Hospital Report

Aspirus Divine Savior Hospital & Clinics

2817 New Pinery Road
Portage, Wisconsin, 53901-0387
608-742-4131
http://www.aspirus.org

Generated: Sunday, April 14, 2024
Measure Hospital Result State Average State Benchmark National Average Report Period
Cesarean Birth 20 21.77 11.65 --- 10/1/2022-9/30/2023
Early Elective Delivery 3.31 0 --- 10/1/2022-9/30/2023
Exclusive Breast Milk Feeding 71.084 62.92 77.55 --- 10/1/2022-9/30/2023
Newborn Screening Card Transit Time 98.925 98.71 100 --- 10/1/2022-9/30/2023
Term Newborn Complications 1.235 3.37 1.31 --- 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Hip and Knee Surgery Complications 2.9 3.1 2.6 3.2 4/1/2019-3/31/2022
Measure Hospital Result State Average State Benchmark National Average Report Period
Catheter-Associated Urinary Tract Infections 0.61 0 1 10/1/2022-9/30/2023
Central Line Associated Blood Stream Infections 0.69 0 1 10/1/2022-9/30/2023
Clostridioides difficile Infections 0.652 0.67 0 1 10/1/2022-9/30/2023
Methicillin-Resistant Staph. aureus Infections 0.42 0 1 10/1/2022-9/30/2023
Surgical Site Infection - Abdominal Hysterectomy 1.15 0 1 10/1/2022-9/30/2023
Surgical Site Infection - Colon Surgery 0.88 0 1 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Acute Stroke 8.838 6.431 0 6.86 10/1/2022-9/30/2023
Chronic Obstructive Pulmonary Disease 8.7 9.3 7.8 9.2 7/1/2019-6/30/2022
GastrointestinaI Hemorrhage 2.336 0 2.51 10/1/2022-9/30/2023
Heart Attack DNR 12.2 10.6 12.6 7/1/2019-6/30/2022
Heart Failure 13.7 12.4 9.9 11.8 7/1/2019-6/30/2022
Hip Fracture 4.731 2.376 0 1.96 10/1/2022-9/30/2023
Pneumonia 16.8 18.1 15.8 18.2 7/1/2019-6/30/2022
Measure Hospital Result State Average State Benchmark National Average Report Period
Abdominal Aortic Aneurism Repair DNR 1.854 0 3.61 10/1/2022-9/30/2023
Carotid Endarterectomy DNR 0.082 0 0.43 10/1/2022-9/30/2023
Coronary Artery Bypass Graft NA 2.985 0 2.49 10/1/2022-9/30/2023
Percutaneous Coronary Intervention NA 2.262 0 3.26 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Always Quiet at Night 60 66 76 62 4/1/2022-3/31/2023
Definitely Recommend Hospital 51 73 83 69 4/1/2022-3/31/2023
Doctors Always Communicated Well 75 81 88 79 4/1/2022-3/31/2023
Nurses Always Communicated Well 74 82 89 79 4/1/2022-3/31/2023
Patient Rated Hospital High 60 75 87 71 4/1/2022-3/31/2023
Patients Always Received Requested Help 66 70 81 66 4/1/2022-3/31/2023
Patients Understood Their Care When They Left 46 55 64 52 4/1/2022-3/31/2023
Room Always Clean 65 77 86 72 4/1/2022-3/31/2023
Staff Always Explained Medications 58 66 75 62 4/1/2022-3/31/2023
Staff Provided Discharge Instructions 87 89 93 86 4/1/2022-3/31/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Falls with Major Injury 0 0.035 0 --- 10/1/2022-9/30/2023
Healthcare Personnel Influenza Immunization 73.97 83.2 94.8 --- 10/1/2022-5/15/2023
Pneumothorax 0 0.01 0 0.02 10/1/2022-9/30/2023
Pressure Ulcers 0 0.064 0 0.07 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
Perioperative Blood Clot 1.44 0.235 0 0.35 10/1/2022-9/30/2023
Perioperative Hemorrhage 0 0.253 0 0.23 10/1/2022-9/30/2023
Postoperative Respiratory Failure 0.537 0 0.73 10/1/2022-9/30/2023
Postoperative Sepsis 0.257 0 0.43 10/1/2022-9/30/2023
Measure Hospital Result State Average State Benchmark National Average Report Period
All Cause Unplanned Readmissions 9.9 9.1 6.38 --- 7/1/2022-6/30/2023
Chronic Obstructive Pulmonary Disease 18.9 18.8 17.8 19.3 7/1/2019-6/30/2022
Coronary Artery Bypass Graft NA 11 9.9 11 7/1/2019-6/30/2022
Heart Attack 13.7 12.5 14 7/1/2019-6/30/2022
Heart Failure 21.1 19.9 18.3 20.2 7/1/2019-6/30/2022
Hip and Knee Surgery 4.2 4.2 3.5 4.3 7/1/2019-6/30/2022
Pneumonia 17 16.6 15.6 16.9 7/1/2019-6/30/2022