Memorial Hospital East

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
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but 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
169	Exempt: No Licensed ICU Beds

Healthcare Facility Onset Incidence Rate	Result	SIR
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections Q1 2019 - Q4 2019 Result 0 infections, 20689 patient days ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 20689 patient days ⁴⁵	N/A ⁴⁵
Description Methicillin-resistant Staphylococcus aureus infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result 0 infections, 19650 patient days ⁴⁵ Rating SIR: N/A ⁴⁵	0 infections, 19650 patient days ⁴⁵	N/A ⁴⁵
Q1 2017 - Q4 2017 Result 0 infections, 22391 patient days ¹¹⁷ Rating SIR: 0.00 ¹¹⁷	0 infections, 22391 patient days ¹¹⁷	0.00 ¹¹⁷
Clostridioides difficile infections (CDI) Q1 2019 - Q4 2019 Result 4 infections, 17934 patient days Rating SIR: 0.52	4 infections, 17934 patient days	0.52
Description Clostridium difficile infections summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result 13 infections, 16686 patient days Rating SIR: 1.67	13 infections, 16686 patient days	1.67
Q1 2017 - Q4 2017 Result 12 infections, 19159 patient days Rating SIR: 1.36	12 infections, 19159 patient days	1.36

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
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but 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
169	Exempt: No Licensed ICU Beds

Adult CLABSI

Adult CLABSI Measure	Result	SIR
Adult Medical/Surgical ICU Q1 2019 - Q4 2019 Result 0 infections, 395 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 395 central-line days ⁴²	N/A ⁴²
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 2018 - Q4 2018 Result 0 infections, 404 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 404 central-line days ⁴²	N/A ⁴²
Q1 2017 - Q4 2017 Result 0 infections, 456 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 456 central-line days ⁴²	N/A ⁴²
Q1 2016 - Q4 2016 Result 0 infections, 212 central-line days ⁴² Rating SIR: N/A ⁴²	0 infections, 212 central-line days ⁴²	N/A ⁴²

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

NICU CLABSI

NICU CLABSI Measure	Result	SIR
Level II/III Neonatal ICU Q1 2019 - Q4 2019 Result 0 infections, 21 central-line days ³³ Rating SIR: N/A ³³	0 infections, 21 central-line days ³³	N/A ³³
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 2018 - Q4 2018 Result 0 infections, 28 central-line days ³³ Rating SIR: N/A ³³	0 infections, 28 central-line days ³³	N/A ³³
Q1 2017 - Q4 2017 Result 0 infections, 32 central-line days ³³ Rating SIR: N/A ³³	0 infections, 32 central-line days ³³	N/A ³³
Q1 2016 - Q4 2016 Result N/A infections, N/A central-line days ³³ Rating SIR: N/A ³³	N/A infections, N/A central-line days ³³	N/A ³³

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
33	Complete Reporting: 50 or Less Central Line Days
38	Exempt: No Licensed PICU Beds
42	Complete Reporting: Zero infections, but 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
169	Exempt: No Licensed ICU Beds

SSI Measure	Result	SIR
Total Knee Replacement Surgery 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
Description Surgical Site Infections Associated with Total Knee Replacement Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2017 - Q4 2017 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2016 - Q4 2016 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Coronary Artery Bypass Graft Surgery 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
Description Surgical Site Infections Associated with Coronary Artery Bypass Graft Surgery Summarized as a Standardized Infection Ratio Historical Data
Measure	Result	Rating
Q1 2018 - Q4 2018 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸
Q1 2016 - Q4 2016 Result N/A infections, N/A procedures ⁴⁸ Rating SIR: N/A ⁴⁸	N/A infections, N/A procedures ⁴⁸	N/A ⁴⁸

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 2017 - Q1 2018 Result 93.00 %	93.00 %
Description Influenza Vaccination Coverage among Healthcare Personnel

Measure

Healthcare workers given influenza vaccination

Q4 2017 - Q1 2018

Result: 93.00 %

Illinois Hospital Report Card

and Consumer Guide to Health Care

Memorial Hospital East

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

Surgical Site Infections (SSIs)

Statistical Significance

Footnotes

Description

Historical Data

Description

Historical Data

Immunization Practices

Immunization

Description