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OrgID Hospital Name Hospital System Hospital System & Name
14175 Addison Gilbert Hospital Lahey Health Lahey Health - Addison Gilbert Hospital
12685 Anna Jaques Hospital Anna Jaques Hospital
13262 Athol Memorial Hospital Athol Memorial Hospital
10482 Baystate Medical Center Baystate Health Baystate Medical Center
12538 Berkshire Medical Center Berkshire Health Systems Berkshire Health Systems - Berkshire Medical Center
13230 Beth Israel Deaconess Hospital - Milton Beth Israel Deaconess Hospital Beth Israel Deaconess Hospital - Milton
12866
Beth Israel Deaconess Hospital -
Needham Beth Israel Deaconess Hospital Beth Israel Deaconess Hospital - Needham
12643
Beth Israel Deaconess Hospital -
Plymouth Beth Israel Deaconess Hospital Beth Israel Deaconess Hospital - Plymouth
13000 Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center Beth Israel Deaconess Medical Center
11571 Beverly Hospital Lahey Health Lahey Health - Beverly Hospital
12698 Boston Children's Hospital Boston Children's Hospital
12630 Boston Medical Center Boston Medical Center
12596 Brigham and Women's Hospital Brigham and Women's Brigham and Women's Hospital
12468 Brockton Hospital Signature Healthcare Signature Healthcare - Brockton Hospital
13213 Cambridge Hospital Cambridge Health Alliance Cambridge Health Alliance - Cambridge Hospital
12515 Cape Cod Hospital Cape Cod Healthcare Cape Cod Healthcare - Cape Cod Hospital
12601 Carney Hospital Steward Health Care Steward Health Care - Carney Hospital
12578 Charlton Memorial Hospital Southcoast Health Southcoast Health - Charlton Memorial Hospital
12751 Clinton Hospital UMass Memorial Health Care UMass Memorial Health Care - Clinton Hospital
12837 Cooley Dickinson Hospital Cooley Dickinson Hospital
12670 Emerson Hospital Emerson Hospital
13189 Fairview Hospital Berkshire Health Systems Berkshire Health Systems - Fairview Hospital
12516 Falmouth Hosptial Cape Cod Healthcare Cape Cod Healthcare - Falmouth Hosptial
12955 Faulkner Hospital Brigham and Women's Brigham and Women's - Faulkner Hospital
13201 Framingham Union Hospital MetroWest Medical Center MetroWest Medical Center - Framingham Union Hospital
12778 Franklin Medical Center Baystate Health Baystate Franklin Medical Center
12622 Good Samaritan Medical Center Steward Health Care Steward Health Care - Good Samaritan Medical Center
13022 Harrington Memorial Hospital Harrington Memorial Hospital
12700 HealthAlliance Hospital UMass Memorial Health Care UMass Memorial Health Care - HealthAlliance Hospital
12686 Heywood Hospital Heywood Hospital
12600 Holy Family Hospital Steward Health Care Steward Health Care - Holy Family Hospital
13301 Holy Family Hospital at Merrimack Valley Steward Health Care
Steward Health Care - Holy Family Hospital at Merrimack
Valley
12598 Holyoke Medical Center Holyoke Medical Center
12679 Lahey Hospital & Medical Center Lahey Health Lahey Health - Lahey Hospital & Medical Center
12793 Lawrence General Hospital Lawrence General Hospital
12710 Lawrence Memorial Hospital of Medford Hallmark Health System
Hallmark Health System - Lawrence Memorial Hospital of
Medford
13309 Leonard Morse Hospital MetroWest Medical Center MetroWest Medical Center - Leonard Morse Hospital
12674 Lowell General Hospital - Main Campus Lowell General Hospital - Main Campus
12714 Lowell General Hospital - Saints Campus Lowell General Hospital - Saints Campus
12875 Marlborough Hospital UMass Memorial Health Care UMass Memorial Health Care - Marlborough Hospital
12833 Martha's Vineyard Hospital Martha's Vineyard Hospital
13049 Mary Lane Hospital Baystate Health Baystate Mary Lane Hospital
12568 Massachusetts General Hospital Massachusetts General Hospital
13298 Melrose-Wakefield Hospital Hallmark Health System Hallmark Health System - Melrose-Wakefield Hospital
13091 Mercy Medical Center Mercy Medical Center
12752 Milford Regional Medical Center Milford Regional Medical Center
12619 Morton Hospital Steward Health Care Steward Health Care - Morton Hospital
12703 Mount Auburn Hospital Mount Auburn Hospital
13206 Nantucket Cottage Hospital Nantucket Cottage Hospital
OrgID Hospital Name Hospital System Hospital System & Name
13290 Nashoba Valley Medical Center Steward Health Care Steward Health Care - Nashoba Valley Medical Center
12709 New England Baptist Hospital New England Baptist Hospital
12618 Newton-Wellesley Hospital Newton-Wellesley Hospital
12708 Noble Hospital Noble Hospital
12582 Norwood Hospital Steward Health Care Steward Health Care - Norwood Hospital
12588 Saint Anne's Hospital Steward Health Care Steward Health Care - Saint Anne's Hospital
13348 Saint Vincent Hospital Saint Vincent Hospital
13116 Salem Hospital North Shore Medical Center North Shore Medical Center - Salem Hospital
12705 Shriners Hospital for Children - Boston Shriners Hospital for Children - Boston
12808 South Shore Hospital South Shore Hospital
12599 St. Elizabeth's Medical Center Steward Health Care Steward Health Care - St. Elizabeth's Medical Center
12576 St. Luke's Hospital Southcoast Health Southcoast Health - St. Luke's Hospital
13174 Sturdy Memorial Hospital Sturdy Memorial Hospital
12574 Tobey Hospital Southcoast Health Southcoast Health - Tobey Hospital
11558 Tufts Medical Center Tufts Medical Center
11303 UMass Memorial Medical Center UMass Memorial Health Care
UMass Memorial Health Care - UMass Memorial Medical
Center
14360 Union Hospital North Shore Medical Center North Shore Medical Center - Union Hospital
13215 Whidden Hospital Cambridge Health Alliance Cambridge Health Alliance - Whidden Hospital
12654 Winchester Hospital Lahey Health Lahey Health - Winchester Hospital
13381 Wing Hospital Baystate Health Baystate Wing Hospital
The central line utilization ratio measures how often and for how long
acute care patients have a central venous catheter in place. This statistic
is important because fewer central lines mean fewer chances for
infection. A downward trend may indicate that hospitals across the state
have implemented interventions to try to reduce CLABSIs by removing
central lines when not absolutely necessary.
The State CLABSI SIRs chart shows how the state SIR has changed
over time across three ICU types. The SIRs in this chart use predicted
values calculated by multiplying the average rate of infection for a given
location from the 2013 national data by the number of device days, so
they are different from the values found in the table above. As CLABSIs
are prevented, the state SIRs should decrease.
The catheter utilization ratio measures how often and for how long
acute care patients have a urinary catheter in place. This statistic is
important because fewer urinary catheters mean fewer chances for
infection. A downward trend may indicate that hospitals across the state
have implemented interventions to try to reduce CAUTIs by removing
urinary catheters when not absolutely necessary.
The State CAUTI SIRs chart shows how the state SIR have changed over
time across two ICU types. The SIRs in this chart use predicted values
calculated by multiplying the average rate of infection for a given location
from the 2009 national data by the number of device days, so they are
different from the values found in the table above. As CAUTIs are
prevented, the state SIRs should decrease.
These statistics aim to provide a broad sense of patient care capacity and staffing in Massachusetts acute care hospitals. Every hospital in
Massachusetts has Infection Preventionists who work to reduce healthcare-associated infections at their hospital. The Society for Healthcare
Epidemiology of America (SHEA) recommends that there be at least one Infection Preventionist per 125 hospital beds.
Massachusetts Calendar Year 2015 HAI Data SummaryStatewide Hospital Summary
This document is designed to help you better understand the data presented on the Summary Page that follows.
Standardized Infection Ratio (SIR): This measure indicates how the actual number of healthcare-associated infections at a location compares to the
predicted number of infections at that location. If a hospital experiences the same number of infections as predicted, the SIR has a value of 1. If a
hospital experiences more infections, the SIR is greater than 1, and vice versa. A statistical interpretation is included with each SIR to indicate if the
hospital experienced a statistically significant higher or lower number of infections than anticipated. Statistical significance means that the number of
infections observed was unlikely to have occurred by chance alone.
Hospital Survey Statistics
Central Line-Associated Blood Stream Infection (CLABSI)
CLABSI data are reported by ICU type since the risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit
and the type of treatments they receive. In addition to adult and pediatric ICUs, 10 hospitals in the state have neonatal ICUs, or NICUs.
The table included shows CLABSI data by ICU type. Each location strives for zero infections. The data presented in this table is from calendar year
2015 (January 1, 2015 through December 31, 2015). The predicted number of infections is calculated by multiplying the state baseline infection rate
from 2013 and 2014 by the number of device days. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have
been suppressed (not calculable).
Catheter-Associated Urinary Tract Infections (CAUTI)
CAUTI data are reported by ICU type since the risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit
and the type of treatments they receive. CAUTI data are new to this statewide summary. MDPH reporting requirements expanded in November 2014 to
include CAUTI data reports starting in January 2012.
The table included shows CAUTI data by ICU type. Each location strives for zero infections. The data presented in this table is from calendar year
2015 (January 1, 2015 through December 31, 2015). Note that there were significant definition changes for CAUTI in 2015; therefore, comparisons to
2013-2014 data are limited. The predicted number of infections is calculated by multiplying the state baseline infection rate from 2013 and 2014 by the
number of device days. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not
calculable).
Surgical Site Infection (SSI)
The risk for SSI varies by procedure type as well as individual patient and hospital factors. The CDC uses a formula that takes into account important
risk factors to determine the predicted number of infections used to calculate the SIR. All deep incisional primary and organ/space infections are
included in this report. In previous years, procedures with implants were observed for infection a full year after the procedure. These procedures
included CABG, HPRO, and KPRO procedures. Beginning in 2013, the surveillance period was changed to 90 days for deep incisional and organ/space
SSI for these three procedure types. Abdominal and vaginal hysterectomies continued to be observed for 30 days after procedure, as in previous years.
Colon procedures (COLO) also observed for 30 days are new to this report. Data reporting for colon procedures began in the year 2012; therefore, you
will not see COLO data for 2011.
The table entitled State CDI and MRSA SIRs for 2015 Calendar Year contain data from calendar year 2015 (January 1, 2015 through December 31,
2015). Each hospital strives for zero infections. A statistical interpretation of Same or Lower means that the number of infections was comparable or
better than expected, while an interpretation of Higher means that the number of infections was worse than the expected.
The chart included depicts SIR statistical variations from the predicted number of LabID Events (CDI and MRSA) for years 2013 through 2015. It is
meant to be used as a quick assessment of significant variation of infection rates over time. This chart does not capture change in infection rates that
were not statistically significant.
The chart included depicts SSI statistical interpretations for 2011 through 2015. It is meant to be used as a quick assessment of significant variation of
infection rates over time. This chart does not capture change in infection rates that were not statistically significant.
Facility Wide LabID Events
The LabID event section includes overall inpatient facility-wide (FacWideIn) Clostridium difficile infection (CDI) and MRSA bacteremia surveillance
LabID event data reported from acute care facilities. Due to variability of hospital-onset incidence in these data over time, risk modeling was performed
at the facility level and calendar year quarter level using negative binomial regression models. LabID events are new to the data summary and are
provided as proxy surveillance measures of healthcare acquisition, exposure burden, and infection burden, based on laboratory and limited admission
data and should be evaluated as such. When interpreting pediatric CDI data, asymptomatic colonization in children less than one year of age may
confound pediatric CDI rates. LabID events are new to the data summary. Reporting requirements were implemented in November 2014 for January
2013 data to date.
The table entitled State SSI SIRs by Procedure Type contains data for 2015 available for each procedure currently under surveillance. Each hospital
strives for zero infections. A statistical interpretation of Same or Lower means that the number of infections was comparable or better than expected,
while an interpretation of Higher means that the number of infections was worse than the expected.
Number of Hospitals
Medical School Affiliation
Average Number of Beds
Average Number of ICU Beds
Average Number of Admissions
Average Number of Patient Days
Beds per Infection Preventionist
Number of
ICUsInfections Line Days Rate
Predicted
InfectionsSIR Interpretation
2 6 1,474 4.07 3.69 1.63 Same
9 14 15,394 0.91 13.85 1.01 Same
11 15 23,288 0.64 16.30 0.92 Same
18 36 35,589 1.01 34.58 1.04 Same
53 34 56,082 0.61 44.70 0.76 Same
2 2 4,173 0.48 3.34 0.60 Same
8 30 17,610 1.70 18.78 1.60 Higher
14 25 33,711 0.74 32.83 0.76 Same
3 2 4,561 0.44 5.47 0.37 Same
10 37 16,945 2.18 18.81 1.97 Higher
Number of
ICUsInfections
Catheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 3 1,156 2.60 4.97 0.60 Same
9 26 15,813 1.64 30.04 0.87 Same
11 12 24,728 0.49 39.56 0.30 Lower
18 67 44,090 1.52 88.34 0.76 Lower
54 99 81,582 1.21 51.97 1.91 Higher
2 31 6,502 4.77 28.61 1.08 Same
8 3 7,434 0.40 0.34
14 98 42,778 2.29 111.22 0.88 Same
3 40 7,258 5.51 24.68 1.62 Higher
State Catheter Utilization Ratios State CAUTI SIRs Compared to National Average
Pediatric Not calculable
Surgical 0.71 - 1.06
Trauma 1.17 - 2.18
Medical 0.59 - 0.95
Medical/Surgical 1.55 - 2.30
Neurosurgical 0.74 - 1.51
Burn 0.15 - 1.64
Cardiac 0.57 - 1.25
Cardiothoracic 0.16 - 0.51
State Central Line Utilization Ratios State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Surgical 0.50 - 1.10
Trauma 0.06 - 1.20
Neonatal 1.40 - 2.68
Medical/Surgical 0.53 - 1.05
Neurosurgical 0.1 - 1.97
Pediatric 1.09 - 2.25
Cardiac 0.57 - 1.65
Cardiothoracic 0.53 - 1.48
Medical 0.74 - 1.42
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Burn 0.66 - 3.38
14,758 45,156 154,193
67.4 72.2 135.4
6 15 90
3,329 10,638 31,218
18% 50% 85%
65 187 547
<100 Beds 100-299 beds 300+ beds
22 34 13
Massachusetts Calendar Year 2015 HAI Data SummaryStatewide Hospital Summary
Release Date: August 2016
2015 Hospital Survey Statistics
Small Hospital Medium Hospital Large Hospital
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Neonatal
Pediatric
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
Adult
Pediatric
Neonatal
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Adult
Pediatric
Hospitals
ReportingInfections Procedures
Predicted
InfectionsSIR Interpretation
(CABG) 14 31 3,970 49.89 0.62 Lower
(KPRO) 59 57 16222 87.82 0.65 Lower
(HPRO) 59 64 12804 96.75 0.66 Lower
(HYST) 55 43 5115 40.1 1.07 Same
(VHYS) 53 11 1640 8.78 1.25 Same
(COLO) 63 223 6848 204.13 1.09 Same
Hospitals
ReportingEvents Patient Days
Predicted
EventsSIR Interpretation
(CDI) 68 2,771 3,393,447 2,832 0.98 Same
(MRSA) 68 180 3,694,486 239 0.75 Lower
Clostridium difficile 0.94 - 1.01
Methicillin-resistant
Staphylococcus 0.65 - 0.87
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
Facility Wide LabID Events
State CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Abdominal Hysterectomy 0.78 - 1.43
Vaginal Hysterectomy 0.65 - 2.17
Colon 0.95 - 1.24
Coronary Artery Bypass 0.43 - 0.87
Knee Prosthesis 0.49 - 0.83
Hip Prosthesis 0.51 - 0.83
Surgical Site Infection
State SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
MRSA
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS COLO
Hospital Survey Statistics Influenza Vaccination
These statistics aim to provide a broad sense of a hospital’s patient
care capacity and staffing. When reviewing these data, keep in mind
that a single infection at a smaller hospital may have a greater impact on
infection rates than at a larger hospital. Every hospital in Massachusetts
has Infection Preventionists who work to reduce healthcare-associated
infections at their hospital. The Society for Healthcare Epidemiology of
America (SHEA) recommends that there be at least one Infection
Preventionist per 125 beds at a hospital.
For the 2015-2016 influenza season, MA hospitals were required by
MDPH and the Centers for Medicare and Medicaid Services (CMS) to
report detailed vaccination data on their healthcare personnel (HCP) via
the NHSN. The percent of HCP by vaccination status for the hospital
are presented in comparison to the state median. Massachusetts
expected that a 90% influenza vaccination rate would be reached for
acute care hospital employees. Vaccination rates include those
vaccinated both within and outside of the hospital.
The central line utilization ratio measures how often and for how long
acute care patients have a central venous catheter in place. This statistic
is important because fewer central lines mean fewer chances for
infection. A downward trend may indicate that a hospital has
implemented an intervention to reduce CLABSIs by removing central
lines when not absolutely necessary. An upward trend does not
necessarily indicate a change that is within the hospital’s control. The
state line represents central line utilization among comparable adult ICUs
in the state.
The Hospital and State CLABSI SIRs chart shows how the hospital SIR
and the state SIR have changed over time across all ICU types. The state
line represents the SIR among comparable ICU types in the state. The
SIRs in this chart use predicted values calculated by multiplying the
average rate of infection for a given location from the 2013 national data
by the number of device days, so they are different from the values found
in the table above. As CLABSIs are prevented, the SIR for a hospital
should decrease.
The catheter utilization ratio measures how often and for how long
acute care patients have a urinary catheter in place. This statistic is
important because fewer urinary catheters mean fewer chances for
infection. A downward trend may indicate that a hospital has
implemented an intervention to try to reduce CAUTIs by removing urinary
catheters when not absolutely necessary. An upward trend does not
necessarily indicate a change that is within the hospital’s control.
The Hospital and State CAUTI SIRs chart shows how the hospital SIR
and the state SIR have changed over time across all ICU types. The state
line represents the SIR among comparable ICU types in the state. The
SIRs in this chart use predicted values calculated by multiplying the
average rate of infection for a given location from the 2009 national data
by the number of device days, so they are different from the values found
in the table above. As CAUTIs are prevented, the SIR for a hospital
should decrease.
Massachusetts Calendar Year 2015 HAI Data SummaryHospital-Specific Summaries
This document is designed to help you better understand the data presented on the Summary Pages that follow.
Standardized Infection Ratio (SIR): This measure indicates how the actual number of healthcare-associated infections at a location compares to the
predicted number of infections at that location. If a hospital experiences the exact same number of infections as predicted, the SIR has a value of 1. If a
hospital experiences more infections, the SIR is greater than 1, and vice versa. Statistical significance means that the number of infections observed
was unlikely to have occurred by chance alone. A statistical interpretation of Same or Lower means that the number of infections was comparable or
significantly better than expected, while an interpretation of Higher means that the number of infections was significantly worse than the expected.
Central Line-Associated Blood Stream Infection (CLABSI)
CLABSI data are reported by ICU type. The risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit
and the type of treatments received. In addition to adult and pediatric ICUs, 10 hospitals in the state have neonatal ICUs (NICUs).
The table included shows CLABSI data by ICU type. Each location strives for zero infections. The data presented in this table is from calendar year
2015 (January 1, 2015 through December 31, 2015). The predicted number of infections is calculated by multiplying the state baseline infection rate
from 2013 and 2014 by the number of device days. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have
been suppressed (not calculable).
Catheter-Associated Urinary Tract Infections (CAUTI)
CAUTI data are reported by ICU type since the risk of infection can vary greatly from one ICU to another depending on the type of patients in the unit
and the type of treatments they receive. CAUTI data are new to this statewide summary. MDPH reporting requirements expanded in November 2014
to include CAUTI data reports starting in January 2012.
The table included shows CAUTI data by ICU type. Each location strives for zero infections. The data presented in this table is from calendar year
2015 (January 1, 2015 through December 31, 2015). Note that there were significant definition changes for CAUTI in 2015; therefore, comparisons to
2013-2014 data are limited. The predicted number of infections is calculated by multiplying the state baseline infection rate from 2013 and 2014 by the
number of device days. The SIR and confidence interval of ICUs with a predicted number of infections less than 0.5 have been suppressed (not
calculable).
The chart included depicts SIR statistical variations from the predicted number of LabID Events (CDI and MRSA) for years 2013 through 2015. It is
meant to be used as a quick assessment of significant variation of infection rates over time. This chart does not capture change in infection rates that
were not statistically significant.
The chart included depicts SSI statistical interpretations for 2011 through 2015. It is meant to be used as a quick assessment of significant variation of
infection rates over time. This chart does not capture change in infection rates that were not statistically significant.
Surgical Site Infection (SSI)
The table entitled Hospital CDI and MRSA SIRs for 2015 Calendar Year contain data from calendar year 2015 (January 1, 2015 through December
31, 2015). Each hospital strives for zero infections. The SIR and confidence interval of procedures with a predicted number of infections less than
0.5 have been suppressed (not calculable).
The table titled Hospital SSI SIRs by Procedure Type contains hospital data for 2015 for each procedure currently under surveillance. Each hospital
strives for zero infections. The SIR and confidence interval of procedures with a predicted number of infections less than 0.5 have been suppressed
(not calculable).
The risk for SSI varies by procedure type as well as individual patient and hospital factors. The CDC uses a formula that takes into account important
risk factors to determine the predicted number of infections used to calculate the SIR. All deep incisional primary and organ/space infections are
included in this report. In previous years, procedures with implants were observed for infection a full year after the procedure. These procedures
included CABG, HPRO, and KPRO procedures. Beginning in 2013, the surveillance period was changed to 90 days for deep incisional and
organ/space SSI for these three procedure types. Abdominal and vaginal hysterectomies continued to be observed for 30 days after procedure, as in
previous years. Colon procedures (COLO), also observed for 30 days, are new to this report. Data reporting for colon procedures began in the year
2012; therefore, you will not see COLO data for 2011.
Facility Wide LabID Events
The LabID event section includes overall inpatient facility-wide (FacWideIn) Clostridium difficile infection (CDI) and MRSA bacteremia surveillance
LabID event data reported from acute care facilities. Due to variability of hospital-onset incidence in these data over time, risk modeling was performed
at the facility level and calendar year quarter level using negative binomial regression models. LabID events are new to the data summary and are
provided as proxy surveillance measures of healthcare acquisition, exposure burden, and infection burden, based on laboratory and limited admission
data and should be evaluated as such. When interpreting pediatric CDI data, asymptomatic colonization in children less than one year of age may
confound pediatric CDI rates. Reporting requirements were implemented in November 2014 for January 2013 data to date.
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 939 1.06 0.83 1.21 Same
0 1,416 0.00 0.85 0.00 Same
1 2,521 0.40 2.86 0.35 Same
2 286 6.99 0.29
2 1,428 1.40 1.38 1.45 Same
8 2,228 3.59 2.79 2.86 Higher
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
6 1,156 5.19 5.20 1.15 Same
2 1,327 1.51 3.03 0.66 Same
15 3,998 3.75 19.39 0.77 Same
0 256 0.00 0.63 0.00 Same
8 2,359 3.39 10.01 0.80 Same
Pediatric medical/surgical (0 - 4.75)
Surgical (0.37 - 1.51)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical cardiac (0.46 - 2.4)
Surgical cardiothoracic (0.11 - 2.17)
Medical (0.45 - 1.24)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Pediatric medical/surgical Not calculable
Surgical (0.24 - 4.78)
Neonatal (1.33 - 5.43)
Medical cardiac (0.06 - 5.96)
Surgical cardiothoracic (0 - 3.53)
Medical (0.01 - 1.72)
128.17
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
200,032
Massachusetts Calendar Year 2015 HAI Data SummaryBaystate Medical Center - Springfield, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
769
124
40,897
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 8 417 6.43 1.24 Same
(KPRO) 2 552 3.62 0.55 Same
(HPRO) 0 377 3.57 0.00 Lower
(HYST) 8 438 2.94 2.73 Higher
(VHYS) 5 197 1.42 3.53 Higher
(COLO) 18 348 12.55 1.43 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 99 163,277 161.56 0.61 Lower
(MRSA) 15 184,465 23.78 0.63 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.50 - 0.74)
Methicillin-resistant
Staphylococcus aureus(0.36 - 1.01)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy (1.29 - 7.82)
Colon Surgery (0.87 - 2.22)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.09 - 1.82)
Hip Prosthesis (0 - 0.83)
Abdominal Hysterectomy (1.26 - 5.17)
Coronary Artery Bypass Graft (0.57 - 2.36)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 2,009 0.00 1.20 0.00 Same
3 7,129 0.42 8.09 0.37 Same
2 472 4.24 0.47
2 3,669 0.55 3.55 0.56 Same
2 1,484 1.35 0.17
4 2,185 1.83 2.76 1.45 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 2,523 1.19 5.77 0.52 Same
14 9,420 1.49 45.68 0.31 Lower
0 400 0.00 0.99 0.00 Same
5 4,602 1.09 19.54 0.26 Lower
19 3,049 6.23 26.17 0.73 Same
Surgical (0.09 - 0.56)
Trauma (0.45 - 1.11)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Surgical cardiothoracic (0.13 - 1.41)
Medical (0.17 - 0.50)
Pediatric medical/surgical (0 - 3.04)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Surgical (0.09 - 1.86)
Trauma Not calculable
Neonatal (0.46 - 3.49)
Surgical cardiothoracic (0 - 2.49)
Medical (0.09 - 1.00)
Pediatric medical/surgical Not calculable
129.83
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
215,032
Massachusetts Calendar Year 2015 HAI Data SummaryUMass Memorial Health Care - UMass Memorial Medical Center - Worcester, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
779
161
38,396
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 85%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 0 302 3.56 0.00 Lower
(KPRO) 1 351 2.22 0.45 Same
(HPRO) 1 290 3.06 0.33 Same
(HYST) 2 235 1.47 1.36 Same
(VHYS) 0 41 0.37
(COLO) 9 312 9.73 0.93 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 197 193,639 184.33 1.07 Same
(MRSA) 24 216,282 18.72 1.28 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.92 - 1.22)
Methicillin-resistant
Staphylococcus aureus(0.84 - 1.87)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.45 - 1.69)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.02 - 2.21)
Hip Prosthesis (0.01 - 1.61)
Abdominal Hysterectomy (0.22 - 4.5)
Coronary Artery Bypass Graft (0 - 0.84)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
2 1,630 1.23 1.44 1.39 Same
0 2,316 0.00 1.38 0.00 Same
3 1,768 1.70 2.01 1.50 Same
0 521 0.00 0.52 0.00 Same
0 919 0.00 0.47
0 1,634 0.00 1.58 0.00 Same
1 2,285 0.44 2.57 0.39 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
4 1,304 3.07 5.87 0.68 Same
1 2,017 0.50 4.61 0.22 Same
2 1,624 1.23 7.87 0.25 Lower
0 331 0.00 0.82 0.00 Same
5 1,411 3.54 7.68 0.65 Same
6 1,661 3.61 7.05 0.85 SameSurgical (0.34 - 1.77)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical (0.04 - 0.83)
Pediatric medical/surgical (0 - 3.67)
Neurosurgical (0.23 - 1.44)
Surgical cardiothoracic (0.01 - 1.07)
Neonatal (0.02 - 1.92)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical cardiac (0.21 - 1.64)
Pediatric medical/surgical (0 - 5.73)
Neurosurgical Not calculable
Surgical (0 - 1.89)
Medical cardiac (0.23 - 4.6)
Surgical cardiothoracic (0 - 2.16)
Medical (0.38 - 4.07)
127.33
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
95,279
Massachusetts Calendar Year 2015 HAI Data SummaryTufts Medical Center - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
382
98
17,572
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 4 239 3.81 1.05 Same
(KPRO) 3 222 1.60 1.88 Same
(HPRO) 1 204 2.25 0.45 Same
(HYST) 4 140 1.45 2.77 Same
(VHYS) 1 17 0.12
(COLO) 11 121 4.59 2.39 Higher
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 86 81,017 71.99 1.20 Same
(MRSA) 3 90,548 5.05 0.59 SameMethicillin-resistant
Staphylococcus aureus(0.15 - 1.61)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.96 - 1.46)
Colon Surgery (1.25 - 4.16)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0.02 - 2.19)
Abdominal Hysterectomy (0.87 - 6.67)
Vaginal Hysterectomy Not calculable
Knee Prosthesis (0.47 - 5.10)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Coronary Artery Bypass Graft (0.33 - 2.53)
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 1,350 0.74 0.82 1.22 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 2,217 1.35 3.15 0.95 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.24 - 2.59)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.06 - 6.01)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
109.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
75,407
Massachusetts Calendar Year 2015 HAI Data SummaryLahey Health - Beverly Hospital - Beverly, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
219
14
19,878
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 88%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 559 2.84 0.00 Same
(HPRO) 1 285 1.82 0.55 Same
(HYST) 1 48 0.37
(VHYS) 1 34 0.12
(COLO) 0 89 3.46 0.00 Lower
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 51 62,650 36.77 1.39 Higher
(MRSA) 1 71,416 2.94 0.34 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (1.04 - 1.80)
Methicillin-resistant
Staphylococcus aureus(0.01 - 1.67)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 0.86)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 1.05)
Hip Prosthesis (0.02 - 2.70)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
2 2,294 0.87 1.39 1.44 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 3,209 0.31 7.28 0.14 Lower
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.00 - 0.67)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.24 - 4.74)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
105.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
42,797
Massachusetts Calendar Year 2015 HAI Data SummarySignature Healthcare - Brockton Hospital - Brockton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
210
16
11,217
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 93%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 137 0.84 0.00 Same
(HPRO) 0 118 1.19 0.00 Same
(HYST) 0 48 0.40
(VHYS) 0 4 0.05
(COLO) 2 68 1.76 1.14 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 31 39,223 29.87 1.04 Same
(MRSA) 1 44,246 1.65 0.61 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.71 - 1.45)
Methicillin-resistant
Staphylococcus aureus(0.03 - 2.98)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.19 - 3.75)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 3.56)
Hip Prosthesis (0 - 2.52)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
2 1,322 1.51 0.79 2.53 Same
0 1,174 0.00 0.71 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 2,294 0.00 5.24 0.00 Lower
7 2,417 2.90 5.48 1.28 SameMedical/surgical (0.55 - 2.52)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Surgical cardiothoracic (0 - 0.57)
Surgical cardiothoracic (0.42 - 8.35)
Medical/surgical (0 - 4.20)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
246.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
77,499
Massachusetts Calendar Year 2015 HAI Data SummaryCape Cod Healthcare - Cape Cod Hospital - Hyannis, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
246
22
20,935
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 87%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 0 136 1.16 0.00 Same
(KPRO) 0 356 1.93 0.00 Same
(HPRO) 2 350 3.09 0.65 Same
(HYST) 1 69 0.47
(VHYS) 0 56 0.15
(COLO) 5 180 6.81 0.74 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 43 75,545 56.93 0.76 Same
(MRSA) 1 77,348 3.19 0.31 SameMethicillin-resistant
Staphylococcus aureus(0.01 - 1.54)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.55 - 1.00)
Colon Surgery (0.26 - 1.62)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0.10 - 2.13)
Abdominal Hysterectomy Not calculable
Vaginal Hysterectomy Not calculable
Knee Prosthesis (0 - 1.55)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Coronary Artery Bypass Graft (0 - 2.59)
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,137 0.00 0.69 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
4 1,717 2.33 2.44 1.64 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.52 - 3.95)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 4.34)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
237.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
28,945
Massachusetts Calendar Year 2015 HAI Data SummaryCape Cod Healthcare - Falmouth Hospital - Falmouth, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
95
10
8,916
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 87%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 2 252 1.01 1.97 Same
(HPRO) 0 199 1.03 0.00 Same
(HYST) 1 35 0.24
(VHYS) 0 49 0.14
(COLO) 1 54 1.69 0.59 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 15 27,731 17.38 0.86 Same
(MRSA) 3 28,945 1.27 2.36 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.50 - 1.39)
Methicillin-resistant
Staphylococcus aureus(0.6 - 6.41)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.03 - 2.91)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.33 - 6.51)
Hip Prosthesis (0 - 2.89)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,794 0.00 1.32 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 3,096 0.97 7.80 0.39 Same
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.09 - 1.04)
Medical/surgical (0 - 2.26)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
148.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
66,475
Massachusetts Calendar Year 2015 HAI Data SummaryBerkshire Health Systems - Berkshire Medical Center - Pittsfield, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
297
20
15,218
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 84%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 288 1.61 0.00 Same
(HPRO) 0 281 2.36 0.00 Same
(HYST) 1 33 0.28
(VHYS) 0 19 0.11
(COLO) 1 120 3.14 0.32 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 43 51,766 48.34 0.89 Same
(MRSA) 1 55,246 2.98 0.34 SameMethicillin-resistant
Staphylococcus aureus(0.01 - 1.65)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.65 - 1.18)
Colon Surgery (0.01 - 1.56)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0 - 1.27)
Abdominal Hysterectomy Not calculable
Vaginal Hysterectomy Not calculable
Knee Prosthesis (0 - 1.86)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
3 894 3.36 6.43 0.47 Same
8 4,284 1.87 3.78 2.12 Same
5 4,225 1.18 2.53 1.98 Same
6 4,336 1.38 4.92 1.22 Same
1 1,095 0.91 1.10 0.91 Same
2 3,254 0.61 1.68 1.19 Same
5 7,733 0.65 7.49 0.67 Same
2 1,753 1.14 2.12 0.94 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 882 3.40 7.80 0.38 Same
4 3,753 1.07 16.88 0.24 Lower
1 4,160 0.24 9.51 0.11 Lower
2 4,987 0.40 24.18 0.08 Lower
0 687 0.00 1.69 0.00 Same
26 5,091 5.11 27.71 0.94 Same
9 9,467 0.95 40.19 0.22 Lower
Pediatric medical/surgical (0 - 1.77)
Neurosurgical (0.62 - 1.35)
Surgical (0.10 - 0.41)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical cardiac (0.07 - 0.57)
Surgical cardiothoracic (0.00 - 0.51)
Medical (0.01 - 0.27)
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Burn (0.09 - 1.04)
Surgical (0.24 - 1.48)
Neonatal (0.15 - 3.11)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Medical (0.49 - 2.53)
Pediatric medical/surgical (0.04 - 4.48)
Neurosurgical (0.2 - 3.94)
Burn (0.11 - 1.26)
Medical cardiac (0.98 - 4.02)
Surgical cardiothoracic (0.72 - 4.38)
107.67
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
296,000
Massachusetts Calendar Year 2015 HAI Data SummaryMassachusetts General Hospital - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
969
144
50,000
0
0.2
0.4
0.6
0.8
1
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 83%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 9 448 5.31 1.70 Same
(KPRO) 5 821 4.55 1.10 Same
(HPRO) 3 792 6.44 0.47 Same
(HYST) 5 587 4.30 1.16 Same
(VHYS) 0 100 0.66 0.00 Same
(COLO) 38 647 19.90 1.91 Higher
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 311 284,456 267.80 1.16 Higher
(MRSA) 19 302,004 27.70 0.69 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (1.03 - 1.29)
Methicillin-resistant
Staphylococcus aureus(0.42 - 1.05)
Facility Wide LabID Events
Abdominal Hysterectomy (0.42 - 2.57)
Vaginal Hysterectomy (0 - 4.54)
Colon Surgery (1.37 - 2.59)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Coronary Artery Bypass Graft (0.82 - 3.11)
Knee Prosthesis (0.40 - 2.43)
Hip Prosthesis (0.11 - 1.26)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 714 0.00 0.43
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 943 1.06 1.34 0.75 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.03 - 3.68)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
74.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
20,684
Massachusetts Calendar Year 2015 HAI Data SummarySouthcoast Health - Tobey Hospital - Wareham, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
74
10
5,302
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91%
71%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 73 0.32
(HPRO) 0 42 0.23
(HYST) 0 27 0.20
(VHYS) 0 14 0.05
(COLO) 0 23 0.54 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 10 19,657 12.61 0.79 Same
(MRSA) 0 20,684 1.02 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.40 - 1.41)
Methicillin-resistant
Staphylococcus aureus(0 - 2.92)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 5.55)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
2 3,724 0.54 2.26 0.89 Same
0 1,583 0.00 1.45 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
6 2,914 2.06 6.61 0.91 Same
1 1,504 0.66 6.38 0.16 Lower
Medical/surgical (0.36 - 1.88)
Surgical (0.00 - 0.77)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.14 - 2.92)
Surgical (0 - 2.06)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
280.67
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
91,140
Massachusetts Calendar Year 2015 HAI Data SummarySouthcoast Health - St. Luke's Hospital - New Bedford, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
421
24
17,852
0
0.2
0.4
0.6
0.8
1
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 89%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 140 0.74 1.35 Same
(HPRO) 3 158 1.30 2.31 Same
(HYST) 0 92 0.66 0.00 Same
(VHYS) 0 53 0.14
(COLO) 2 125 3.66 0.55 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 61 85,529 67.63 0.90 Same
(MRSA) 3 91,140 6.40 0.47 SameMethicillin-resistant
Staphylococcus aureus(0.11 - 1.27)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.69 - 1.15)
Colon Surgery (0.09 - 1.80)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0.58 - 6.27)
Abdominal Hysterectomy (0 - 4.55)
Vaginal Hysterectomy Not calculable
Knee Prosthesis (0.06 - 6.64)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,317 0.00 1.16 0.00 Same
0 1,535 0.00 0.92 0.00 Same
1 1,737 0.58 0.30
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,643 0.00 7.39 0.00 Lower
1 1,515 0.66 3.46 0.29 Same
0 2,098 0.00 4.30 0.00 Lower
Medical cardiac (0 - 0.40)
Surgical cardiothoracic (0.01 - 1.42)
Medical (0 - 0.69)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical cardiac (0 - 2.58)
Surgical cardiothoracic (0 - 3.26)
Medical Not calculable
218.67
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
81,238
Massachusetts Calendar Year 2015 HAI Data SummarySouthcoast Health - Charlton Memorial Hospital - Fall River, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
328
24
15,887
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 88%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 1 229 2.46 0.41 Same
(KPRO) 0 208 0.90 0.00 Same
(HPRO) 0 139 0.97 0.00 Same
(HYST) 0 134 1.05 0.00 Same
(VHYS) 1 63 0.25
(COLO) 2 78 2.27 0.88 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 49 68,699 53.52 0.92 Same
(MRSA) 3 74,822 3.45 0.87 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.68 - 1.2)
Methicillin-resistant
Staphylococcus aureus(0.22 - 2.36)
Facility Wide LabID Events
Abdominal Hysterectomy (0 - 2.84)
Vaginal Hysterectomy Not calculable
Colon Surgery (0.14 - 2.90)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Coronary Artery Bypass Graft (0.02 - 2.00)
Knee Prosthesis (0 - 3.33)
Hip Prosthesis (0 - 3.08)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,038 0.00 0.63 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 1,697 1.77 2.41 1.25 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.31 - 3.38)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 4.75)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
244.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
56,325
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Norwood Hospital - Norwood, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
244
11
11,548
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 86%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
5.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 133 0.71 1.40 Same
(HPRO) 2 124 1.01 1.99 Same
(HYST) 0 52 0.41
(VHYS) 0 4 0.01
(COLO) 5 88 2.91 1.72 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 34 34,162 26.14 1.30 Same
(MRSA) 0 35,350 1.57 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.91 - 1.79)
Methicillin-resistant
Staphylococcus aureus(0 - 1.90)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.63 - 3.81)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.07 - 6.91)
Hip Prosthesis (0.33 - 6.55)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,078 0.00 0.65 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,809 0.00 2.57 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 1.16)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 4.57)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
175.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
44,459
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Saint Anne's Hospital - Fall River, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
175
12
8,967
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 86%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 4 358 1.21 3.31 Higher
(HPRO) 1 192 0.61 1.65 Same
(HYST) 0 9 0.06
(VHYS) 0 31 0.10
(COLO) 1 73 1.44 0.69 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 44 35,316 26.77 1.64 Higher
(MRSA) 1 36,230 1.74 0.58 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (1.20 - 2.18)
Methicillin-resistant
Staphylococcus aureus(0.02 - 2.83)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.03 - 3.41)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (1.05 - 7.98)
Hip Prosthesis (0.08 - 8.13)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
2 1,575 1.27 1.39 1.44 Same
5 5,401 0.93 3.23 1.55 Same
6 3,964 1.51 4.50 1.33 Same
5 4,807 1.04 4.65 1.08 Same
11 1,867 5.89 2.33 4.72 Higher
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 2,107 0.95 9.48 0.21 Lower
3 5,978 0.50 13.66 0.22 Lower
6 4,551 1.32 22.07 0.27 Lower
20 8,873 2.25 37.67 0.53 Lower
Surgical cardiothoracic (0.05 - 0.59)
Medical (0.11 - 0.56)
Surgical (0.33 - 0.80)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical cardiac (0.03 - 0.69)
Surgical (0.39 - 2.38)
Neonatal (2.48 - 8.20)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Medical cardiac (0.24 - 4.76)
Surgical cardiothoracic (0.56 - 3.43)
Medical (0.54 - 2.77)
138.73
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
239,301
Massachusetts Calendar Year 2015 HAI Data SummaryBrigham and Women's Hospital - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
763
156
53,542
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 90%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 1 468 5.88 0.17 Lower
(KPRO) 1 567 3.55 0.28 Same
(HPRO) 5 533 5.96 0.84 Same
(HYST) 1 429 3.57 0.28 Same
(VHYS) 1 64 0.36
(COLO) 25 649 21.41 1.17 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 192 227,054 201.84 0.95 Same
(MRSA) 14 258,767 20.50 0.68 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.82 - 1.09)
Methicillin-resistant
Staphylococcus aureus(0.38 - 1.11)
Facility Wide LabID Events
Abdominal Hysterectomy (0.01 - 1.38)
Vaginal Hysterectomy Not calculable
Colon Surgery (0.77 - 1.69)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Coronary Artery Bypass Graft (0.00 - 0.83)
Knee Prosthesis (0.01 - 1.38)
Hip Prosthesis (0.30 - 1.85)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 973 0.00 0.59 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,072 0.00 1.52 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 1.96)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 5.07)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
110.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
24,355
Massachusetts Calendar Year 2015 HAI Data SummaryHolyoke Medical Center - Holyoke, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
198
10
5,868
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
5.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 80%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 90 0.43
(HPRO) 1 76 0.49
(HYST) 0 7 0.07
(VHYS) 0 9 0.04
(COLO) 1 50 1.30 0.77 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 5 20,001 10.10 0.50 Same
(MRSA) 1 21,125 0.88 1.13 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.18 - 1.09)
Methicillin-resistant
Staphylococcus aureus(0.05 - 5.59)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.03 - 3.80)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
3 5,853 0.51 4.31 0.70 Same
3 260 11.54 0.33
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
12 6,234 1.92 15.71 0.76 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.41 - 1.29)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.17 - 1.89)
Neonatal Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
287.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
61,022
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - St. Elizabeth's Medical Center - Brighton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
For-profit
287
46
11,216
0
0.2
0.4
0.6
0.8
1
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 86%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 3 405 5.33 0.56 Same
(KPRO) 4 126 0.79 5.06 Higher
(HPRO) 2 83 0.68 2.95 Same
(HYST) 3 216 1.52 1.97 Same
(VHYS) 0 24 0.12
(COLO) 5 131 4.06 1.23 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 40 47,999 43.01 0.93 Same
(MRSA) 3 53,698 2.94 1.02 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.67 - 1.25)
Methicillin-resistant
Staphylococcus aureus(0.25 - 2.77)
Facility Wide LabID Events
Abdominal Hysterectomy (0.50 - 5.35)
Vaginal Hysterectomy Not calculable
Colon Surgery (0.45 - 2.72)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Coronary Artery Bypass Graft (0.14 - 1.53)
Knee Prosthesis (1.60 - 12.21)
Hip Prosthesis (0.49 - 9.75)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,254 0.00 0.76 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,893 0.00 4.29 0.00 Lower
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 0.69)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 3.93)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
195.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
47,163
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Holy Family Hospital - Methuen, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
195
12
9,997
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 88%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 289 1.22 0.00 Same
(HPRO) 0 189 0.94 0.00 Same
(HYST) 0 41 0.27
(VHYS) 0 31 0.11
(COLO) 0 90 2.28 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 24 36,566 25.46 0.94 Same
(MRSA) 2 40,132 1.59 1.26 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.61 - 1.38)
Methicillin-resistant
Staphylococcus aureus(0.21 - 4.16)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 1.31)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 2.46)
Hip Prosthesis (0 - 3.18)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 883 1.13 0.54 1.87 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,227 0.00 2.78 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 1.07)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.09 - 9.2)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
93.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
26,404
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Carney Hospital - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
For-profit
93
8
4,869
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 89%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 46 0.20
(HPRO) 0 33 0.17
(HYST) 0 24 0.14
(VHYS) 0 4 0.03
(COLO) 2 47 0.94 2.14 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 14 16,036 12.38 1.13 Same
(MRSA) 2 16,036 0.61 3.29 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.64 - 1.85)
Methicillin-resistant
Staphylococcus aureus(0.55 - 10.86)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.35 - 7.06)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 809 0.00 0.49
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 1,291 2.32 1.83 1.64 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.41 - 4.45)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
125.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
74,760
Massachusetts Calendar Year 2015 HAI Data SummaryNewton-Wellesley Hospital - Newton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
250
12
20,149
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 87%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 413 2.32 0.00 Same
(HPRO) 5 656 4.65 1.08 Same
(HYST) 0 108 0.75 0.00 Same
(VHYS) 0 44 0.15
(COLO) 1 135 3.77 0.27 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 31 62,635 44.77 0.69 Lower
(MRSA) 3 70,199 3.72 0.81 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.47 - 0.97)
Methicillin-resistant
Staphylococcus aureus(0.20 - 2.19)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.01 - 1.31)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 1.29)
Hip Prosthesis (0.39 - 2.38)
Abdominal Hysterectomy (0 - 3.96)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
2 710 2.82 0.43
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 1,103 1.81 1.57 1.28 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.21 - 4.22)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
133.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
24,190
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Morton Hospital - Taunton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
133
12
5,775
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 90%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 3 141 0.78 3.87 Same
(HPRO) 1 60 0.37
(HYST) 0 10 0.09
(VHYS) 0 1 0.01
(COLO) 0 93 2.35 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 14 23,054 16.51 0.85 Same
(MRSA) 1 23,054 1.43 0.70 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.48 - 1.38)
Methicillin-resistant
Staphylococcus aureus(0.03 - 3.44)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 1.27)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.98 - 10.52)
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 1,975 0.51 1.20 0.83 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
7 3,335 2.10 7.56 0.93 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.40 - 1.83)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.04 - 4.11)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
6.68
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
72,326
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Good Samaritan Medical Center - Brockton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
267
18
17,284
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 92%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 251 1.08 0.00 Same
(HPRO) 1 159 0.99 1.01 Same
(HYST) 0 68 0.43
(VHYS) 0 115 0.28
(COLO) 3 169 5.34 0.56 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 45 51,634 40.40 1.11 Same
(MRSA) 1 55,636 2.53 0.40 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.82 - 1.47)
Methicillin-resistant
Staphylococcus aureus(0.02 - 1.94)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.14 - 1.52)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 2.77)
Hip Prosthesis (0.05 - 4.99)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 2,012 0.50 1.77 0.56 Same
8 3,129 2.56 3.55 2.25 Higher
0 102 0.00 0.10
1 2,784 0.36 2.69 0.37 Same
0 1,299 0.00 0.15
1 840 1.19 1.14 0.88 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 1,492 2.01 6.71 0.45 Same
12 3,005 3.99 14.57 0.82 Same
0 68 0.00 0.17
9 2,608 3.45 11.07 0.81 Same
10 1,686 5.93 14.47 0.69 Same
Surgical (0.39 - 1.49)
Trauma (0.35 - 1.23)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical cardiac (0.11 - 1.21)
Medical (0.44 - 1.4)
Pediatric medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Surgical (0.01 - 1.83)
Trauma Not calculable
Neonatal (0.04 - 4.34)
Medical cardiac (0.02 - 2.78)
Medical (1.04 - 4.27)
Pediatric medical/surgical Not calculable
120.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
138,554
Massachusetts Calendar Year 2015 HAI Data SummaryBoston Medical Center - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
482
86
35,737
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 93%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Pediatric
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 0 101 1.26 0.00 Same
(KPRO) 0 72 0.44
(HPRO) 0 83 0.74 0.00 Same
(HYST) 2 206 2.26 0.88 Same
(VHYS) 0 45 0.40
(COLO) 5 139 4.67 1.07 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 118 126,600 114.27 1.03 Same
(MRSA) 8 137,666 12.68 0.63 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.85 - 1.23)
Methicillin-resistant
Staphylococcus aureus(0.29 - 1.19)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.39 - 2.37)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis (0 - 4.06)
Abdominal Hysterectomy (0.14 - 2.91)
Coronary Artery Bypass Graft (0 - 2.37)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,263 0.00 0.77 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 1,940 0.52 2.75 0.36 Same
44,054
Massachusetts Calendar Year 2015 HAI Data SummaryBeth Israel Deaconess Hospital - Plymouth - Plymouth, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
155
13
9,457
77.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 3.90)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.01 - 1.79)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 155 0.75 0.00 Same
(HPRO) 1 174 1.14 0.88 Same
(HYST) 0 29 0.23
(VHYS) 0 15 0.08
(COLO) 0 86 1.94 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 37 35,441 31.67 1.17 Same
(MRSA) 1 38,721 1.57 0.64 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0 - 3.99)
Hip Prosthesis (0.04 - 4.32)
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 1.54)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.83 - 1.59)
Methicillin-resistant
Staphylococcus aureus(0.03 - 3.14)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 736 0.00 0.45
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 1,573 0.64 2.23 0.45 Same
50,103
Massachusetts Calendar Year 2015 HAI Data SummaryLahey Health - Winchester Hospital - Winchester, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
189
10
12,968
94.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.02 - 2.20)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 380 1.84 0.00 Same
(HPRO) 0 216 1.19 0.00 Same
(HYST) 1 48 0.30
(VHYS) 0 10 0.07
(COLO) 6 137 2.90 2.07 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 26 47,837 37.90 0.69 Lower
(MRSA) 1 56,174 2.32 0.43 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0 - 1.62)
Hip Prosthesis (0 - 2.52)
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.83 - 4.30)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.45 - 0.99)
Methicillin-resistant
Staphylococcus aureus(0.02 - 2.12)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 1,098 0.91 0.67 1.50 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 1,385 1.44 1.97 1.02 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.17 - 3.36)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.07 - 7.39)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
177.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
40,069
Massachusetts Calendar Year 2015 HAI Data SummaryEmerson Hospital - Concord, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
177
14
6,496
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 93%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 230 1.04 0.00 Same
(HPRO) 0 157 1.03 0.00 Same
(HYST) 0 13 0.08
(VHYS) 0 18 0.05
(COLO) 1 51 1.24 0.80 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 13 26,828 22.62 0.58 Lower
(MRSA) 0 31,225 1.51 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.32 - 0.95)
Methicillin-resistant
Staphylococcus aureus(0 - 1.98)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.04 - 3.96)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 2.87)
Hip Prosthesis (0 - 2.89)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
3 3,138 0.96 1.91 1.58 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 3,254 0.31 4.62 0.22 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.01 - 1.06)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.40 - 4.28)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
117.08
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
94,252
Massachusetts Calendar Year 2015 HAI Data SummaryLowell General Hospital - Main Campus - Lowell, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
281
22
22,353
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 99%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 4 582 3.11 1.28 Same
(HPRO) 1 271 2.12 0.47 Same
(HYST) 0 22 0.16
(VHYS) 0 20 0.05
(COLO) 0 121 3.55 0.00 Lower
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 25 67,793 39.26 0.64 Lower
(MRSA) 2 77,248 3.30 0.61 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.42 - 0.92)
Methicillin-resistant
Staphylococcus aureus(0.10 - 2.00)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 0.84)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.40 - 3.09)
Hip Prosthesis (0.02 - 2.33)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,084 0.00 0.96 0.00 Same
1 1,318 0.76 0.79 1.27 Same
5 4,679 1.07 5.31 0.94 Same
6 4,179 1.44 4.04 1.48 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 1,344 0.74 6.05 0.17 Lower
0 1,397 0.00 3.19 0.00 Lower
8 5,200 1.54 25.21 0.32 Lower
10 4,384 2.28 18.61 0.54 Lower
Medical (0.14 - 0.60)
Surgical (0.27 - 0.95)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Surgical cardiothoracic (0 - 0.93)
Surgical (0.60 - 3.08)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical cardiac (0.00 - 0.81)
Medical cardiac (0 - 3.13)
Surgical cardiothoracic (0.06 - 6.25)
Medical (0.34 - 2.08)
172.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
111,075
Massachusetts Calendar Year 2015 HAI Data SummaryLahey Health - Lahey Hospital & Medical Center - Burlington, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
345
54
22,925
0
0.2
0.4
0.6
0.8
1
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 94%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 0 311 3.91 0.00 Lower
(KPRO) 0 494 3.14 0.00 Lower
(HPRO) 2 475 4.52 0.44 Same
(HYST) 3 178 2.24 1.34 Same
(VHYS) 0 44 0.29
(COLO) 7 417 13.82 0.51 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 103 111,075 103.96 0.99 Same
(MRSA) 4 111,075 6.08 0.66 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.81 - 1.19)
Methicillin-resistant
Staphylococcus aureus(0.20 - 1.58)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.22 - 1.00)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 0.95)
Hip Prosthesis (0.07 - 1.46)
Abdominal Hysterectomy (0.34 - 3.64)
Coronary Artery Bypass Graft (0 - 0.76)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 434 0.00 0.26
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 909 1.10 1.29 0.78 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.03 - 3.82)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
111.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
26,420
Massachusetts Calendar Year 2015 HAI Data SummaryAnna Jaques Hospital - Newburyport, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
111
8
6,898
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 2 148 0.59 3.38 Same
(HPRO) 2 106 0.58 3.46 Same
(HYST) 0 13 0.09
(VHYS) 0 27 0.10
(COLO) 3 53 1.32 2.28 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 16 31,963 23.26 0.69 Same
(MRSA) 0 35,191 1.37 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.40 - 1.09)
Methicillin-resistant
Staphylococcus aureus(0 - 2.19)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.57 - 6.19)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.56 - 11.17)
Hip Prosthesis (0.58 - 11.43)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 278 0.00 0.05
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 958 1.04 1.96 0.51 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical (0.02 - 2.51)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
134.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
28,604
Massachusetts Calendar Year 2015 HAI Data SummaryHeywood Hospital - Gardner, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
134
6
618
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
2.0
4.0
6.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 93%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 80 0.45
(HPRO) 0 81 0.59 0.00 Same
(HYST) 0 11 0.07
(VHYS) 0 45 0.15
(COLO) 0 32 0.64 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 9 25,707 11.37 0.79 Same
(MRSA) 1 28,074 1.07 0.94 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.38 - 1.45)
Methicillin-resistant
Staphylococcus aureus(0.04 - 4.62)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 4.69)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis (0 - 5.08)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR
14 7,713 1.82 9.60 1.46
7 5,946 1.18 5.97 1.17
4 1,475 2.71 1.47 2.72
5 3,411 1.47 3.96 1.26
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR
1 2,243 0.45 3.85 0.26
2 3,064 0.65 7.55 0.27
0 385 0.00 1.32 0.00
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Pediatric cardiothoracic (0.01 - 1.28)
Pediatric medical/surgical (0.04 - 0.87)
Pediatric medical (0 - 2.27)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Neonatal (0.46 - 2.80)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
Pediatric cardiothoracic (0.83 - 2.38)
Pediatric medical/surgical (0.51 - 2.32)
Pediatric medical (0.86 - 6.56)
79.60
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
124,926
Massachusetts Calendar Year 2015 HAI Data SummaryBoston Children's Hospital - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
398
95
23,587
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Neonatal
Pediatric
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
91% 96%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.1
0.2
0.3
2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Pediatric
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Infections ProceduresPredicted
InfectionsSIR
(COLO) 1 21 0.78 1.28
Infections Patient DaysPredicted
InfectionsSIR
(CDI) 108 116,979 105.16 1.03
(MRSA) 8 124,467 6.55 1.22
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Event Confidence Interval
Clostridium difficile (0.84 - 1.23)
Methicillin-resistant
Staphylococcus aureus(0.56 - 2.32)
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Colon Surgery (0.06 - 6.32)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Surgical Site Infection
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
2015
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Interpretation
Same
Same
Same
Same
Interpretation
Same
Lower
Same
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
Hospital & State CAUTI SIRs Compared to National Average
Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
Massachusetts Calendar Year 2015 HAI Data SummaryBoston Children's Hospital - Boston, MA
HCP Influenza Vaccination Coverage
State v. Hospital, 2015-2016 Season
Hospital
State
Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
Hospital
State
Interpretation
Same
Interpretation
Same
Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Surgical Site Infection
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 934 1.07 0.57 1.76 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
6 2,448 2.45 3.48 1.73 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.7 - 3.59)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.08 - 8.69)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
143.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
32,160
Massachusetts Calendar Year 2015 HAI Data SummaryUMass Memorial Health Care - HealthAlliance Hospital - Leominster, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
143
10
7,302
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 79%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 2 151 0.72 2.78 Same
(HPRO) 1 105 0.84 1.20 Same
(HYST) 0 50 0.38
(VHYS) 0 1 0.00
(COLO) 3 56 1.18 2.55 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 31 29,847 23.25 1.33 Same
(MRSA) 2 32,077 1.39 1.44 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.92 - 1.86)
Methicillin-resistant
Staphylococcus aureus(0.24 - 4.76)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.64 - 6.93)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.46 - 9.16)
Hip Prosthesis (0.06 - 5.89)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,334 0.00 1.51 0.00 Same
1 1,821 0.55 1.76 0.57 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 1,593 1.88 7.72 0.39 Same
2 1,693 1.18 7.19 0.28 LowerSurgical (0.04 - 0.91)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical (0.09 - 1.05)
Medical (0 - 1.97)
Surgical (0.02 - 2.79)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
81.60
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
64,123
Massachusetts Calendar Year 2015 HAI Data SummaryMount Auburn Hospital - Cambridge, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
204
20
20,025
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 92%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 1 142 1.93 0.52 Same
(KPRO) 0 203 1.27 0.00 Same
(HPRO) 1 178 1.90 0.53 Same
(HYST) 1 131 1.21 0.83 Same
(VHYS) 0 35 0.28
(COLO) 2 90 3.03 0.66 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 58 56,687 48.01 1.21 Same
(MRSA) 1 64,123 3.52 0.28 SameMethicillin-resistant
Staphylococcus aureus(0.01 - 1.40)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.92 - 1.55)
Colon Surgery (0.11 - 2.18)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0.02 - 2.59)
Abdominal Hysterectomy (0.04 - 4.08)
Vaginal Hysterectomy Not calculable
Knee Prosthesis (0 - 2.35)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Coronary Artery Bypass Graft (0.02 - 2.56)
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
3 580 5.17 4.17 0.72 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 274 0.00 2.42 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Burn (0 - 1.23)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Burn (0.18 - 1.95)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
30.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
3,087
Massachusetts Calendar Year 2015 HAI Data SummaryShriners Hospital for Children - Boston - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
30
6
1,091
0
0.5
1
1.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 90%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 0 2,638 1.26 0.00 Same
(MRSA) 1 2,638 0.09
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0 - 2.37)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 172 0.00 0.10
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 448 0.00 0.64 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 4.71)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
82.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
16,953
Massachusetts Calendar Year 2015 HAI Data SummaryNoble Hospital - Westfield, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
82
6
3,053
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 89%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 52 0.34
(HPRO) 0 28 0.32
(COLO) 0 14 0.37
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 2 7,310 4.71 0.43 Same
(MRSA) 0 7,310 0.32
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.07 - 1.40)
Methicillin-resistant
Staphylococcus aureusNot calculable
Facility Wide LabID Events
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 718 0.00 0.44
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
3 1,100 2.73 1.56 1.92 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.48 - 5.22)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
118.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
24,282
Massachusetts Calendar Year 2015 HAI Data SummaryNew England Baptist Hospital - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
118
10
8,139
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 90%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 7 3,421 18.88 0.37 Lower
(HPRO) 3 2691 15.70 0.19 Lower
(COLO) 0 2 0.07
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 8 32,557 21.52 0.37 Lower
(MRSA) 0 32,557 1.27 0.00 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.17 - 0.70)
Methicillin-resistant
Staphylococcus aureus(0 - 2.36)
Facility Wide LabID Events
Knee Prosthesis (0.16 - 0.73)
Hip Prosthesis (0.04 - 0.52)
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 420 0.00 0.25
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 637 0.00 0.90 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 3.31)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
98.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
18,952
Massachusetts Calendar Year 2015 HAI Data SummaryHallmark Health System - Lawrence Memorial Hospital of Medford - Medford, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
98
10
2,899
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 21 0.12
(HPRO) 0 9 0.06
(COLO) 1 21 0.55 1.82 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 12 10,645 5.82 2.06 Higher
(MRSA) 1 10,645 0.52 1.93 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (1.11 - 3.50)
Methicillin-resistant
Staphylococcus aureus(0.09 - 9.5)
Facility Wide LabID Events
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Colon Surgery (0.09 - 8.97)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 1,128 0.89 0.68 1.46 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 1,037 1.93 1.47 1.36 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.22 - 4.48)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.07 - 7.20)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
125.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
25,850
Massachusetts Calendar Year 2015 HAI Data SummaryLowell General Hospital - Saints Campus - Lowell, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
75
10
5,195
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 98%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(HYST) 0 2 0.02
(COLO) 0 24 0.61 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 5 20,586 9.89 0.51 Same
(MRSA) 1 20,586 0.97 1.03 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.18 - 1.12)
Methicillin-resistant
Staphylococcus aureus(0.05 - 5.09)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Abdominal Hysterectomy Not calculable
Colon Surgery (0 - 4.88)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 0 3,914 1.60 0.00 Same
(MRSA) 0 5,556 0.20
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0 - 1.86)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
41.00
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
9,354
Massachusetts Calendar Year 2015 HAI Data SummaryUMass Memorial Health Care - Clinton Hospital - Clinton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
41
0
1,043 91% 81%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 814 0.00 0.60 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 1,689 0.59 4.26 0.24 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.01 - 1.15)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 5)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
75.63
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
28,048
Massachusetts Calendar Year 2015 HAI Data SummaryMilford Regional Medical Center - Milford, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
121
10
7,965
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 87%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 97 0.62 0.00 Same
(HPRO) 1 97 0.80 1.25 Same
(HYST) 0 89 0.58 0.00 Same
(VHYS) 0 12 0.10
(COLO) 2 73 1.61 1.24 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 35 29,794 22.29 1.57 Higher
(MRSA) 0 30,945 2.02 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (1.11 - 2.16)
Methicillin-resistant
Staphylococcus aureus(0 - 1.48)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.20 - 4.11)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0 - 4.83)
Hip Prosthesis (0.06 - 6.14)
Abdominal Hysterectomy (0 - 5.16)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 222 0.00 0.13
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 723 0.00 1.03 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 2.91)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
112.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
20,442
Massachusetts Calendar Year 2015 HAI Data SummaryBaystate Franklin Medical Center - Greenfield, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
90
6
5,103
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 82%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 49 0.20
(HPRO) 0 34 0.19
(HYST) 0 26 0.19
(VHYS) 0 31 0.12
(COLO) 0 34 0.91 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 11 19,127 11.02 1.00 Same
(MRSA) 0 20,442 0.73 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.52 - 1.73)
Methicillin-resistant
Staphylococcus aureus(0 - 4.09)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 3.30)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 1,142 0.88 0.69 1.44 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
4 2,564 1.56 3.64 1.10 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.34 - 2.65)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0.07 - 7.11)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
94.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
50,994
Massachusetts Calendar Year 2015 HAI Data SummaryLawrence General Hospital - Lawrence, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
189
19
15,535
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 93%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 56 0.28
(HPRO) 0 53 0.39
(HYST) 1 34 0.24
(VHYS) 0 13 0.05
(COLO) 1 53 1.39 0.72 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 58 46,124 33.27 1.74 Higher
(MRSA) 3 49,547 2.42 1.24 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (1.33 - 2.23)
Methicillin-resistant
Staphylococcus aureus(0.31 - 3.37)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.03 - 3.55)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,079 0.00 0.95 0.00 Same
0 1,410 0.00 0.86 0.00 Same
1 1,361 0.73 1.25 0.80 Same
1 462 2.16 0.47
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,373 0.00 6.18 0.00 Lower
0 1,810 0.00 2.57 0.00 Same
5 1,836 2.72 7.79 0.64 SameSurgical (0.23 - 1.42)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical (0 - 1.16)
Neonatal Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical cardiac (0 - 0.48)
Medical cardiac (0 - 3.15)
Medical/surgical (0 - 3.5)
Surgical (0.04 - 3.94)
217.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
112,918
Massachusetts Calendar Year 2015 HAI Data SummarySouth Shore Hospital - South Weymouth, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
434
54
27,255
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Neonatal
State (Adult)
0.0
1.0
2.0
3.0
4.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 83%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 339 2.11 0.00 Same
(HPRO) 3 318 2.58 1.16 Same
(HYST) 3 341 2.68 1.12 Same
(VHYS) 1 27 0.17
(COLO) 7 180 5.75 1.22 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 62 112,018 94.29 0.66 Lower
(MRSA) 5 127,410 7.15 0.70 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.50 - 0.83)
Methicillin-resistant
Staphylococcus aureus(0.25 - 1.55)
Facility Wide LabID Events
Abdominal Hysterectomy (0.28 - 3.04)
Vaginal Hysterectomy Not calculable
Colon Surgery (0.53 - 2.40)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hip Prosthesis (0.29 - 3.16)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Knee Prosthesis (0 - 1.41)
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 29 0.11
(HPRO) 0 26 0.10
(HYST) 0 2 0.01
(VHYS) 0 1 0.00
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Abdominal Hysterectomy Not calculable
Vaginal Hysterectomy Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
Procedure Confidence Interval
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
21.00
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
5,712
Massachusetts Calendar Year 2015 HAI Data SummaryMartha's Vineyard Hospital - Oak Bluffs, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
21
3
1,318 91% 85%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 614 0.00 0.37
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 819 1.22 1.16 0.86 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.04 - 4.24)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
70.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
31,538
Massachusetts Calendar Year 2015 HAI Data SummaryCooley Dickinson Hospital - Northampton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
140
11
9,151
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 238 1.00 1.00 Same
(HPRO) 1 144 0.91 1.10 Same
(HYST) 0 59 0.51 0.00 Same
(VHYS) 0 12 0.03
(COLO) 2 66 1.73 1.16 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 21 24,072 18.37 1.14 Same
(MRSA) 0 25,599 1.22 0.00 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.72 - 1.71)
Methicillin-resistant
Staphylococcus aureus(0 - 2.45)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.19 - 3.82)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.05 - 4.92)
Hip Prosthesis (0.05 - 5.42)
Abdominal Hysterectomy (0 - 5.89)
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 415 0.00 0.25
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 985 2.03 1.40 1.43 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.24 - 4.72)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
58.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
7,800
Massachusetts Calendar Year 2015 HAI Data SummaryBeth Israel Deaconess Hospital - Needham - Needham, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
58
7
4,152
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 98%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 34 0.17
(HPRO) 0 52 0.40
(COLO) 0 20 0.53 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 8 11,692 7.86 1.02 Same
(MRSA) 1 11,692 0.47
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.47 - 1.93)
Methicillin-resistant
Staphylococcus aureusNot calculable
Facility Wide LabID Events
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Colon Surgery (0 - 5.60)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 451 0.00 0.33
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 1,049 0.95 2.64 0.38 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.01 - 1.86)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
79.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
19,263
Massachusetts Calendar Year 2015 HAI Data SummaryUMass Memorial Health Care - Marlborough Hospital - Marlborough, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
79
10
5,017
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 96%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 83 0.45
(HPRO) 0 50 0.34
(COLO) 0 10 0.18
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 12 19,272 15.03 0.80 Same
(MRSA) 0 19,272 1.05 0.00 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.43 - 1.35)
Methicillin-resistant
Staphylococcus aureus(0 - 2.86)
Facility Wide LabID Events
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 538 1.86 0.40
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,061 0.00 2.67 0.00 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 1.12)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
138.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
36,660
Massachusetts Calendar Year 2015 HAI Data SummaryBrigham and Women's - Faulkner Hospital - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
138
12
10,723
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 96%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 444 1.87 0.53 Same
(HPRO) 1 192 0.98 1.02 Same
(HYST) 0 40 0.33
(VHYS) 0 12 0.09
(COLO) 1 38 0.86 1.17 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 28 31,252 27.08 1.03 Same
(MRSA) 1 31,252 1.73 0.58 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.70 - 1.47)
Methicillin-resistant
Staphylococcus aureus(0.02 - 2.84)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.05 - 5.76)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.02 - 2.63)
Hip Prosthesis (0.05 - 5.01)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 1,474 0.00 1.30 0.00 Same
2 3,060 0.65 1.83 1.09 Same
2 3,378 0.59 3.83 0.52 Same
1 2,119 0.47 1.56 0.64 Same
2 2,712 0.74 2.63 0.76 Same
0 1,778 0.00 0.20
1 1,654 0.60 1.91 0.52 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
6 1,641 3.66 7.38 0.81 Same
1 2,973 0.34 6.79 0.15 Lower
4 3,922 1.02 19.02 0.21 Lower
1 2,203 0.45 5.55 0.18 Lower
23 3,791 6.07 16.09 1.43 Same
11 2,523 4.36 21.66 0.51 LowerTrauma (0.26 - 0.88)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical (0.06 - 0.50)
Medical/surgical (0.00 - 0.88)
Surgical (0.92 - 2.11)
Surgical cardiothoracic (0.00 - 0.72)
Neonatal (0.02 - 2.58)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical cardiac (0.32 - 1.69)
Medical/surgical (0.03 - 3.16)
Surgical (0.12 - 2.51)
Trauma Not calculable
Medical cardiac (0 - 2.30)
Surgical cardiothoracic (0.18 - 3.61)
Medical (0.08 - 1.72)
147.20
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
226,733
Massachusetts Calendar Year 2015 HAI Data SummaryBeth Israel Deaconess Medical Center - Boston, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
736
124
44,952
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
Neonatal
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 94%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 4 551 6.49 0.62 Same
(KPRO) 5 414 2.63 1.90 Same
(HPRO) 4 377 4.11 0.97 Same
(HYST) 1 429 3.18 0.31 Same
(VHYS) 0 78 0.54 0.00 Same
(COLO) 19 506 13.84 1.37 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 162 188,087 172.15 0.94 Same
(MRSA) 12 215,604 16.53 0.73 SameMethicillin-resistant
Staphylococcus aureus(0.39 - 1.23)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.80 - 1.09)
Colon Surgery (0.85 - 2.10)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0.31 - 2.35)
Abdominal Hysterectomy (0.01 - 1.55)
Vaginal Hysterectomy (0 - 5.50)
Knee Prosthesis (0.69 - 4.21)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Coronary Artery Bypass Graft (0.19 - 1.48)
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 259 0.00 0.16
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 436 2.29 0.62 1.62 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.08 - 7.96)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
114.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
4,219
Massachusetts Calendar Year 2015 HAI Data SummaryHarrington Memorial Hospital - Southbridge, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
0
Not-for-profit
114
6
1,037
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 88%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 72 0.36
(HPRO) 0 44 0.25
(HYST) 0 5 0.04
(VHYS) 0 5 0.02
(COLO) 0 31 0.60 0.00 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 6 17,362 13.08 0.46 Lower
(MRSA) 3 18,052 0.65 4.64 Higher
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.18 - 0.95)
Methicillin-resistant
Staphylococcus aureus(1.18 - 12.62)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 5.02)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 25 0.13
(HPRO) 0 10 0.06
(HYST) 0 12 0.11
(VHYS) 0 4 0.02
(COLO) 0 5 0.19
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 1 1,890 1.39 0.72 Same
(MRSA) 0 2,632 0.12
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.03 - 3.53)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
25.00
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
2,632
Massachusetts Calendar Year 2015 HAI Data SummaryBaystate Mary Lane Hospital - Ware, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
25
4
968 91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
5 691 7.24 0.42
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
7 767 9.13 1.09 6.43 Higher
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (2.81 - 12.71)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
251.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
46,198
Massachusetts Calendar Year 2015 HAI Data SummaryMercy Medical Center - Springfield, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
0
Not-for-profit
251
16
11,656
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
2.0
4.0
6.0
8.0
10.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 92%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
2.0
4.0
6.0
8.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 2 162 0.97 2.06 Same
(HPRO) 2 128 1.42 1.41 Same
(HYST) 1 66 0.48
(VHYS) 0 16 0.10
(COLO) 14 162 4.63 3.02 Higher
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 25 43,054 27.03 0.93 Same
(MRSA) 4 46,198 2.35 1.70 Same
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.61 - 1.34)
Methicillin-resistant
Staphylococcus aureus(0.54 - 4.10)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (1.72 - 4.94)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Knee Prosthesis (0.34 - 6.80)
Hip Prosthesis (0.23 - 4.66)
Abdominal Hysterectomy Not calculable
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 686 0.00 0.41
3 2,431 1.23 1.79 1.68 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 544 0.00 1.24 0.00 Same
2 2,609 0.77 6.57 0.30 SameMedical/surgical (0.05 - 1.00)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Surgical cardiothoracic (0 - 2.40)
Surgical cardiothoracic Not calculable
Medical/surgical (0.42 - 4.56)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
67.75
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
73,260
Massachusetts Calendar Year 2015 HAI Data SummaryNorth Shore Medical Center - Salem Hospital - Salem, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
271
40
14,490
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 0 119 1.35 0.00 Same
(KPRO) 1 226 1.27 0.79 Same
(HPRO) 2 209 1.88 1.07 Same
(HYST) 1 68 0.56 1.78 Same
(VHYS) 0 62 0.51 0.00 Same
(COLO) 3 157 4.75 0.63 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 73 59,021 65.94 1.11 Same
(MRSA) 2 64,309 3.83 0.52 SameMethicillin-resistant
Staphylococcus aureus(0.08 - 1.72)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.87 - 1.38)
Colon Surgery (0.16 - 1.71)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Hip Prosthesis (0.17 - 3.52)
Abdominal Hysterectomy (0.08 - 8.75)
Vaginal Hysterectomy (0 - 5.82)
Knee Prosthesis (0.03 - 3.88)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Coronary Artery Bypass Graft (0 - 2.21)
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 1,194 0.84 0.20
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 2,466 0.00 5.05 0.00 Lower
33,651
Massachusetts Calendar Year 2015 HAI Data SummarySturdy Memorial Hospital - Attleboro, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
128
14
8,391
128.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical (0 - 0.59)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 94%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 154 0.71 1.42 Same
(HPRO) 1 94 0.58 1.72 Same
(HYST) 0 136 0.83 0.00 Same
(VHYS) 1 35 0.12
(COLO) 1 63 1.56 0.64 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 24 31,436 22.16 1.08 Same
(MRSA) 1 33,651 1.54 0.65 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0.07 - 6.99)
Hip Prosthesis (0.08 - 8.49)
Abdominal Hysterectomy (0 - 3.60)
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.03 - 3.15)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.71 - 1.58)
Methicillin-resistant
Staphylococcus aureus(0.03 - 3.20)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 657 1.52 0.40
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
5 1,836 2.72 2.61 1.92 Same
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.70 - 4.25)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
147.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
25,406
Massachusetts Calendar Year 2015 HAI Data SummaryMetroWest Medical Center - Framingham Union Hospital - Framingham, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
For-profit
147
14
6,762
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(HYST) 0 39 0.35
(VHYS) 0 2 0.01
(COLO) 1 70 1.68 0.59 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 20 25,843 22.43 0.89 Same
(MRSA) 4 28,680 1.41 2.83 Same
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.56 - 1.35)
Methicillin-resistant
Staphylococcus aureus(0.89 - 6.82)
Facility Wide LabID Events
Abdominal Hysterectomy Not calculable
Vaginal Hysterectomy Not calculable
Colon Surgery (0.03 - 2.93)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
VHYS VHYS HYST
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 25 0.00 0.02
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 115 0.00 0.16
3,543
Massachusetts Calendar Year 2015 HAI Data SummaryBerkshire Health Systems - Fairview Hospital - Great Barrington, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
25
4
829
25.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 90%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 22 0.11
(HPRO) 0 7 0.03
(HYST) 0 3 0.02
(VHYS) 0 3 0.01
(COLO) 0 6 0.14
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 0 3,425 1.85 0.00 Same
(MRSA) 0 3,425 0.12
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0 - 1.62)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 1 2,167 0.00
(MRSA) 0 2,343 0.08
2,803
Massachusetts Calendar Year 2015 HAI Data SummaryNantucket Cottage Hospital - Nantucket, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
19
0
936
19.00
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile Not calculable
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 439 2.28 0.27
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
2 719 2.78 1.02 1.96 Same
32,483
Massachusetts Calendar Year 2015 HAI Data SummaryCambridge Health Alliance - Cambridge Hospital - Cambridge, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
145
6
8,066
145.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.32 - 6.47)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 96%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
1.0
2.0
3.0
4.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 1 60 0.32
(HPRO) 3 44 0.39
(HYST) 0 34 0.36
(VHYS) 0 14 0.14
(COLO) 1 25 0.75 1.34 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 19 28,829 22.33 0.85 Same
(MRSA) 1 31,177 1.47 0.68 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.06 - 6.61)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.52 - 1.30)
Methicillin-resistant
Staphylococcus aureus(0.03 - 3.36)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 532 0.00 0.32
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 936 1.07 1.33 0.75 Same
27,049
Massachusetts Calendar Year 2015 HAI Data SummaryCambridge Health Alliance - Whidden Hospital - Everett, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
Not-for-profit
94
6
5,634
94.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.03 - 3.71)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 96%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(COLO) 0 15 0.39
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 13 25,538 17.67 0.74 Same
(MRSA) 0 25,538 1.13 0.00 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Clostridium difficile (0.40 - 1.22)
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Methicillin-resistant
Staphylococcus aureus(0 - 2.65)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
2011
2013
2014
COLO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 389 2.57 0.24
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 604 0.00 0.86 0.00 Same
23,922
Massachusetts Calendar Year 2015 HAI Data SummaryBeth Israel Deaconess Hospital - Milton - Milton, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
88
8
4,884
110.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 3.49)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 305 1.28 0.00 Same
(HPRO) 0 200 0.97 0.00 Same
(HYST) 0 17 0.16
(VHYS) 0 2 0.01
(COLO) 2 100 2.46 0.81 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 36 23,902 17.26 2.09 Higher
(MRSA) 0 23,902 1.36 0.00 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0 - 2.33)
Hip Prosthesis (0 - 3.08)
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.13 - 2.69)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (1.48 - 2.85)
Methicillin-resistant
Staphylococcus aureus(0 - 2.19)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections ProceduresPredicted
InfectionsSIR Interpretation
(COLO) 0 1 0.03
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 1 3,427 1.51 0.66 Same
(MRSA) 0 3,427 0.17
3,427
Massachusetts Calendar Year 2015 HAI Data SummaryAthol Memorial Hospital - Athol, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
25
0
711
50.00
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Clostridium difficile (0.03 - 3.27)
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
2015
CDI MRSA
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
#REF!
COLO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 96 0.00 0.06
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 321 0.00 0.73 0.00 Same
10,957
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Nashoba Valley Medical Center - Ayer, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
73
6
1,983
73.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 4.11)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 87%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 32 0.20
(HPRO) 0 34 0.25
(HYST) 0 4 0.05
(COLO) 0 18 0.48
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 8 5,274 4.03 1.98 Same
(MRSA) 0 5,271 0.37
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Clostridium difficile (0.92 - 3.76)
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST KPRO COLO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 925 1.08 0.56 1.78 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 1,410 0.00 2.00 0.00 Same
44,742
Massachusetts Calendar Year 2015 HAI Data SummaryHallmark Health System - Melrose-Wakefield Hospital - Melrose, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
198
12
8,769
198.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.08 - 8.78)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 1.49)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.2
0.4
0.6
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 146 0.70 0.00 Same
(HPRO) 1 112 0.71 1.41 Same
(HYST) 0 58 0.39
(VHYS) 0 28 0.07
(COLO) 6 96 2.79 2.15 Same
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 31 36,540 21.96 1.41 Same
(MRSA) 1 40,327 1.49 0.67 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0 - 4.27)
Hip Prosthesis (0.07 - 6.93)
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0.87 - 4.47)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.97 - 1.97)
Methicillin-resistant
Staphylococcus aureus(0.03 - 3.32)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 423 0.00 0.26
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 931 0.00 1.32 0.00 Same
17,962
Massachusetts Calendar Year 2015 HAI Data SummarySteward Health Care - Holy Family Hospital at Merrimack Valley - Haverhill, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
For-profit
83
6
3,214
83.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 2.26)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 82%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 7 9,733 7.01 1.00 Same
(MRSA) 0 9,733 0.43
Event Confidence Interval
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.43 - 1.97)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 188 0.00 0.11
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 927 1.08 1.32 0.76 Same
29,295
Massachusetts Calendar Year 2015 HAI Data SummaryMetroWest Medical Center - Leonard Morse Hospital - Natick, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Graduate teaching
For-profit
152
10
2,332
152.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.03 - 3.74)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 97%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 122 0.62 0.00 Same
(HPRO) 5 112 0.90 5.53 Higher
(HYST) 0 2 0.03
(VHYS) 0 1 0.00
(COLO) 0 17 0.36
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 5 13,826 12.61 0.40 Lower
(MRSA) 0 13,826 0.65 0.00 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0 - 4.80)
Hip Prosthesis (2.02 - 12.25)
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.14 - 0.87)
Methicillin-resistant
Staphylococcus aureus(0 - 4.62)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
1 3,294 0.30 2.42 0.41 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
1 4,699 0.21 11.84 0.08 Lower
72,282
Massachusetts Calendar Year 2015 HAI Data SummarySaint Vincent Hospital - Worcester, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
For-profit
304
24
17,236
152.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.02 - 2.03)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0.00 - 0.41)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 94%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(CABG) 0 102 1.01 0.00 Same
(KPRO) 1 500 3.40 0.29 Same
(HPRO) 0 463 4.16 0.00 Lower
(HYST) 2 95 0.77 2.60 Same
(VHYS) 0 44 0.38
(COLO) 0 130 3.41 0.00 Lower
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 64 81,162 81.30 0.79 Lower
(MRSA) 7 87,386 5.79 1.21 Same
Coronary Artery Bypass Graft (0 - 2.95)
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Procedure Confidence Interval
Knee Prosthesis (0.01 - 1.45)
Hip Prosthesis (0 - 0.72)
Abdominal Hysterectomy (0.43 - 8.59)
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery (0 - 0.87)
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.61 - 0.99)
Methicillin-resistant
Staphylococcus aureus(0.52 - 2.39)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CABG CABG KPRO KPRO HPRO HYST VHYS VHYS
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 345 0.00 0.21
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 551 0.00 1.25 0.00 Same
16,294
Massachusetts Calendar Year 2015 HAI Data SummaryBaystate Wing Hospital - Palmer, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
74
6
2,839
74.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 2.39)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2.0
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 6 0.03
(HPRO) 0 8 0.05
(COLO) 2 14 0.44
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 4 8,105 4.48 0.89 Same
(MRSA) 1 10,718 0.42
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Facility Wide LabID Events
Knee Prosthesis Not calculable
Hip Prosthesis Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Hospital CDI and MRSA SIRs for 2015 Calendar Year
Event Confidence Interval
Clostridium difficile (0.28 - 2.15)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO KPRO
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 142 0.00 0.02
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 268 0.00 0.55 0.00 Same
12,651
Massachusetts Calendar Year 2015 HAI Data SummaryLahey Health - Addison Gilbert Hospital - Gloucester, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
No State v. Hospital, 2015-2016 Season
Nonteaching
Not-for-profit
79
8
3,279
39.50
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical Not calculable
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical (0 - 5.45)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.1
0.2
0.3
0.4
0.5
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 89%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 7 12,527 7.10 0.99 Same
(MRSA) 0 12,527 0.49
Event Confidence Interval
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.43 - 1.95)
Methicillin-resistant
Staphylococcus aureusNot calculable
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
Medical School Affiliation
Hospital Type
Profit Status
Number of Beds
Number of ICU Beds
Number of Admissions
Number of Patient Days
Beds per Infection Preventionist
Infections Line Days RatePredicted
InfectionsSIR Interpretation
0 862 0.00 0.63 0.00 Same
InfectionsCatheter
DaysRate
Predicted
InfectionsSIR Interpretation
0 913 0.00 2.30 0.00 Same
27,951
Massachusetts Calendar Year 2015 HAI Data SummaryNorth Shore Medical Center - Union Hospital - Lynn, MA
Release Date: August 2016
2015 Hospital Survey Statistics HCP Influenza Vaccination Coverage
Yes State v. Hospital, 2015-2016 Season
Major teaching
Not-for-profit
147
12
4,494
147.00
Central Line-Associated Blood Stream Infection
CLABSI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 4.72)
Hospital Central Line Utilization Ratios Hospital & State CLABSI SIRs Compared to National Average
Catheter-Associated Urinary Tract Infection
CAUTI Rates by ICU Type for 2015, Compared to State Data from 2013-2014
ICU Type Confidence Interval
Medical/surgical (0 - 1.30)
Hospital Catheter Utilization Ratios Hospital & State CAUTI SIRs Compared to National Average
0
0.2
0.4
0.6
0.8
2011 2012 2013 2014 2015
Uti
liza
tio
n R
ati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2011 2012 2013 2014 2015
SIR
Hospital
State
91% 95%
50%
60%
70%
80%
90%
100%Unknown status
Medical contraindication
Declined vaccine
Vaccine coverage
State Hospital
0
0.2
0.4
0.6
0.8
1
2012 2013 2014 2015
Uti
lizati
on
Rati
o
Adult
State (Adult)
0.0
0.5
1.0
1.5
2012 2013 2014 2015
SIR
Hospital
State
Infections ProceduresPredicted
InfectionsSIR Interpretation
(KPRO) 0 245 1.12 0.00 Same
(HPRO) 0 82 0.43
(HYST) 0 3 0.03
(VHYS) 0 4 0.02
(COLO) 0 4 0.09
Infections Patient DaysPredicted
InfectionsSIR Interpretation
(CDI) 19 16,895 17.64 1.08 Same
(MRSA) 1 16,895 1.16 0.87 Same
Procedure Confidence Interval
Surgical Site Infection
Hospital SSI SIRs by Procedure Type for 2015 Calendar Year
Knee Prosthesis (0 - 2.67)
Hip Prosthesis Not calculable
Abdominal Hysterectomy Not calculable
Event Confidence Interval
Vaginal Hysterectomy Not calculable
Colon Surgery Not calculable
Statistically Significant Variation from Predicted Number of Surgical Site Infections, 2011-2015
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Facility Wide LabID Events
Hospital CDI and MRSA SIRs for 2015 Calendar Year
*Missing data is either not calculable or not collected during that time period. Please see the "One Page Description Hospital CY2015" for more
information.
Clostridium difficile (0.66 - 1.65)
Methicillin-resistant
Staphylococcus aureus(0.04 - 4.26)
Statistically Significant Variation from Predicted Number of LabID Events, 2013-2015
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
CDI MRSA
COLO
Statistically Higher than Predicted
Statistically the Same as Predicted
Statistically Lower than Predicted
HPRO HYST VHYS VHYS KPRO
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