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Measure Last Updated
HCP/IMM-3 Q4 2023 – Q1 2024

Influenza Vaccination Coverage Among Healthcare Personnel (HCP)

Antibiotic Stewardship 2024

Measured via Center for Disease Control National Healthcare Safety Network (CDC NHSN) Annual Facility Survey

St. Charles- Madras Q4 2020 – Q1 2021 Q4 2021 – Q1 2022 Q4 2022 – Q1 2023 Q4 2023 – Q1 2024 Q4 2024 – Q1 2025 OR CAH Rate Q4 2024 – Q1 2025 National CAH Rate Q4 2024 – Q1 2025
IMM-3 Influenza Vaccination Coverage Among Healthcare Personnel N/A 63% of 252 patients 61% of 281 patients 41% of 356 patients 43.4% of 304 patients 84.5% 75.0%

Influenza Vaccination Coverage Among Healthcare Personnel

Antibiotic Stewardship 2020 2022 2023 2024 % of OR CAHs Meeting Element (2024) State CAH Average (2024) National CAH Average (2024)
Number of Elements Met 7 7 7 7 92% 100.0% 94.0%
Element 1: Leadership Y Y Y Y 92% 100.0% 99.0%
Element 2: Accountability Y Y Y Y 92% 100.0% 99.0%
Element 3: Drug Expertise Y Y Y Y 92% 100.0% 98.0%
Element 4: Action Y Y Y Y 92% 100.0% 99.0%
Element 5: Tracking Y Y Y Y 92% 100.0% 97.0%
Element 6: Reporting Y Y Y Y 92% 100.0% 99.0%
Element 7: Education Y Y Y Y 92% 100.0% 100.0%

Antibiotic Stewardship Trend in St. Charles- Madras

Safe Use of Opioids 2023 2024 % of OR CAHs Meeting Element (2024) State CAH Rate (2024) National CAH Rate (2024)
Safe Use of Opioids Rate 17% of 135 patients 11% of 152 patients 100% 15.3% 16.5%

Opioid Rate Trend in St. Charles- Madras