Essentia Health St Marys - Detroit Lakes

Hospital in Detroit Lakes, MN, Medicare certification number 240101. CMS publishes 53 quality measures for it.

Medicare certification

Provider of Services

CCN: 240101The number CMS certifies the facility under, not a provider identifier
Status: Active
Provider type: Hospital – Short-term
Listed by Care Compare as: Acute Care Hospitals
Ownership: Voluntary non-profit - Church
Control type: Church
Participating since: Jul 1, 1966
Last certification: Jul 18, 1997
Beds: 87
Overall star rating: 4 of 5Care Compare
Address: 1027 Washington Ave
Detroit Lakes, MN 56501
(218) 847-0888

NPI records for this facility 3

St Mary'S Regional Health Center
- Rural Health Clinic/Center
- Frazee, MN
- NPI 1902364482
Medicare enrollment
St Marys Regional Health Center
- Rural Health Clinic/Center
- Park Rapids, MN
- NPI 1730706656
Medicare enrollment
St. Marys Regional Health Center
- Rural Acute Care Hospital
- Detroit Lakes, MN
- NPI 1679561088
Medicare enrollment

Patient survey (HCAHPS) 9

Medicare Care Compare

Cleanliness - star rating Worse3 of 5
- State average 3.44 (computed here)
- National average 3.44 (computed here)
- Period from 10/01/2024
Communication about medicines - star rating Better3 of 5
- State average 3.2 (computed here)
- National average 2.71 (computed here)
- Period from 10/01/2024
Discharge information - star rating Better4 of 5
- State average 3.93 (computed here)
- National average 3.31 (computed here)
- Period from 10/01/2024
Doctor communication - star rating Better4 of 5
- State average 3.74 (computed here)
- National average 3.12 (computed here)
- Period from 10/01/2024
Nurse communication - star rating Better4 of 5
- State average 4.13 (computed here)
- National average 3.43 (computed here)
- Period from 10/01/2024
Overall hospital rating - star rating Better4 of 5
- State average 3.67 (computed here)
- National average 3.29 (computed here)
- Period from 10/01/2024
Quietness - star rating Better4 of 5
- State average 3.89 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024
Recommend hospital - star rating Better4 of 5
- State average 4.11 (computed here)
- National average 3.64 (computed here)
- Period from 10/01/2024
Summary star rating Better4 of 5
- State average 3.83 (computed here)
- National average 3.27 (computed here)
- Period from 10/01/2024

Complications and deaths 16

Medicare Care Compare

Abdominopelvic accidental puncture or laceration rate As expected1.03
- State average 1.08 (computed here)
- National average 1.06
- No different than the national rate
- 76 patients
- Period from 07/01/2022
CMS Medicare PSI 90: Patient safety and adverse events composite As expected0.95
- State average 0.96 (computed here)
- National average 1
- No different than the national value
- Period from 07/01/2022
Death rate for COPD patients As expected8.1
- State average 7.92 (computed here)
- National average 8.6
- No different than the national rate
- 58 patients
- Period from 07/01/2022
Death rate for heart failure patients As expected8.1
- State average 10.72 (computed here)
- National average 11.1
- No different than the national rate
- 80 patients
- Period from 07/01/2022
Death rate for pneumonia patients As expected13.5
- State average 14.31 (computed here)
- National average 15.2
- No different than the national rate
- 69 patients
- Period from 07/01/2022
Death rate for stroke patients As expected8.2
- State average 11.08 (computed here)
- National average 11.9
- No different than the national rate
- 33 patients
- Period from 07/01/2023
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate As expected3.5
- State average 3.77 (computed here)
- National average 3.9
- No different than the national rate
- 527 patients
- Period from 07/01/2024
Iatrogenic pneumothorax rate As expected0.21
- State average 0.2 (computed here)
- National average 0.21
- No different than the national rate
- 1,041 patients
- Period from 07/01/2022
In-hospital fall-associated fracture rate As expected0.35
- State average 0.29 (computed here)
- National average 0.27
- No different than the national rate
- 974 patients
- Period from 07/01/2022
Perioperative pulmonary embolism or deep vein thrombosis rate As expected3.3
- State average 3.56 (computed here)
- National average 3.52
- No different than the national rate
- 136 patients
- Period from 07/01/2022
Postoperative acute kidney injury requiring dialysis rate As expected1.63
- State average 1.66 (computed here)
- National average 1.67
- No different than the national rate
- 41 patients
- Period from 07/01/2022
Postoperative hemorrhage or hematoma rate As expected2.63
- State average 2.27 (computed here)
- National average 2.34
- No different than the national rate
- 133 patients
- Period from 07/01/2022
Postoperative respiratory failure rate As expected7.81
- State average 8.45 (computed here)
- National average 9.42
- No different than the national rate
- 42 patients
- Period from 07/01/2022
Postoperative sepsis rate As expected5.91
- State average 5.28 (computed here)
- National average 5.27
- No different than the national rate
- 36 patients
- Period from 07/01/2022
Postoperative wound dehiscence rate As expected1.75
- State average 1.83 (computed here)
- National average 1.77
- No different than the national rate
- 30 patients
- Period from 07/01/2022
Pressure ulcer rate As expected0.5
- State average 0.55 (computed here)
- National average 0.63
- No different than the national rate
- 734 patients
- Period from 07/01/2022

Measures CMS does not publish for this facility (4)

Death rate among surgical inpatients with serious treatable complications — 1
Death rate for CABG surgery patients — 5
Death rate for heart attack patients — 1
Rate of complications for hip/knee replacement patients — 1

Infections 2

Medicare Care Compare

Clostridium Difficile (C.Diff) As expected0
- State average 0.38
- National average 1
- No different than national benchmark
- Period from 10/01/2024
SSI - Colon Surgery As expected0.99
- State average 0.84
- National average 1
- No different than national benchmark
- Period from 10/01/2024

Measures CMS does not publish for this facility (4)

Catheter Associated Urinary Tract Infections (ICU + select Wards) — 13
Central Line Associated Bloodstream Infection (ICU + select Wards) — 13
MRSA Bacteremia — 13
SSI - Abdominal Hysterectomy — 13

Outpatient imaging 2

Medicare Care Compare

Abdomen CT Use of Contrast Material 5.5
- State average 4.42 (computed here)
- National average 5.83 (computed here)
- Period from 07/01/2024
Breast Cancer Screening Recall Rates 2.2
- State average 6.17 (computed here)
- National average 8.08 (computed here)
- Period from 07/01/2024

Spending per patient 1

Medicare Care Compare

Medicare hospital spending per patient (Medicare Spending per Beneficiary) 0.86
- State average 0.9
- National average 0.99 (computed here)
- Period from 01/01/2024

Timely and effective care 14

Medicare Care Compare

Appropriate care for severe sepsis and septic shock 75
- State average 58
- National average 65
- 115 patients
- Period from 10/01/2024
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better 152
- State average 138
- National average 168
- 377 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better 272
- State average 263
- National average 287
- 40 patients
- Period from 10/01/2024
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better 140
- State average 131
- National average 162
- 321 patients
- Period from 10/01/2024
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better 217
- State average 204
- National average 257
- 23 patients
- Period from 10/01/2024
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients 100
- State average 95
- National average 93
- 108 patients
- Period from 01/01/2024
Head CT results 62
- State average 73
- National average 69
- 16 patients
- Period from 10/01/2024
Healthcare workers given influenza vaccination 60
- State average 66
- National average 78
- 780 patients
- Period from 10/01/2024
Left before being seen 1
- State average 2
- National average 2
- 14,305 patients
- Period from 01/01/2024
Safe Use of Opioids - Concurrent Prescribing 9
- State average 13
- National average 15
- 461 patients
- Period from 01/01/2024
Septic Shock 3-Hour Bundle 71
- State average 65
- National average 73
- 24 patients
- Period from 10/01/2024
Septic Shock 6-Hour Bundle 85
- State average 76
- National average 87
- 13 patients
- Period from 10/01/2024
Severe Sepsis 3-Hour Bundle 89
- State average 76
- National average 81
- 115 patients
- Period from 10/01/2024
Severe Sepsis 6-Hour Bundle 87
- State average 94
- National average 93
- 55 patients
- Period from 10/01/2024

Measures CMS does not publish for this facility (16)

Anticoagulation Therapy for Atrial Fibrillation/Flutter — 1
Antithrombotic Therapy by End of Hospital Day 2 — 1
Discharged on Antithrombotic Therapy — 1
Emergency department volume — low
Global Malnutrition Composite Score — 5
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented — 5
Global Malnutrition Composite Score: Malnutrition Risk Screening — 5
Global Malnutrition Composite Score: Nutrition Assessment — 5
Global Malnutrition Composite Score: Nutritional Care Plan — 5
Hospital Harm - Opioid Related Adverse Events — 5
Hospital Harm - Severe Hyperglycemia — 5
Hospital Harm - Severe Hypoglycemia — 5
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery — 5
Intensive Care Unit Venous Thromboembolism Prophylaxis — 5
ST-Segment Elevation Myocardial Infarction (STEMI) — 1
Venous Thromboembolism Prophylaxis — 5

Unplanned visits 9

Medicare Care Compare

Heart failure (HF) 30-Day Readmission Rate As expected21.8
- State average 21.08 (computed here)
- National average 21.3
- No different than the national rate
- 129 patients
- Period from 07/01/2023
Hospital return days for heart failure patients -35.3
- State average -6.6 (computed here)
- National average 4.02 (computed here)
- Fewer days than average per 100 discharges
- 100 patients
- Period from 07/01/2022
Hospital return days for pneumonia patients -32
- State average -1.93 (computed here)
- National average 5.65 (computed here)
- Fewer days than average per 100 discharges
- 70 patients
- Period from 07/01/2022
Pneumonia (PN) 30-Day Readmission Rate As expected16.7
- State average 17.11 (computed here)
- National average 17.3
- No different than the national rate
- 93 patients
- Period from 07/01/2023
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy As expected5.7
- State average 5.83 (computed here)
- National average 5.4
- No different than the national rate
- 65 patients
- Period from 01/01/2024
Rate of inpatient admissions for patients receiving outpatient chemotherapy As expected10.9
- State average 10.87 (computed here)
- National average 10.7
- No different than the national rate
- 65 patients
- Period from 01/01/2024
Rate of readmission for chronic obstructive pulmonary disease (COPD) patients As expected19.7
- State average 19.72 (computed here)
- National average 20
- No different than the national rate
- 106 patients
- Period from 07/01/2023
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies) As expected12.7
- State average 13.16 (computed here)
- National average 13
- No different than the national rate
- 446 patients
- Period from 01/01/2022
Ratio of unplanned hospital visits after hospital outpatient surgery As expected1.1
- State average 1.03 (computed here)
- National average 1.01 (computed here)
- No different than expected
- 140 patients
- Period from 01/01/2024

Measures CMS does not publish for this facility (5)

Acute Myocardial Infarction (AMI) 30-Day Readmission Rate — 1
Hospital return days for heart attack patients — 1
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR) — 4
Rate of readmission after hip/knee replacement — 1
Rate of readmission for CABG — 5

Sources for this page

Provider of Services: the certification, provider type, beds and status.
Medicare Care Compare: the star rating and every measure on this page, with the state and national rates CMS publishes beside them.
NPPES NPI Registry: the NPI records connected to this certification.

Better and worse are CMS's own comparison with the national rate, not ours: for most measures a low score is the good one (deaths, infections) and for others a high one is, so measures where CMS states no comparison are left uncoloured. The exception is star ratings, which are read against the national average here. Quality measures are published by CMS and are not adjusted or re-scored here. Averages marked “computed here” are the mean of every facility reporting that measure, worked out by NPIMap because CMS publishes no comparison for it. Confirm anything you rely on at Medicare Care Compare.