Illinois Hospital Report Card

and Consumer Guide to Health Care

Endeavor Northwest Community Hospital

Patient Safety - Surgical Site Infections (SSIs)

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
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
154	Complete Reporting: Number of predicted events too low to calculate a precise SIR

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2024 - Q4 2024 Result 0 infections, 581 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 581 procedures ¹¹⁷	0.00 ¹¹⁷
Description Surgical Site Infections Associated with Total Knee Replacement Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 1 infections, 736 procedures Rating SIR: 0.43	1 infections, 736 procedures	0.43
Q1 2022 - Q4 2022 Result 0 infections, 548 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 548 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 2 infections, 527 procedures Rating SIR: 1.01	2 infections, 527 procedures	1.01
Q1 2020 - Q4 2020 Result 2 infections, 346 procedures Rating SIR: 1.55	2 infections, 346 procedures	1.55
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 2024 - Q4 2024 Result 1 infections, 125 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 125 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 2023 - Q4 2023 Result 0 infections, 130 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 130 procedures ¹¹⁸	N/A ¹¹⁸
Q1 2022 - Q4 2022 Result 1 infections, 126 procedures ¹⁵⁴ Rating SIR: N/A ¹⁵⁴	1 infections, 126 procedures ¹⁵⁴	N/A ¹⁵⁴
Q1 2021 - Q4 2021 Result 0 infections, 129 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 129 procedures ¹¹⁸	N/A ¹¹⁸
Q1 2020 - Q4 2020 Result 0 infections, 92 procedures ¹¹⁸ Rating SIR: N/A ¹¹⁸	0 infections, 92 procedures ¹¹⁸	N/A ¹¹⁸
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