Seal of Illinois

Illinois Hospital Report Card

and Consumer Guide to Health Care

Endeavor Northwest Community 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 Statistically significantly better than state average or performing at the best possible rate
Not statistically significantly better or worse Not statistically significantly better or worse than state average
Statistically significantly worse than state average Statistically significantly worse than state average

Footnotes

Key Description
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
43 Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44 Complete Reporting: Too few central line days to calculate a precise SIR
46 Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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
118 Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
169 Exempt: No Licensed ICU Beds
Healthcare Facility Onset Incidence Rate SIR

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 Statistically significantly better than state average or performing at the best possible rate
Not statistically significantly better or worse Not statistically significantly better or worse than state average
Statistically significantly worse than state average Statistically significantly worse than state average

Footnotes

Key Description
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
43 Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44 Complete Reporting: Too few central line days to calculate a precise SIR
46 Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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
118 Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
169 Exempt: No Licensed ICU Beds

Adult CLABSI

Adult CLABSI Measure SIR

Pediatric CLABSI

Ped. CLABSI Measure SIR

NICU CLABSI

NICU CLABSI Measure SIR

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 Statistically significantly better than state average or performing at the best possible rate
Not statistically significantly better or worse Not statistically significantly better or worse than state average
Statistically significantly worse than state average Statistically significantly worse than state average

Footnotes

Key Description
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
43 Complete Reporting: Zero infections, but too few central line days to calculate a precise SIR
44 Complete Reporting: Too few central line days to calculate a precise SIR
46 Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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
118 Complete Reporting: Zero infections. Number of predicted events too low to calculate a precise SIR
169 Exempt: No Licensed ICU Beds
SSI Measure SIR

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