Hospital Report
Ascension SE Wisconsin Hospital - Elmbrook Campus
19333 West North Avenue
Brookfield, Wisconsin, 53045
262-785-2000
http://healthcare.ascension.org/locations/wisconsin
Generated: Monday, September 7, 2026
Birth
Hip and Knee Surgical Complications
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Hip and Knee Surgery Complications | 3.8 | 3.763 | 2.7 | 4.1 | 7/1/2022-6/30/2025 |
Infections
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Catheter-Associated Urinary Tract Infections | 0 | 0.39 | 0 | 1 | 4/1/2025-3/31/2026 |
| Central Line Associated Blood Stream Infections | 0 | 0.52 | 0 | 1 | 4/1/2025-3/31/2026 |
| Clostridioides difficile Infections | 0.186 | 0.5 | 0 | 1 | 4/1/2025-3/31/2026 |
| Methicillin-Resistant Staph. aureus Infections | 0.5 | 0 | 1 | 4/1/2025-3/31/2026 | |
| Surgical Site Infection - Abdominal Hysterectomy | 0.77 | 0 | 1 | 4/1/2025-3/31/2026 | |
| Surgical Site Infection - Colon Surgery | 0.818 | 0.93 | 0 | 1 | 4/1/2025-3/31/2026 |
Mortality - Conditions
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Acute Stroke | 5.728 | 4.656 | 0 | 6.95 | 4/1/2025-3/31/2026 |
| Chronic Obstructive Pulmonary Disease | 8.9 | 8.668 | 7.2 | 8.6 | 7/1/2022-6/30/2025 |
| GastrointestinaI Hemorrhage | 0 | 1.376 | 0 | 2.72 | 4/1/2025-3/31/2026 |
| Heart Attack | 11.3 | 11.63 | 10.76 | 11.9 | 7/1/2022-6/30/2025 |
| Heart Failure | 9.8 | 12.104 | 9.8 | 11.1 | 7/1/2022-6/30/2025 |
| Hip Fracture | 1.223 | 1.185 | 0 | 2 | 4/1/2025-3/31/2026 |
| Pneumonia | 15.8 | 15.063 | 12.56 | 15.2 | 7/1/2022-6/30/2025 |
Mortality - Procedures
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Abdominal Aortic Aneurism Repair | 1.773 | 0 | 3.69 | 4/1/2025-3/31/2026 | |
| Carotid Endarterectomy | 0.26 | 0 | 0.47 | 4/1/2025-3/31/2026 | |
| Coronary Artery Bypass Graft | NA | 2.066 | 0 | 2.54 | 4/1/2025-3/31/2026 |
| Percutaneous Coronary Intervention | 3.883 | 2.182 | 0 | 3.46 | 4/1/2025-3/31/2026 |
Patient Experience
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Always Quiet at Night | 60 | 65 | 76 | 60 | 10/1/2024-9/30/2025 |
| Definitely Recommend Hospital | 68 | 75 | 85 | 71 | 10/1/2024-9/30/2025 |
| Doctors Always Communicated Well | 79 | 82 | 88 | 80 | 10/1/2024-9/30/2025 |
| Nurses Always Communicated Well | 80 | 83 | 89 | 80 | 10/1/2024-9/30/2025 |
| Patient Rated Hospital High | 71 | 76 | 87 | 72 | 10/1/2024-9/30/2025 |
| Room Always Clean | 66 | 78 | 88 | 74 | 10/1/2024-9/30/2025 |
| Staff Always Explained Medications | 61 | 66 | 76 | 62 | 10/1/2024-9/30/2025 |
| Staff Provided Discharge Instructions | 87 | 89 | 93 | 86 | 10/1/2024-9/30/2025 |
Patient Safety - All Patients
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Healthcare Personnel Influenza Immunization | 57.865 | 80.64 | 94.26 | --- | 10/1/2025-5/15/2026 |
| In Hospital Fall Associated Fracture Rate | 0.031 | 0.029 | 0 | 0.03 | 4/1/2025-3/31/2026 |
| Pneumothorax | 0.045 | 0.009 | 0 | 0.02 | 4/1/2025-3/31/2026 |
| Pressure Ulcers | 0.067 | 0.063 | 0 | 0.08 | 4/1/2025-3/31/2026 |
| Sepsis-1 | 70 | 72 | 72 | 65 | 10/1/2024-9/30/2025 |
Patient Safety - Patients with Surgery
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| Perioperative Blood Clot | 0.363 | 0.29 | 0 | 0.33 | 4/1/2025-3/31/2026 |
| Perioperative Hemorrhage | 0 | 0.103 | 0 | 0.23 | 4/1/2025-3/31/2026 |
| Postoperative Respiratory Failure | 0 | 0.439 | 0 | 0.72 | 4/1/2025-3/31/2026 |
| Postoperative Sepsis | 0 | 0.269 | 0 | 0.45 | 4/1/2025-3/31/2026 |
Perinatal
Readmissions
| Measure | Hospital Result | State Average | State Benchmark | National Baseline | Report Period |
|---|---|---|---|---|---|
| All Cause Unplanned Readmissions | 9.9 | 9.95 | 6.9 | --- | 1/1/2025-12/31/2025 |
| Chronic Obstructive Pulmonary Disease | 19.1 | 19.746 | 18.9 | 20 | 7/1/2022-6/30/2025 |
| Coronary Artery Bypass Graft | DNR | 10.526 | 8.66 | 11 | 7/1/2022-6/30/2025 |
| Heart Attack | 13.8 | 13.977 | 12.76 | 14.4 | 7/1/2022-6/30/2025 |
| Heart Failure | 20.3 | 21.029 | 19.9 | 21.3 | 7/1/2022-6/30/2025 |
| Hip and Knee Surgery | 6.9 | 5.834 | 4.8 | 5.8 | 7/1/2022-6/30/2025 |
| Pneumonia | 15.8 | 16.909 | 15.97 | 17.3 | 7/1/2022-6/30/2025 |