patient days Rating SIR: 0.94	37 infections, 53846 patient days	0.94
Q1 2017 - Q4 2017 Result 46 infections, 49405 patient days Rating SIR: 1.09	46 infections, 49405 patient days	1.09
Q1 2016 - Q4 2016 Result 46 infections, 55906 patient days Rating SIR: 1.30	46 infections, 55906 patient days	1.30
Q1 2015 - Q4 2015 Result 39 infections, 61839 patient days Rating SIR: 0.91	39 infections, 61839 patient days	0.91
Q1 2014 - Q4 2014 Result 54 infections, 60596 patient days Rating SIR: 1.29	54 infections, 60596 patient days	1.29
Q1 2013 - Q4 2013 Result 45 infections, 62690 patient days Rating SIR: 1.03	45 infections, 62690 patient days	1.03
Q1 2012 - Q4 2012 Result 48 infections, 65077 patient days Rating SIR: 1.08	48 infections, 65077 patient days	1.08

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2019 - Q4 2019 Result 0 infections, 1768 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1768 central-line days ¹¹⁷	0.00 ¹¹⁷
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 3 infections, 1363 central-line days Rating SIR: 2.19	3 infections, 1363 central-line days	2.19
Q1 2017 - Q4 2017 Result 0 infections, 1600 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1600 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 1602 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1602 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 1 infections, 1936 central-line days Rating SIR: 0.34	1 infections, 1936 central-line days	0.34
Q1 2014 - Q4 2014 Result 3 infections, 1596 central-line days Rating SIR: 1.25	3 infections, 1596 central-line days	1.25
Q1 2013 - Q4 2013 Result 0 infections, 1901 central-line days ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 1901 central-line days ⁴⁶	0.00 ⁴⁶
Q1 2012 - Q4 2012 Result 2 infections, 1939 central-line days Rating SIR: 0.69	2 infections, 1939 central-line days	0.69
Q1 2011 - Q4 2011 Result 4 infections, 2386 central-line days Rating SIR: 1.12	4 infections, 2386 central-line days	1.12
Q1 2010 - Q4 2010 Result 8 infections, 3476 central-line days Rating SIR: 1.53	8 infections, 3476 central-line days	1.53
Q1 2009 - Q4 2009 Result 14 infections, 3716 central-line days Rating SIR: 2.51	14 infections, 3716 central-line days	2.51
Adult Medical ICU Q1 2023 - Q4 2023 Result 2 infections, 3431 central-line days Rating SIR: 0.58	2 infections, 3431 central-line days	0.58
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 7 infections, 4412 central-line days Rating SIR: 1.58	7 infections, 4412 central-line days	1.58
Q1 2021 - Q4 2021 Result 4 infections, 5869 central-line days Rating SIR: 0.68	4 infections, 5869 central-line days	0.68

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2019 - Q4 2019 Result 0 infections, 451 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 451 central-line days ⁴²	N/A ⁴²
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 2018 - Q4 2018 Result 0 infections, 119 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 119 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 0 infections, 37 central-line days ³³ Rating SIR: N/A ³³	0 infections, 37 central-line days ³³	N/A ³³
Q1 2016 - Q4 2016 Result 0 infections, 28 central-line days ³³ Rating SIR: N/A ³³	0 infections, 28 central-line days ³³	N/A ³³
Q1 2015 - Q4 2015 Result 0 infections, 19 central-line days ³³ Rating SIR: N/A ³³	0 infections, 19 central-line days ³³	N/A ³³
Q1 2014 - Q4 2014 Result 0 infections, 13 central-line days ³³ Rating SIR: N/A ³³	0 infections, 13 central-line days ³³	N/A ³³
Q1 2013 - Q4 2013 Result 0 infections, 27 central-line days ³³ Rating SIR: N/A ³³	0 infections, 27 central-line days ³³	N/A ³³
Q1 2012 - Q4 2012 Result 0 infections, 22 central-line days ³³ Rating SIR: 0.00 ³³	0 infections, 22 central-line days ³³	0.00 ³³
Q1 2011 - Q4 2011 Result 0 infections, 12 central-line days ³² Rating SIR: N/A ³²	0 infections, 12 central-line days ³²	N/A ³²
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 1 infections, 1016 central-line days Rating SIR: 0.78	1 infections, 1016 central-line days	0.78
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, 1169 central-line days Rating SIR: 0.74	1 infections, 1169 central-line days	0.74
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

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 3 infections, 285 procedures Rating SIR: 2.56	3 infections, 285 procedures	2.56
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, 407 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 407 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 2 infections, 458 procedures Rating SIR: 1.32	2 infections, 458 procedures	1.32
Q1 2017 - Q4 2017 Result 0 infections, 405 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 405 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 464 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 464 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 0 infections, 428 procedures Rating SIR: 0.00	0 infections, 428 procedures	0.00
Q1 2014 - Q4 2014 Result 0 infections, 422 procedures Rating SIR: 0.00	0 infections, 422 procedures	0.00
Q3 2013 - Q2 2014 Result 1 infections, 385 procedures Rating SIR: 0.35	1 infections, 385 procedures	0.35
Q3 2012 - Q2 2013 Result 4 infections, 407 procedures Rating SIR: 1.24	4 infections, 407 procedures	1.24
Q3 2011 - Q2 2012 Result 2 infections, 404 procedures Rating SIR: 0.61	2 infections, 404 procedures	0.61
Q3 2010 - Q2 2011 Result 3 infections, 333 procedures Rating SIR: 1.34	3 infections, 333 procedures	1.34
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 1 infections, 86 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 86 procedures ¹⁵⁴	N/A ¹⁵⁴
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, 45 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 45 procedures ¹⁵³	N/A ¹⁵³
Q1 2018 - Q4 2018 Result 0 infections, 63 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 63 procedures ¹⁵³	N/A ¹⁵³
Q1 2016 - Q4 2016 Result 2 infections, 136 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	2 infections, 136 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2015 - Q4 2015 Result 1 infections, 125 procedures Rating SIR: 0.58	1 infections, 125 procedures	0.58
Q1 2014 - Q4 2014 Result 1 infections, 120 procedures Rating SIR: 0.59	1 infections, 120 procedures	0.59
Q3 2013 - Q2 2014 Result 0 infections, 120 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 120 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2012 - Q2 2013 Result 1 infections, 133 procedures Rating SIR: 0.67	1 infections, 133 procedures	0.67
Q3 2011 - Q2 2012 Result 0 infections, 127 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 127 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 111 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 111 procedures ⁴⁶	0.00 ⁴⁶