Northwestern Memorial 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 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
38	Exempt: No Licensed PICU Beds
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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
38	Exempt: No Licensed PICU Beds
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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 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
38	Exempt: No Licensed PICU Beds
117	Complete Reporting: Zero infections. Number of reported events is not significantly different than predicted
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 94.00 %	94.00 %
Q4 2020 - Q1 2021 Result 98.00 %	98.00 %
Q4 2019 - Q1 2020 Result N/A %	N/A %
Q4 2018 - Q1 2019 Result 97.00 %	97.00 %
Q4 2017 - Q1 2018 Result 95.00 %	95.00 %

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2024 - Q4 2024 Result 8 infections, 348774 patient days Rating SIR: 0.47	8 infections, 348774 patient days	0.47
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 15 infections, 331885 patient days Rating SIR: 0.86	15 infections, 331885 patient days	0.86
Q1 2022 - Q4 2022 Result 11 infections, 331612 patient days Rating SIR: 0.67	11 infections, 331612 patient days	0.67
Q1 2021 - Q4 2021 Result 7 infections, 328800 patient days Rating SIR: 0.43	7 infections, 328800 patient days	0.43
Q1 2020 - Q4 2020 Result 12 infections, 291802 patient days Rating SIR: 0.85	12 infections, 291802 patient days	0.85
Q1 2019 - Q4 2019 Result 16 infections, 299758 patient days Rating SIR: 1.08	16 infections, 299758 patient days	1.08
Q1 2018 - Q4 2018 Result 9 infections, 291482 patient days Rating SIR: 0.65	9 infections, 291482 patient days	0.65
Q1 2017 - Q4 2017 Result 10 infections, 269791 patient days Rating SIR: 0.75	10 infections, 269791 patient days	0.75
Q1 2016 - Q4 2016 Result 7 infections, 267091 patient days Rating SIR: 0.54	7 infections, 267091 patient days	0.54
Q1 2015 - Q4 2015 Result 16 infections, 262079 patient days Rating SIR: 1.06	16 infections, 262079 patient days	1.06
Q1 2014 - Q4 2014 Result 20 infections, 263932 patient days Rating SIR: 1.25	20 infections, 263932 patient days	1.25
Q1 2013 - Q4 2013 Result 14 infections, 263840 patient days Rating SIR: 0.89	14 infections, 263840 patient days	0.89
Q1 2012 - Q4 2012 Result 18 infections, 273288 patient days Rating SIR: 1.15	18 infections, 273288 patient days	1.15
Q1 2012 - Q2 2012 Result 11 infections, 135697 patient days Rating SIR: 0.81	11 infections, 135697 patient days	0.81
Clostridioides difficile infections (CDI) Q1 2024 - Q4 2024 Result 87 infections, 309042 patient days Rating SIR: 0.52	87 infections, 309042 patient days	0.52
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 76 infections, 298299 patient days Rating SIR: 0.47	76 infections, 298299 patient days	0.47
Q1 2022 - Q4 2022 Result 77 infections, 288988 patient days Rating SIR: 0.49	77 infections, 288988 patient days	0.49
Q1 2021 - Q4 2021 Result 130 infections, 289198 patient days Rating SIR: 0.74	130 infections, 289198 patient days	0.74
Q1 2020 - Q4 2020 Result 131 infections, 255222 patient days Rating SIR: 0.66	131 infections, 255222 patient days	0.66
Q1 2019 - Q4 2019 Result 166 infections, 260000 patient days Rating SIR: 0.81	166 infections, 260000 patient days	0.81
Q1 2018 - Q4 2018 Result 126 infections, 247020 patient days Rating SIR: 0.66	126 infections, 247020 patient days	0.66
Q1 2017 - Q4 2017 Result 160 infections, 226401 patient days Rating SIR: 0.86	160 infections, 226401 patient days	0.86
Q1 2016 - Q4 2016 Result 184 infections, 222582 patient days Rating SIR: 0.93	184 infections, 222582 patient days	0.93
Q1 2015 - Q4 2015 Result 156 infections, 216444 patient days Rating SIR: 0.89	156 infections, 216444 patient days	0.89
Q1 2014 - Q4 2014 Result 164 infections, 215479 patient days Rating SIR: 0.94	164 infections, 215479 patient days	0.94
Q1 2013 - Q4 2013 Result 156 infections, 215654 patient days Rating SIR: 0.88	156 infections, 215654 patient days	0.88
Q1 2012 - Q4 2012 Result 160 infections, 222447 patient days Rating SIR: 0.88	160 infections, 222447 patient days	0.88

Adult CLABSI Measure	Result	SIR
Adult Neurosurgical ICU Q1 2024 - Q4 2024 Result 0 infections, 1682 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1682 central-line days ¹¹⁷	0.00 ¹¹⁷
Description Central Line-associated Bloodstream Infection data in the Adult Neurosurgical ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 2 infections, 2231 central-line days Rating SIR: 0.79	2 infections, 2231 central-line days	0.79
Q1 2022 - Q4 2022 Result 1 infections, 2022 central-line days Rating SIR: 0.44	1 infections, 2022 central-line days	0.44
Q1 2021 - Q4 2021 Result 3 infections, 2479 central-line days Rating SIR: 1.07	3 infections, 2479 central-line days	1.07
Q1 2019 - Q4 2019 Result 2 infections, 1836 central-line days Rating SIR: 0.97	2 infections, 1836 central-line days	0.97
Q1 2018 - Q4 2018 Result 2 infections, 1522 central-line days Rating SIR: 1.17	2 infections, 1522 central-line days	1.17
Q1 2017 - Q4 2017 Result 0 infections, 1602 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1602 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2016 - Q4 2016 Result 1 infections, 2087 central-line days Rating SIR: 0.43	1 infections, 2087 central-line days	0.43
Q1 2015 - Q4 2015 Result 1 infections, 2580 central-line days Rating SIR: 0.16	1 infections, 2580 central-line days	0.16
Q1 2013 - Q4 2013 Result 3 infections, 2664 central-line days Rating SIR: 0.45	3 infections, 2664 central-line days	0.45
Q1 2012 - Q4 2012 Result 1 infections, 3039 central-line days Rating SIR: 0.13	1 infections, 3039 central-line days	0.13
Adult Surgical Cardiothoracic ICU Q1 2024 - Q4 2024 Result 10 infections, 6064 central-line days Rating SIR: 1.46	10 infections, 6064 central-line days	1.46
Description Central Line-associated Bloodstream Infection data in the Adult Surgical Cardiothoracic ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 8 infections, 7958 central-line days Rating SIR: 0.89	8 infections, 7958 central-line days	0.89
Q1 2022 - Q4 2022 Result 6 infections, 5981 central-line days Rating SIR: 0.89	6 infections, 5981 central-line days	0.89
Q1 2021 - Q4 2021 Result 6 infections, 6249 central-line days Rating SIR: 0.85	6 infections, 6249 central-line days	0.85
Q1 2020 - Q4 2020 Result 0 infections, 5026 central-line days Rating SIR: 0.00	0 infections, 5026 central-line days	0.00
Q1 2019 - Q4 2019 Result 4 infections, 4880 central-line days Rating SIR: 0.73	4 infections, 4880 central-line days	0.73
Q1 2018 - Q4 2018 Result 0 infections, 4234 central-line days Rating SIR: 0.00	0 infections, 4234 central-line days	0.00
Q1 2017 - Q4 2017 Result 6 infections, 3997 central-line days Rating SIR: 1.33	6 infections, 3997 central-line days	1.33
Q1 2016 - Q4 2016 Result 7 infections, 3113 central-line days Rating SIR: 1.99	7 infections, 3113 central-line days	1.99
Q1 2015 - Q4 2015 Result 3 infections, 3156 central-line days Rating SIR: 0.68	3 infections, 3156 central-line days	0.68
Q1 2013 - Q4 2013 Result 6 infections, 3097 central-line days Rating SIR: 1.38	6 infections, 3097 central-line days	1.38
Q1 2012 - Q4 2012 Result 9 infections, 3146 central-line days Rating SIR: 2.04	9 infections, 3146 central-line days	2.04
Adult Medical Cardiac ICU Q1 2024 - Q4 2024 Result 3 infections, 2353 central-line days Rating SIR: 1.13	3 infections, 2353 central-line days	1.13
Description Central Line-associated Bloodstream Infection data in the Adult Medical Cardiac ICU Summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 2 infections, 2333 central-line days Rating SIR: 0.76	2 infections, 2333 central-line days	0.76
Q1 2022 - Q4 2022 Result 5 infections, 1465 central-line days Rating SIR: 3.03	5 infections, 1465 central-line days	3.03
Q1 2021 - Q4 2021 Result 1 infections, 2210 central-line days Rating SIR: 0.40	1 infections, 2210 central-line days	0.40
Q1 2019 - Q4 2019 Result 4 infections, 2633 central-line days Rating SIR: 1.35	4 infections, 2633 central-line days	1.35
Q1 2018 - Q4 2018 Result 3 infections, 2194 central-line days Rating SIR: 1.21	3 infections, 2194 central-line days	1.21
Q1 2017 - Q4 2017 Result 1 infections, 2453 central-line days Rating SIR: 0.36	1 infections, 2453 central-line days	0.36
Q1 2016 - Q4 2016 Result 4 infections, 2382 central-line days Rating SIR: 1.49	4 infections, 2382 central-line days	1.49
Q1 2015 - Q4 2015 Result 3 infections, 2245 central-line days Rating SIR: 0.67	3 infections, 2245 central-line days	0.67
Q1 2013 - Q4 2013 Result 3 infections, 1717 central-line days Rating SIR: 0.87	3 infections, 1717 central-line days	0.87
Q1 2012 - Q4 2012 Result 3 infections, 1970 central-line days Rating SIR: 0.76	3 infections, 1970 central-line days	0.76
Adult Medical/Surgical ICU Q1 2016 - Q4 2016 Result N/A infections, N/A central-line days Rating SIR: N/A	N/A infections, N/A central-line days	N/A
Description Central Line-associated Bloodstream Infection data in the Adult Medical/Surgical ICU summarized as a Standardized Infection Ratio.
Adult Surgical ICU Q1 2024 - Q4 2024 Result 1 infections, 3500 central-line days Rating SIR: 0.25	1 infections, 3500 central-line days	0.25
Description Central Line-associated Bloodstream Infection data in the Adult Surgical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 2 infections, 2819 central-line days Rating SIR: 0.63	2 infections, 2819 central-line days	0.63
Q1 2022 - Q4 2022 Result 0 infections, 2564 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 2564 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2021 - Q4 2021 Result 3 infections, 2677 central-line days Rating SIR: 0.99	3 infections, 2677 central-line days	0.99
Q1 2020 - Q4 2020 Result 0 infections, 2321 central-line days Rating SIR: 0.00	0 infections, 2321 central-line days	0.00
Q1 2019 - Q4 2019 Result 3 infections, 1859 central-line days Rating SIR: 1.43	3 infections, 1859 central-line days	1.43
Q1 2018 - Q4 2018 Result 3 infections, 1927 central-line days Rating SIR: 1.38	3 infections, 1927 central-line days	1.38
Q1 2017 - Q4 2017 Result 1 infections, 2002 central-line days Rating SIR: 0.44	1 infections, 2002 central-line days	0.44
Q1 2016 - Q4 2016 Result 4 infections, 2034 central-line days Rating SIR: 1.74	4 infections, 2034 central-line days	1.74
Q1 2015 - Q4 2015 Result 1 infections, 2137 central-line days Rating SIR: 0.20	1 infections, 2137 central-line days	0.20
Q1 2013 - Q4 2013 Result 4 infections, 2181 central-line days Rating SIR: 0.80	4 infections, 2181 central-line days	0.80
Q1 2012 - Q4 2012 Result 2 infections, 2703 central-line days Rating SIR: 0.32	2 infections, 2703 central-line days	0.32
Q1 2011 - Q4 2011 Result 4 infections, 2579 central-line days Rating SIR: 0.67	4 infections, 2579 central-line days	0.67
Q1 2010 - Q4 2010 Result 2 infections, 2339 central-line days Rating SIR: 0.37	2 infections, 2339 central-line days	0.37
Q1 2009 - Q4 2009 Result 1 infections, 2474 central-line days Rating SIR: 0.18	1 infections, 2474 central-line days	0.18
Q1 2009 - Q2 2009 Result 1 infections, 1175 central-line days Rating SIR: 0.85	1 infections, 1175 central-line days	0.85
Adult Medical ICU Q1 2024 - Q4 2024 Result 10 infections, 6797 central-line days Rating SIR: 1.30	10 infections, 6797 central-line days	1.30
Description Central Line-associated Bloodstream Infection data in the Adult Medical ICU summarized as a Standardized Infection Ratio. Historical Data
Measure	Result	Rating
Q1 2023 - Q4 2023 Result 9 infections, 6600 central-line days Rating SIR: 1.21	9 infections, 6600 central-line days	1.21
Q1 2022 - Q4 2022 Result 16 infections, 8889 central-line days Rating SIR: 1.60	16 infections, 8889 central-line days	1.60
Q1 2021 - Q4 2021 Result 12 infections, 6529 central-line days Rating SIR: 1.63	12 infections, 6529 central-line days	1.63
Q1 2020 - Q4 2020 Result 3 infections, 4176 central-line days Rating SIR: 0.64	3 infections, 4176 central-line days	0.64
Q1 2019 - Q4 2019 Result 3 infections, 4694 central-line days Rating SIR: 0.57	3 infections, 4694 central-line days	0.57
Q1 2018 - Q4 2018 Result 2 infections, 3875 central-line days Rating SIR: 0.46	2 infections, 3875 central-line days	0.46
Q1 2017 - Q4 2017 Result 3 infections, 4125 central-line days Rating SIR: 0.65	3 infections, 4125 central-line days	0.65
Q1 2016 - Q4 2016 Result 3 infections, 4861 central-line days Rating SIR: 0.55	3 infections, 4861 central-line days	0.55
Q1 2015 - Q4 2015 Result 12 infections, 5107 central-line days Rating SIR: 1.24	12 infections, 5107 central-line days	1.24
Q1 2014 - Q4 2014 Result 8 infections, 5285 central-line days Rating SIR: 0.80	8 infections, 5285 central-line days	0.80
Q1 2013 - Q4 2013 Result 13 infections, 6052 central-line days Rating SIR: 1.13	13 infections, 6052 central-line days	1.13
Q1 2012 - Q4 2012 Result 11 infections, 6202 central-line days Rating SIR: 0.93	11 infections, 6202 central-line days	0.93
Q1 2011 - Q4 2011 Result 8 infections, 5876 central-line days Rating SIR: 0.72	8 infections, 5876 central-line days	0.72
Q1 2010 - Q4 2010 Result 2 infections, 5490 central-line days Rating SIR: 0.19	2 infections, 5490 central-line days	0.19
Q1 2009 - Q4 2009 Result 6 infections, 5633 central-line days Rating SIR: 0.41	6 infections, 5633 central-line days	0.41
Q1 2009 - Q2 2009 Result 4 infections, 2823 central-line days Rating SIR: 1.42	4 infections, 2823 central-line days	1.42

NICU CLABSI Measure	Result	SIR
Level III Neonatal ICU Q1 2023 - Q4 2023 Result 2 infections, 1955 central-line days Rating SIR: 0.79	2 infections, 1955 central-line days	0.79
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 2 infections, 2275 central-line days Rating SIR: 0.71	2 infections, 2275 central-line days	0.71
Q1 2021 - Q4 2021 Result 5 infections, 1919 central-line days Rating SIR: 1.74	5 infections, 1919 central-line days	1.74
Q1 2020 - Q4 2020 Result 1 infections, 2169 central-line days Rating SIR: 0.32	1 infections, 2169 central-line days	0.32
Q1 2019 - Q4 2019 Result 4 infections, 2041 central-line days Rating SIR: 1.38	4 infections, 2041 central-line days	1.38
Q1 2018 - Q4 2018 Result 0 infections, 1958 central-line days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 1958 central-line days ¹¹⁷	0.00 ¹¹⁷
Q1 2017 - Q4 2017 Result 1 infections, 2013 central-line days Rating SIR: 0.36	1 infections, 2013 central-line days	0.36
Q1 2016 - Q4 2016 Result 2 infections, 2081 central-line days Rating SIR: 0.74	2 infections, 2081 central-line days	0.74
Q1 2015 - Q4 2015 Result 5 infections, 2164 central-line days Rating SIR: 0.99	5 infections, 2164 central-line days	0.99
Q1 2014 - Q4 2014 Result 1 infections, 2073 central-line days Rating SIR: 0.20	1 infections, 2073 central-line days	0.20
Q1 2013 - Q4 2013 Result 1 infections, 2412 central-line days Rating SIR: 0.18	1 infections, 2412 central-line days	0.18
Q1 2012 - Q4 2012 Result 3 infections, 2613 central-line days Rating SIR: 0.46	3 infections, 2613 central-line days	0.46
Q1 2011 - Q4 2011 Result 3 infections, 2370 central-line days Rating SIR: 0.50	3 infections, 2370 central-line days	0.50
Q1 2010 - Q4 2010 Result 0 infections, 3628 central-line days Rating SIR: 0.00	0 infections, 3628 central-line days	0.00
Q1 2010 - Q2 2010 Result 0 infections, 1299 central-line days Rating SIR: 0.00	0 infections, 1299 central-line days	0.00

SSI Measure	Result	SIR
Total Knee Replacement Surgery Q1 2024 - Q4 2024 Result 0 infections, 893 procedures Rating SIR: 0.00	0 infections, 893 procedures	0.00
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 0 infections, 895 procedures Rating SIR: 0.00	0 infections, 895 procedures	0.00
Q1 2022 - Q4 2022 Result 1 infections, 693 procedures Rating SIR: 0.31	1 infections, 693 procedures	0.31
Q1 2021 - Q4 2021 Result 3 infections, 704 procedures Rating SIR: 0.92	3 infections, 704 procedures	0.92
Q1 2020 - Q4 2020 Result 1 infections, 508 procedures Rating SIR: 0.41	1 infections, 508 procedures	0.41
Q1 2019 - Q4 2019 Result 5 infections, 780 procedures Rating SIR: 1.32	5 infections, 780 procedures	1.32
Q1 2018 - Q4 2018 Result 2 infections, 752 procedures Rating SIR: 0.61	2 infections, 752 procedures	0.61
Q1 2017 - Q4 2017 Result 5 infections, 715 procedures Rating SIR: 1.68	5 infections, 715 procedures	1.68
Q1 2016 - Q4 2016 Result 4 infections, 705 procedures Rating SIR: 1.45	4 infections, 705 procedures	1.45
Q1 2015 - Q4 2015 Result 3 infections, 653 procedures Rating SIR: 0.61	3 infections, 653 procedures	0.61
Q1 2014 - Q4 2014 Result 3 infections, 663 procedures Rating SIR: 0.62	3 infections, 663 procedures	0.62
Q3 2013 - Q2 2014 Result 1 infections, 642 procedures Rating SIR: 0.22	1 infections, 642 procedures	0.22
Q3 2012 - Q2 2013 Result 3 infections, 848 procedures Rating SIR: 0.51	3 infections, 848 procedures	0.51
Q3 2011 - Q2 2012 Result 2 infections, 967 procedures Rating SIR: 0.32	2 infections, 967 procedures	0.32
Q3 2010 - Q2 2011 Result 3 infections, 1028 procedures Rating SIR: 0.43	3 infections, 1028 procedures	0.43
Coronary Artery Bypass Graft Surgery Q1 2024 - Q4 2024 Result 3 infections, 392 procedures Rating SIR: 0.75	3 infections, 392 procedures	0.75
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, 347 procedures Rating SIR: 0.00	0 infections, 347 procedures	0.00
Q1 2022 - Q4 2022 Result 1 infections, 301 procedures Rating SIR: 0.33	1 infections, 301 procedures	0.33
Q1 2021 - Q4 2021 Result 0 infections, 253 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 253 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2020 - Q4 2020 Result 1 infections, 156 procedures Rating SIR: 0.49	1 infections, 156 procedures	0.49
Q1 2019 - Q4 2019 Result 1 infections, 246 procedures Rating SIR: 0.36	1 infections, 246 procedures	0.36
Q1 2018 - Q4 2018 Result 3 infections, 250 procedures Rating SIR: 1.15	3 infections, 250 procedures	1.15
Q1 2016 - Q4 2016 Result 0 infections, 225 procedures ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 225 procedures ¹¹⁷	0.00 ¹¹⁷
Q1 2015 - Q4 2015 Result 5 infections, 228 procedures Rating SIR: 1.52	5 infections, 228 procedures	1.52
Q1 2014 - Q4 2014 Result 2 infections, 244 procedures Rating SIR: 0.55	2 infections, 244 procedures	0.55
Q3 2013 - Q2 2014 Result 1 infections, 252 procedures Rating SIR: 0.27	1 infections, 252 procedures	0.27
Q3 2012 - Q2 2013 Result 1 infections, 229 procedures Rating SIR: 0.29	1 infections, 229 procedures	0.29
Q3 2011 - Q2 2012 Result 1 infections, 241 procedures Rating SIR: 0.30	1 infections, 241 procedures	0.30
Q3 2010 - Q2 2011 Result 1 infections, 290 procedures Rating SIR: 0.25	1 infections, 290 procedures	0.25