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

Not statistically significantly better or 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

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
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

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
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

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 97.00 %	97.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel Historical Data
Measure	Result
Q4 2021 - Q1 2022 Result 95.00 %	95.00 %
Q4 2020 - Q1 2021 Result 94.00 %	94.00 %
Q4 2019 - Q1 2020 Result N/A %	N/A %
Q4 2018 - Q1 2019 Result 72.00 %	72.00 %
Q4 2017 - Q1 2018 Result 75.00 %	75.00 %

Illinois Hospital Report Card

and Consumer Guide to Health Care

Endeavor Northwest Community 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

Pediatric CLABSI

Description

Historical Data

NICU CLABSI

Description

Historical Data

Description

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 2 infections, 94159 patient days Rating SIR: 0.44	2 infections, 94159 patient days	0.44
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 4 infections, 92515 patient days Rating SIR: 1.22	4 infections, 92515 patient days	1.22
Q1 2021 - Q4 2021 Result 4 infections, 88858 patient days Rating SIR: 1.02	4 infections, 88858 patient days	1.02
Q1 2020 - Q4 2020 Result 7 infections, 83600 patient days Rating SIR: 1.90	7 infections, 83600 patient days	1.90
Q1 2019 - Q4 2019 Result 5 infections, 90245 patient days Rating SIR: 1.41	5 infections, 90245 patient days	1.41
Q1 2018 - Q4 2018 Result 3 infections, 89503 patient days Rating SIR: 0.91	3 infections, 89503 patient days	0.91
Q1 2017 - Q4 2017 Result 1 infections, 85738 patient days Rating SIR: 0.30	1 infections, 85738 patient days	0.30
Q1 2016 - Q4 2016 Result 3 infections, 81422 patient days Rating SIR: 1.00	3 infections, 81422 patient days	1.00
Q1 2015 - Q4 2015 Result 4 infections, 89759 patient days Rating SIR: 1.03	4 infections, 89759 patient days	1.03
Q1 2014 - Q4 2014 Result 3 infections, 100620 patient days Rating SIR: 0.44	3 infections, 100620 patient days	0.44
Q1 2013 - Q4 2013 Result 4 infections, 93871 patient days Rating SIR: 0.98	4 infections, 93871 patient days	0.98
Q1 2012 - Q4 2012 Result 6 infections, 98092 patient days Rating SIR: 0.94	6 infections, 98092 patient days	0.94
Q1 2012 - Q2 2012 Result 4 infections, 49493 patient days Rating SIR: 0.81	4 infections, 49493 patient days	0.81
Clostridioides difficile infections (CDI) Q1 2023 - Q4 2023 Result 12 infections, 86682 patient days Rating SIR: 0.29	12 infections, 86682 patient days	0.29
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2022 - Q4 2022 Result 15 infections, 84904 patient days Rating SIR: 0.40	15 infections, 84904 patient days	0.40
Q1 2021 - Q4 2021 Result 14 infections, 80841 patient days Rating SIR: 0.37	14 infections, 80841 patient days	0.37
Q1 2020 - Q4 2020 Result 21 infections, 75352 patient days Rating SIR: 0.63	21 infections, 75352 patient days	0.63
Q1 2019 - Q4 2019 Result 37 infections, 81852 patient days Rating SIR: 0.73	37 infections, 81852 patient days	0.73
Q1 2018 - Q4 2018 Result 58 infections, 80611 patient days Rating SIR: 1.00	58 infections, 80611 patient days	1.00
Q1 2017 - Q4 2017 Result 99 infections, 77232 patient days Rating SIR: 1.74	99 infections, 77232 patient days	1.74
Q1 2016 - Q4 2016 Result 78 infections, 72789 patient days Rating SIR: 1.47	78 infections, 72789 patient days	1.47
Q1 2015 - Q4 2015 Result 81 infections, 81906 patient days Rating SIR: 1.13	81 infections, 81906 patient days	1.13
Q1 2014 - Q4 2014 Result 82 infections, 91045 patient days Rating SIR: 1.14	82 infections, 91045 patient days	1.14
Q1 2013 - Q4 2013 Result 66 infections, 87122 patient days Rating SIR: 0.96	66 infections, 87122 patient days	0.96
Q1 2012 - Q4 2012 Result 89 infections, 88660 patient days Rating SIR: 1.23	89 infections, 88660 patient days	1.23

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2023 - Q4 2023 Result 2 infections, 1867 central-line days Rating SIR: 1.24	2 infections, 1867 central-line days	1.24
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 2022 - Q4 2022 Result 1 infections, 1831 central-line days Rating SIR: 0.63	1 infections, 1831 central-line days	0.63
Q1 2021 - Q4 2021 Result 3 infections, 1947 central-line days Rating SIR: 1.78	3 infections, 1947 central-line days	1.78
Q1 2020 - Q4 2020 Result 5 infections, 1988 central-line days Rating SIR: 2.90	5 infections, 1988 central-line days	2.90
Q1 2019 - Q4 2019 Result 1 infections, 2135 central-line days Rating SIR: 0.54	1 infections, 2135 central-line days	0.54
Q1 2018 - Q4 2018 Result 3 infections, 2380 central-line days Rating SIR: 1.45	3 infections, 2380 central-line days	1.45
Q1 2017 - Q4 2017 Result 2 infections, 2265 central-line days Rating SIR: 1.02	2 infections, 2265 central-line days	1.02
Q1 2016 - Q4 2016 Result 2 infections, 2816 central-line days Rating SIR: 0.82	2 infections, 2816 central-line days	0.82
Q1 2015 - Q4 2015 Result 2 infections, 2547 central-line days Rating SIR: 0.52	2 infections, 2547 central-line days	0.52
Q1 2014 - Q4 2014 Result 2 infections, 2708 central-line days Rating SIR: 0.49	2 infections, 2708 central-line days	0.49
Q1 2013 - Q4 2013 Result 6 infections, 3022 central-line days Rating SIR: 1.32	6 infections, 3022 central-line days	1.32
Q1 2012 - Q4 2012 Result 7 infections, 3039 central-line days Rating SIR: 1.53	7 infections, 3039 central-line days	1.53
Q1 2011 - Q4 2011 Result 4 infections, 3182 central-line days Rating SIR: 0.84	4 infections, 3182 central-line days	0.84
Q1 2010 - Q4 2010 Result 4 infections, 3660 central-line days Rating SIR: 0.73	4 infections, 3660 central-line days	0.73
Q1 2009 - Q4 2009 Result 6 infections, 3825 central-line days Rating SIR: 1.05	6 infections, 3825 central-line days	1.05
Q1 2009 - Q2 2009 Result 3 infections, 2020 central-line days Rating SIR: 1.49	3 infections, 2020 central-line days	1.49

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2023 - Q4 2023 Result 0 infections, 258 central-line days Rating SIR: N/A	0 infections, 258 central-line days	N/A
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 2022 - Q4 2022 Result 0 infections, 317 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 317 central-line days ⁴²	N/A ⁴²
Q1 2021 - Q4 2021 Result 0 infections, 358 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 358 central-line days ⁴²	N/A ⁴²
Q1 2020 - Q4 2020 Result 1 infections, 335 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 335 central-line days ⁴⁴	N/A ⁴⁴
Q1 2019 - Q4 2019 Result 0 infections, 404 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 404 central-line days ⁴²	N/A ⁴²
Q1 2018 - Q4 2018 Result 0 infections, 676 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 676 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 1 infections, 477 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 477 central-line days ⁴⁴	N/A ⁴⁴
Q1 2016 - Q4 2016 Result 1 infections, 403 central-line days ⁴⁴ Rating SIR: N/A ⁴⁴	1 infections, 403 central-line days ⁴⁴	N/A ⁴⁴
Q1 2015 - Q4 2015 Result 0 infections, 437 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 437 central-line days ⁴²	N/A ⁴²
Q1 2014 - Q4 2014 Result 1 infections, 602 central-line days Rating SIR: 0.83	1 infections, 602 central-line days	0.83
Q1 2013 - Q4 2013 Result 2 infections, 570 central-line days Rating SIR: 1.48	2 infections, 570 central-line days	1.48
Q1 2012 - Q4 2012 Result 3 infections, 757 central-line days Rating SIR: 1.78	3 infections, 757 central-line days	1.78
Q1 2011 - Q4 2011 Result 0 infections, 730 central-line days ⁴³ Rating SIR: 0.00 ⁴³	0 infections, 730 central-line days ⁴³	0.00 ⁴³
Q1 2010 - Q4 2010 Result 1 infections, 430 central-line days ⁴⁴ Rating SIR: 0.00 ⁴⁴	1 infections, 430 central-line days ⁴⁴	0.00 ⁴⁴
Level III Neonatal ICU 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
Description Central Line-associated Bloodstream Infection data in the Level III Neonatal ICU summarized as a Standardized Infection Ratio.

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2020 - Q4 2020 Result 2 infections, 346 procedures Rating SIR: 1.55	2 infections, 346 procedures	1.55
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, 452 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 452 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2018 - Q4 2018 Result 1 infections, 644 procedures Rating SIR: 0.38	1 infections, 644 procedures	0.38
Q1 2017 - Q4 2017 Result 0 infections, 530 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 530 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 0 infections, 495 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 495 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 1 infections, 543 procedures Rating SIR: 0.27	1 infections, 543 procedures	0.27
Q1 2014 - Q4 2014 Result 0 infections, 534 procedures Rating SIR: 0.00	0 infections, 534 procedures	0.00
Q3 2013 - Q2 2014 Result 2 infections, 503 procedures Rating SIR: 0.56	2 infections, 503 procedures	0.56
Q3 2012 - Q2 2013 Result 2 infections, 490 procedures Rating SIR: 0.59	2 infections, 490 procedures	0.59
Q3 2011 - Q2 2012 Result 0 infections, 512 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 512 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 0 infections, 516 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 516 procedures ⁴⁶	0.00 ⁴⁶
Coronary Artery Bypass Graft Surgery Q1 2020 - Q4 2020 Result 0 infections, 92 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 92 procedures ¹¹⁸	N/A ¹¹⁸
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 1 infections, 122 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 122 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2018 - Q4 2018 Result 1 infections, 143 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	1 infections, 143 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2016 - Q4 2016 Result 2 infections, 137 procedures ¹¹⁴ Rating SIR: N/A ¹¹⁴	2 infections, 137 procedures ¹¹⁴	N/A ¹¹⁴
Q1 2015 - Q4 2015 Result 0 infections, 137 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 137 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2014 - Q4 2014 Result 2 infections, 158 procedures Rating SIR: 1.28	2 infections, 158 procedures	1.28
Q3 2013 - Q2 2014 Result 1 infections, 135 procedures Rating SIR: 0.77	1 infections, 135 procedures	0.77
Q3 2012 - Q2 2013 Result 0 infections, 154 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 154 procedures ¹¹⁷	0.00 ¹¹⁷
Q3 2011 - Q2 2012 Result 0 infections, 160 procedures ⁴⁶ Rating SIR: 0.00 ⁴⁶	0 infections, 160 procedures ⁴⁶	0.00 ⁴⁶
Q3 2010 - Q2 2011 Result 2 infections, 208 procedures Rating SIR: 0.99	2 infections, 208 procedures	0.99