St. Lukes Episcopal Hospital


About the Facility

CMS Certification Number (CCN)
45T193
Ownership Type
Non-profit
CMS Region
Dallas
Certification Date
Address
6720 Bertner
Houston, Texas 77030
Phone Number
(832) 355-6281

Facility Medical Condition Statistics

All other conditions
32
Brain disease or condition (non-traumatic)
11
Brain injury (traumatic)
Data not available for this reporting period.
Hip or femur fracture
14
Hip or knee replacement, amputation or other bone or joint condition
11
Nervous system disorder (excluding stroke)
16
Spinal cord disease or condition (non-traumatic)
Data not available for this reporting period.
Spinal cord injury (traumatic)
-
Stroke
22

Facility Quality of Patient Care Measures

Catheter-associated urinary tract infections (CAUTI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
Not Available
Comparative performance category
Not Available
Catheter days
170
Predicted number of infections (B)
0.350
Number of infections reported (A)
0
SIR (A/B)
Not Available
Percentage of patients whose functional abilities were assessed and functional goals were included in their treatment plan
Numerator
118
Denominator
118
Facility rate
100.0
Change in patients ability to care for themselves
Average risk-adjusted change score
11.3
Denominator
105
Average observed change score
13.0
Change in patients ability to move around
Average risk-adjusted change score
28.8
Denominator
105
Average observed change score
32.1
Percentage of patients who are at or above an expected ability to care for themselves at discharge
Numerator
52
Denominator
105
Facility rate
49.5
Percentage of patients who are at or above an expected ability to move around at discharge
Numerator
54
Denominator
105
Facility rate
51.4
Percentage of IRF patients who experience one or more falls with major injury during their IRF stay
Numerator
0
Denominator
118
Facility rate
0.0
Clostridium difficile Infection (CDI)
Standardized infection ratio (SIR) 95% confidence interval - lower limit
Not Available
SIR 95% confidence interval - upper limit
1.595
Comparative performance category
No Different than the National Benchmark
Patient days
2,990
Predicted number of infections (B)
1.878
Number of infections reported (A)
0
SIR (A/B)
0.000
Percentage of healthcare personnel who got a flu shot for the current season
Number of health care workers vaccinated
893
Number of health care workers
2,239
Rate of flu vaccination
39.9
Rate of potentially preventable hospital readmissions 30 days after discharge from an IRF
Number of potentially preventable readmissions following discharge
11
Number of eligible stays
157
Unadjusted potentially preventable readmission rate
7.01
Risk-standardized potentially preventable readmission rate (RSRR)
7.96
Lower limit of the 95% confidence interval on the RSRR
6.17
Upper limit of the 95% confidence interval on the RSRR
10.07
Comparative performance category
No Different than the National Rate
Rate of potentially preventable hospital readmissions during the IRF stay
Number of potentially preventable readmissions
12
Number of eligible stays
185
Unadjusted potentially preventable readmission rate
6.49
Risk-standardized potentially preventable readmission rate (RSRR)
4.95
Lower limit of the 95% confidence interval on the RSRR
3.68
Upper limit of the 95% confidence interval on the RSRR
6.40
Comparative performance category
No Different than the National Rate
Rate of successful return to home or community from an IRF
Observed number of discharges to community (DTC)
102
Number of eligible stays
142
Observed discharge to community rate
71.83
Risk-standardized discharge to community rate
71.80
Lower limit of the 95% confidence interval on the risk-standardized discharge to community rate
65.65
Upper limit of the 95% confidence interval on the risk-standardized discharge to community rate
77.75
Comparative performance category
No Different than the National Rate
Medicare Spending Per Beneficiary (MSPB) for patients in IRFs
MSPB score
0.94
Number of eligible episodes
156
Percentage of patients whose medications were reviewed and who received follow-up care when medication issues were identified
Numerator
117
Denominator
118
Facility rate
99.2
Percentage of patients with pressure ulcers/pressure injuries that are new or worsened
Numerator
0
Denominator
118
Facility observed rate
0.0
Facility risk-adjusted rate
0.0
Percentage of IRF healthcare personnel who completed COVID-19 primary vaccination series
Number of health care workers vaccinated
Not Available
Number of health care workers
Not Available
Rate of COVID-19 vaccination
Not Available