Mercyhealth Javon Bea Hospital-Rockton Avenue Campus

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
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
48	No Target 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
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 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
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
48	No Target 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
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 0 infections, 342 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 342 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 1 infections, 426 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 426 central-line days ⁴⁴	N/A ⁴⁴
Q1 2016 - Q4 2016 Result 0 infections, 493 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	0 infections, 493 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 1 infections, 549 central-line days Rating SIR: 0.61	1 infections, 549 central-line days	0.61
Q1 2014 - Q4 2014 Result 2 infections, 415 central-line days Rating SIR: 1.61	2 infections, 415 central-line days	1.61
Q1 2013 - Q4 2013 Result 1 infections, 589 central-line days Rating SIR: 0.57	1 infections, 589 central-line days	0.57
Q1 2012 - Q4 2012 Result 1 infections, 393 central-line days Rating SIR: 0.85	1 infections, 393 central-line days	0.85
Q1 2011 - Q4 2011 Result 2 infections, 606 central-line days Rating SIR: 1.10	2 infections, 606 central-line days	1.10
Q1 2010 - Q4 2010 Result 1 infections, 444 central-line days Rating SIR: 0.75	1 infections, 444 central-line days	0.75
Q1 2010 - Q2 2010 Result 1 infections, 257 central-line days Rating SIR: 1.30	1 infections, 257 central-line days	1.30

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 2 infections, 2896 central-line days Rating SIR: 0.49	2 infections, 2896 central-line days	0.49
Q1 2017 - Q4 2017 Result 0 infections, 2447 central-line days Rating SIR: 0.00	0 infections, 2447 central-line days	0.00
Q1 2016 - Q4 2016 Result 2 infections, 2721 central-line days Rating SIR: 0.53	2 infections, 2721 central-line days	0.53
Q1 2015 - Q4 2015 Result 2 infections, 3493 central-line days Rating SIR: 0.25	2 infections, 3493 central-line days	0.25
Q1 2014 - Q4 2014 Result 1 infections, 2298 central-line days Rating SIR: 0.18	1 infections, 2298 central-line days	0.18
Q1 2013 - Q4 2013 Result 4 infections, 2383 central-line days Rating SIR: 0.62	4 infections, 2383 central-line days	0.62
Q1 2012 - Q4 2012 Result 1 infections, 2825 central-line days Rating SIR: 0.15	1 infections, 2825 central-line days	0.15
Q1 2011 - Q4 2011 Result 2 infections, 3222 central-line days Rating SIR: 0.26	2 infections, 3222 central-line days	0.26
Q1 2010 - Q4 2010 Result 8 infections, 3809 central-line days Rating SIR: 0.85	8 infections, 3809 central-line days	0.85
Q1 2010 - Q2 2010 Result 1 infections, 1557 central-line days Rating SIR: 0.22	1 infections, 1557 central-line days	0.22

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
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
48	No Target 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
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 82.00 %	82.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 83.00 %	83.00 %
Q4 2020 - Q1 2021 Result 97.00 %	97.00 %
Q4 2019 - Q1 2020 Result 95.00 %	95.00 %
Q4 2018 - Q1 2019 Result 97.00 %	97.00 %
Q4 2017 - Q1 2018 Result 94.00 %	94.00 %

Patient Safety

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
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
48	No Target 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
169	Exempt: No Licensed ICU Beds

Measure	Risk-Adjusted Rate
Postoperative Lung Embolism or Deep Vein Thrombosis (clotting) Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of deep vein thrombosis or pulmonary embolism per 1,000 surgical discharges (PSI 12). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 4.11	4.11
Q4 2018 - Q3 2019 Rating SIR: 9.34	9.34
Q2 2018 - Q1 2019 Rating SIR: 8.67	8.67
Q1 2015 - Q4 2015 Rating SIR: 4.40	4.40
Q4 2014 - Q3 2015 Rating SIR: 4.44	4.44
Q1 2014 - Q4 2014 Rating SIR: 4.90	4.90
Q4 2013 - Q3 2014 Rating SIR: 3.93	3.93
Q1 2013 - Q4 2013 Rating SIR: 2.56	2.56
Q3 2012 - Q2 2013 Rating SIR: 3.11	3.11
Q1 2012 - Q4 2012 Rating SIR: 2.53	2.53
Q4 2011 - Q3 2012 Rating SIR: 1.39	1.39
Q2 2011 - Q1 2012 Rating SIR: 0.30	0.30
Q1 2011 - Q4 2011 Rating SIR: 2.77	2.77
Q4 2010 - Q3 2011 Rating SIR: 3.38	3.38
Q1 2010 - Q4 2010 Rating SIR: 3.78	3.78
Q4 2009 - Q3 2010 Rating SIR: 3.04	3.04
Q1 2009 - Q4 2009 Rating SIR: 3.62	3.62
Q3 2008 - Q2 2009 Rating SIR: 7.20	7.20
Q1 2008 - Q4 2008 Rating SIR: 6.80	6.80
Wound Complications in Abdominal Wall Surgery Q4 2020 - Q3 2021 Rating SIR: N/A	N/A
Description The number of cases of reclosure of postoperative disruption of abdominal wall per 1,000 cases of abdominopelvic surgery. (PSI 14) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 1.81	1.81
Q1 2013 - Q4 2013 Rating SIR: 5.92	5.92
Q3 2012 - Q2 2013 Rating SIR: 1.98	1.98
Q1 2012 - Q4 2012 Rating SIR: 2.05	2.05
Q4 2011 - Q3 2012 Rating SIR: 0.93	0.93
Q2 2011 - Q1 2012 Rating SIR: 0.98	0.98
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.98	0.98
Q1 2010 - Q4 2010 Rating SIR: 2.67	2.67
Q4 2009 - Q3 2010 Rating SIR: 3.72	3.72
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Accidental Puncture and Laceration Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of accidental cut, puncture, perforation, or laceration during procedure per 1,000 discharges. (PSI 15) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 2.51	2.51
Q1 2015 - Q4 2015 Rating SIR: 3.08	3.08
Q4 2014 - Q3 2015 Rating SIR: 2.29	2.29
Q1 2014 - Q4 2014 Rating SIR: 1.62	1.62
Q4 2013 - Q3 2014 Rating SIR: 1.45	1.45
Q1 2013 - Q4 2013 Rating SIR: 1.46	1.46
Q3 2012 - Q2 2013 Rating SIR: 2.04	2.04
Q1 2012 - Q4 2012 Rating SIR: 2.28	2.28
Q4 2011 - Q3 2012 Rating SIR: 2.29	2.29
Q2 2011 - Q1 2012 Rating SIR: 0.28	0.28
Q1 2011 - Q4 2011 Rating SIR: 4.59	4.59
Q4 2010 - Q3 2011 Rating SIR: 3.31	3.31
Q1 2010 - Q4 2010 Rating SIR: 2.87	2.87
Q4 2009 - Q3 2010 Rating SIR: 4.85	4.85
Q1 2009 - Q4 2009 Rating SIR: 5.67	5.67
Q3 2008 - Q2 2009 Rating SIR: 3.90	3.90
Q1 2008 - Q4 2008 Rating SIR: 4.80	4.80
Collapsed Lung caused by Medical Care Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description This measure is used to assess the number of cases of collapsed lung caused by medical care per 1,000 patients. (PSI 06) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.56	0.56
Q2 2018 - Q1 2019 Rating SIR: 0.51	0.51
Q1 2015 - Q4 2015 Rating SIR: 0.29	0.29
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.13	0.13
Q4 2013 - Q3 2014 Rating SIR: 0.30	0.30
Q1 2013 - Q4 2013 Rating SIR: 0.32	0.32
Q3 2012 - Q2 2013 Rating SIR: 0.15	0.15
Q1 2012 - Q4 2012 Rating SIR: 0.29	0.29
Q4 2011 - Q3 2012 Rating SIR: 0.18	0.18
Q2 2011 - Q1 2012 Rating SIR: 0.06	0.06
Q1 2011 - Q4 2011 Rating SIR: 3.11	3.11
Q4 2010 - Q3 2011 Rating SIR: 0.56	0.56
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.26	0.26
Q3 2008 - Q2 2009 Rating SIR: 0.50	0.50
Q1 2008 - Q4 2008 Rating SIR: 0.40	0.40
Postoperative Hemorrhage or Hematoma Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of hematoma or hemorrhage requiring a procedure per 1,000 surgical discharges. (PSI 09) Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 1.36	1.36
Q2 2018 - Q1 2019 Rating SIR: 1.96	1.96
Q1 2015 - Q4 2015 Rating SIR: 5.15	5.15
Q4 2014 - Q3 2015 Rating SIR: 3.47	3.47
Q1 2014 - Q4 2014 Rating SIR: 4.19	4.19
Q4 2013 - Q3 2014 Rating SIR: 5.49	5.49
Q1 2013 - Q4 2013 Rating SIR: 4.70	4.70
Q3 2012 - Q2 2013 Rating SIR: 3.70	3.70
Q1 2012 - Q4 2012 Rating SIR: 5.52	5.52
Q4 2011 - Q3 2012 Rating SIR: 1.47	1.47
Q2 2011 - Q1 2012 Rating SIR: 2.50	2.50
Q1 2011 - Q4 2011 Rating SIR: 2.09	2.09
Q4 2010 - Q3 2011 Rating SIR: 3.04	3.04
Q1 2010 - Q4 2010 Rating SIR: 3.85	3.85
Q4 2009 - Q3 2010 Rating SIR: 3.71	3.71
Q1 2009 - Q4 2009 Rating SIR: 2.64	2.64
Q3 2008 - Q2 2009 Rating SIR: 0.13	0.13
Q1 2008 - Q4 2008 Rating SIR: 0.09	0.09
Postoperative Respiratory Failure Q4 2020 - Q3 2021 Rating SIR: N/A	N/A
Description The number of cases of acute respiratory failure per 1,000 elective surgical discharges. (PSI 11) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 6.20	6.20
Q1 2015 - Q4 2015 Rating SIR: 11.88	11.88
Q4 2014 - Q3 2015 Rating SIR: 13.84	13.84
Q1 2014 - Q4 2014 Rating SIR: 13.94	13.94
Q4 2013 - Q3 2014 Rating SIR: 9.95	9.95
Q1 2013 - Q4 2013 Rating SIR: 3.74	3.74
Q3 2012 - Q2 2013 Rating SIR: 6.70	6.70
Q1 2012 - Q4 2012 Rating SIR: 7.81	7.81
Q4 2011 - Q3 2012 Rating SIR: 8.80	8.80
Q2 2011 - Q1 2012 Rating SIR: 14.51	14.51
Q1 2011 - Q4 2011 Rating SIR: 12.87	12.87
Q4 2010 - Q3 2011 Rating SIR: 17.87	17.87
Q1 2010 - Q4 2010 Rating SIR: 14.68	14.68
Q4 2009 - Q3 2010 Rating SIR: 21.16	21.16
Q1 2009 - Q4 2009 Rating SIR: 16.79	16.79
Q3 2008 - Q2 2009 Rating SIR: 1.02	1.02
Q1 2008 - Q4 2008 Rating SIR: 1.72	1.72
Postoperative Hip Fracture Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of in-hospital hip fracture per 1,000 surgical discharges(PSI 08). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.51	0.51
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.00	0.00
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 0.00	0.00
Q4 2013 - Q3 2014 Rating SIR: 0.00	0.00
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
Q3 2012 - Q2 2013 Rating SIR: 0.00	0.00
Q1 2012 - Q4 2012 Rating SIR: 0.00	0.00
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.00	0.00
Q4 2010 - Q3 2011 Rating SIR: 0.00	0.00
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.00	0.00
Pressure Ulcer Q4 2021 - Q3 2022 Rating SIR: 0.00	0.00
Description The number of cases of pressure ulcer per 1,000 discharges with a length of stay greater than 4 days (PSI 03). Historical Data
Measure	Result	Rating
Q4 2020 - Q3 2021 Rating SIR: 0.00	0.00
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.21	0.21
Q1 2015 - Q4 2015 Rating SIR: 0.52	0.52
Q4 2014 - Q3 2015 Rating SIR: 0.68	0.68
Q1 2014 - Q4 2014 Rating SIR: 0.43	0.43
Q4 2013 - Q3 2014 Rating SIR: 0.81	0.81
Q1 2013 - Q4 2013 Rating SIR: 0.41	0.41
Q3 2012 - Q2 2013 Rating SIR: 0.39	0.39
Q1 2012 - Q4 2012 Rating SIR: 0.40	0.40
Q4 2011 - Q3 2012 Rating SIR: 0.33	0.33
Q2 2011 - Q1 2012 Rating SIR: 0.78	0.78
Q1 2011 - Q4 2011 Rating SIR: 2.23	2.23
Q4 2010 - Q3 2011 Rating SIR: 0.82	0.82
Q1 2010 - Q4 2010 Rating SIR: 0.92	0.92
Q4 2009 - Q3 2010 Rating SIR: 3.20	3.20
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.22	0.22
Postoperative Sepsis Q4 2020 - Q3 2021 Rating SIR: N/A	N/A
Description The number of cases of sepsis per 1,000 elective surgery patients with a length of stay of 4 days or more (PSI 13). Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 1.70	1.70
Q1 2015 - Q4 2015 Rating SIR: 10.15	10.15
Q4 2014 - Q3 2015 Rating SIR: 6.19	6.19
Q1 2014 - Q4 2014 Rating SIR: 8.67	8.67
Q4 2013 - Q3 2014 Rating SIR: 9.28	9.28
Q1 2013 - Q4 2013 Rating SIR: 3.74	3.74
Q3 2012 - Q2 2013 Rating SIR: 10.48	10.48
Q1 2012 - Q4 2012 Rating SIR: 10.37	10.37
Q4 2011 - Q3 2012 Rating SIR: 17.28	17.28
Q2 2011 - Q1 2012 Rating SIR: 11.67	11.67
Q1 2011 - Q4 2011 Rating SIR: 11.73	11.73
Q4 2010 - Q3 2011 Rating SIR: 4.67	4.67
Q1 2010 - Q4 2010 Rating SIR: 0.00	0.00
Q4 2009 - Q3 2010 Rating SIR: 0.00	0.00
Q1 2009 - Q4 2009 Rating SIR: 5.74	5.74
Q3 2008 - Q2 2009 Rating SIR: 0.54	0.54
Q1 2008 - Q4 2008 Rating SIR: 1.20	1.20
Postoperative Acute Kidney Injury Requiring Dialysis Q4 2020 - Q3 2021 Rating SIR: N/A	N/A
Description This measure is used to assess the number of cases of specified physiological or metabolic derangement per 1,000 elective surgical discharges with an operating room procedure. (PSI 10) Historical Data
Measure	Result	Rating
Q4 2019 - Q3 2020 Rating SIR: 0.00	0.00
Q4 2018 - Q3 2019 Rating SIR: 0.00	0.00
Q2 2018 - Q1 2019 Rating SIR: 0.00	0.00
Q1 2015 - Q4 2015 Rating SIR: 0.84	0.84
Q4 2014 - Q3 2015 Rating SIR: 0.00	0.00
Q1 2014 - Q4 2014 Rating SIR: 1.56	1.56
Q4 2013 - Q3 2014 Rating SIR: 1.70	1.70
Q1 2013 - Q4 2013 Rating SIR: 0.00	0.00
Q3 2012 - Q2 2013 Rating SIR: 0.59	0.59
Q1 2012 - Q4 2012 Rating SIR: 0.59	0.59
Q4 2011 - Q3 2012 Rating SIR: 0.00	0.00
Q2 2011 - Q1 2012 Rating SIR: 0.00	0.00
Q1 2011 - Q4 2011 Rating SIR: 0.58	0.58
Q4 2010 - Q3 2011 Rating SIR: 0.64	0.64
Q1 2010 - Q4 2010 Rating SIR: 0.66	0.66
Q4 2009 - Q3 2010 Rating SIR: 0.63	0.63
Q1 2009 - Q4 2009 Rating SIR: 0.00	0.00
Q3 2008 - Q2 2009 Rating SIR: 0.00	0.00
Q1 2008 - Q4 2008 Rating SIR: 0.12	0.12

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2022 - Q4 2022 Result 0 infections, 59 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 59 patient days ¹¹⁸	N/A ¹¹⁸
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2021 - Q4 2021 Result 0 infections, 1144 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 1144 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2020 - Q4 2020 Result 0 infections, 9914 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 9914 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2019 - Q4 2019 Result 0 infections, 16712 patient days ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 16712 patient days ⁴⁵	N/A ⁴⁵
Q1 2018 - Q4 2018 Result 4 infections, 62897 patient days Rating SIR: 1.15	4 infections, 62897 patient days	1.15
Q1 2017 - Q4 2017 Result 3 infections, 64615 patient days Rating SIR: 0.82	3 infections, 64615 patient days	0.82
Q1 2016 - Q4 2016 Result 1 infections, 63435 patient days Rating SIR: 0.22	1 infections, 63435 patient days	0.22
Q1 2015 - Q4 2015 Result 1 infections, 64616 patient days Rating SIR: 0.32	1 infections, 64616 patient days	0.32
Q1 2014 - Q4 2014 Result 1 infections, 65764 patient days Rating SIR: 0.34	1 infections, 65764 patient days	0.34
Q1 2013 - Q4 2013 Result 1 infections, 67015 patient days Rating SIR: 0.29	1 infections, 67015 patient days	0.29
Q1 2012 - Q4 2012 Result 1 infections, 65457 patient days Rating SIR: 0.34	1 infections, 65457 patient days	0.34
Q1 2012 - Q2 2012 Result 1 infections, 32353 patient days Rating SIR: 0.31	1 infections, 32353 patient days	0.31
Clostridioides difficile infections (CDI) Q1 2022 - Q4 2022 Result 0 infections, 59 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 59 patient days ¹¹⁸	N/A ¹¹⁸
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2021 - Q4 2021 Result 0 infections, 1144 patient days ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 1144 patient days ¹¹⁸	N/A ¹¹⁸
Q1 2020 - Q4 2020 Result 3 infections, 9914 patient days Rating SIR: 1.03	3 infections, 9914 patient days	1.03
Q1 2019 - Q4 2019 Result 3 infections, 16515 patient days Rating SIR: 0.79	3 infections, 16515 patient days	0.79
Q1 2018 - Q4 2018 Result 55 infections, 45774 patient days Rating SIR: 1.40	55 infections, 45774 patient days	1.40
Q1 2017 - Q4 2017 Result 59 infections, 46058 patient days Rating SIR: 1.21	59 infections, 46058 patient days	1.21
Q1 2016 - Q4 2016 Result 36 infections, 47009 patient days Rating SIR: 0.52	36 infections, 47009 patient days	0.52
Q1 2015 - Q4 2015 Result 46 infections, 48721 patient days Rating SIR: 1.04	46 infections, 48721 patient days	1.04
Q1 2014 - Q4 2014 Result 62 infections, 51071 patient days Rating SIR: 1.28	62 infections, 51071 patient days	1.28
Q1 2013 - Q4 2013 Result 59 infections, 52981 patient days Rating SIR: 1.23	59 infections, 52981 patient days	1.23
Q1 2012 - Q4 2012 Result 52 infections, 51556 patient days Rating SIR: 1.21	52 infections, 51556 patient days	1.21

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2020 - Q4 2020 Result 0 infections, 176 central-line days Rating SIR: N/A	0 infections, 176 central-line days	N/A
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 2019 - Q4 2019 Result 1 infections, 447 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 447 central-line days ⁴⁴	N/A ⁴⁴
Q1 2018 - Q4 2018 Result 0 infections, 1834 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1834 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 1 infections, 2156 central-line days Rating SIR: 0.54	1 infections, 2156 central-line days	0.54
Q1 2016 - Q4 2016 Result 3 infections, 2004 central-line days Rating SIR: 1.73	3 infections, 2004 central-line days	1.73
Q1 2015 - Q4 2015 Result 9 infections, 2434 central-line days Rating SIR: 2.47	9 infections, 2434 central-line days	2.47
Q1 2014 - Q4 2014 Result 4 infections, 2357 central-line days Rating SIR: 1.13	4 infections, 2357 central-line days	1.13
Q1 2013 - Q4 2013 Result 1 infections, 2533 central-line days Rating SIR: 0.26	1 infections, 2533 central-line days	0.26
Q1 2012 - Q4 2012 Result 7 infections, 3005 central-line days Rating SIR: 1.55	7 infections, 3005 central-line days	1.55
Q1 2011 - Q4 2011 Result 2 infections, 3246 central-line days Rating SIR: 0.41	2 infections, 3246 central-line days	0.41
Q1 2010 - Q4 2010 Result 7 infections, 3595 central-line days Rating SIR: 1.30	7 infections, 3595 central-line days	1.30
Adult Surgical ICU Q1 2009 - Q4 2009 Result 8 infections, 3303 central-line days Rating SIR: 1.05	8 infections, 3303 central-line days	1.05
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2009 - Q2 2009 Result 2 infections, 1759 central-line days Rating SIR: 1.14	2 infections, 1759 central-line days	1.14

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2024 - Q4 2024 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 Total Knee Replacement 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 1 infections, 201 procedures Rating SIR: 0.75	1 infections, 201 procedures	0.75
Q1 2017 - Q4 2017 Result 0 infections, 247 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 247 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 289 procedures Rating SIR: 0.70	1 infections, 289 procedures	0.70
Q1 2015 - Q4 2015 Result 0 infections, 269 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 269 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 2 infections, 323 procedures Rating SIR: 0.94	2 infections, 323 procedures	0.94
Q3 2013 - Q2 2014 Result 4 infections, 256 procedures Rating SIR: 2.60	4 infections, 256 procedures	2.60
Q3 2012 - Q2 2013 Result 1 infections, 263 procedures Rating SIR: 0.52	1 infections, 263 procedures	0.52
Q3 2011 - Q2 2012 Result 1 infections, 268 procedures Rating SIR: 0.51	1 infections, 268 procedures	0.51
Q3 2010 - Q2 2011 Result 1 infections, 214 procedures Rating SIR: 0.89	1 infections, 214 procedures	0.89
Coronary Artery Bypass Graft Surgery Q1 2024 - Q4 2024 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 0 infections, 45 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 45 procedures ¹⁵³	N/A ¹⁵³
Q1 2016 - Q4 2016 Result 0 infections, 64 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 64 procedures ¹⁵³	N/A ¹⁵³
Q1 2015 - Q4 2015 Result 0 infections, 36 procedures ¹⁵³ Rating SIR: N/A ¹⁵³	0 infections, 36 procedures ¹⁵³	N/A ¹⁵³
Q1 2014 - Q4 2014 Result 0 infections, 77 procedures Rating SIR: 0.00	0 infections, 77 procedures	0.00
Q3 2013 - Q2 2014 Result 0 infections, 58 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 58 procedures ¹¹⁸	N/A ¹¹⁸
Q3 2012 - Q2 2013 Result 0 infections, 65 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 65 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 1 infections, 90 procedures Rating SIR: 0.64	1 infections, 90 procedures	0.64
Q3 2010 - Q2 2011 Result 2 infections, 100 procedures Rating SIR: 1.48	2 infections, 100 procedures	1.48