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MEDICATION RECONCILIATION
GLOBAL TRIGGER TOOL
DSRIP
Doing Common Things uncommonly well
June 7, 2011
Shideh Ataii, Pharm.D.
Director of Pharmacy Services
Contra Costa Regional Medical Center
Martinez, California
OBJECTIVES
1)




Medication Reconciliation
How the approach over the years
What the process
Tools the forms
Pearls of wisdom & Lessons learned
OBJECTIVES
2) Global Trigger Tool
3) CA 1115 Waiver – Delivery System Reform
Incentive Payments (DSRIP)
Contra Costa Regional Medical Center &
Health Centers
Martinez
California
San Francisco
Bay Area
About CCRMC……






County hospital with 163 staffed beds
8 owned & operated health centers
Public Health, Mental Health, and Health plan
Teaching Hospital
Hospital & clinics still using paper records
Pharmacy: Inpatient Pharmacy, three
Outpatient/Clinic Pharmacies
 Meditech
About CCRMC……
•
We serve a population of approximately 100,000 individuals
•
450,000 outpatient visit/year
•
65,000 emergency visits/year
•
12,000 hospital discharges each year
•
We deliver 22% of Contra Costa County’s babies/year
•
Payor mix is 45% Medicaid, 18% Medicare, 30% managed care and
7% other
•
We employ 450 physicians and train 39 family medicine
residents/year
•
Pharmacy is consists of ~80 employees and we’re a training site
for all major Pharmacy schools in CA
•
Services include: Emergency Department, hospital, hospitalbased outpatient clinics, and freestanding health centers.
CCRMC Mission Statement
Our mission Statement: “Care for and improve
the health of all people in Contra Costa County
with special attention to those most vulnerable
to health problems.”
CCRMC’s Recognition
• IHI Mentor Hospital since 2006
• IHI Innovation Award Winner (Dec 2007)
• Agency for Healthcare Research & Quality (AHRQ)
Innovation Exchange (www.ahrq.org)
Our Innovation Profile per AHRQ: “Low -Tech Medication Reconciliation process
emphasizing standardized, easy to execute roles significantly reduces rates of
unreconcilied medications…”
• Multiple publications on Medication Reconciliation
• Published case study in Joint Commission Resources’
Medication Reconciliation Toolkit for Implementing NPSG 8
Improve Medication Safety
Reduce rates of unreconciled
medications
Implement an effective
admission, discharge and
transfer reconciliation
process
Model for Improvement Source:
Institute for Healthcare Improvement
(IHI)
Recommendations and Tips
Segment pieces of the improvement process in
bite size increments.
 Allows for small scale tests of change
 Allows for customization where necessary
 Improves likelihood of success
Our Med Rec Team members
CORE:
• Physician champion (Internist)
• Resident
• Nursing champion (Medicine unit staff RN)
• Pharmacists (2) Pharmacy Tech (1)
• Clinical Informaticist (RN)
• Leaders
Ad hoc :
• Forms expert (JD/risk management)
• Nursing rep for every service as we expanded
• MD rep for every service as we expanded
Pearls
Multi-disciplinary team
 Physician champion essential
 Pharmacy Champion essential
 Nursing Champion essential
 Best to have a strong leader who is well
respected by the organization
Recommendations and Tips
Short (45 minutes) weekly team meetings
 Maintains momentum
 Promotes engagement
Med Reconciliation Timeline –Historical data
Year
Month J
A
2005
S O
N
D
J
F
M
A
M
2006
J J
A
S
O
N
D
J
F
M
A
2007
M J J
A
S
O
Pilot unit (4A)
Medicine units
Surgical units
IMCU/ICU
Transfer Rec pilot
Psychiatry units
Transfer Rec live (all areas)
Pediatrics unit
OB unit
Pilot unit (4A)
ICU/IMCU
KEY:
Admission Reconciliation Implemented
Transfer Reconciliation Implemented
Discharge Reconciliation Implemented
Medicine Unit (4B)
Surgical Unit
Psychiatry Unit
Pediatrics unit
OB Unit
N
Pearls
Identify & Mitigate Failures
 Admission reconciliation failure causes
discharge reconciliation failure
 Develop workflows to identify key failure
points so they can be fixed immediately
Example  Daily report in Pharmacy for
identifying admitted patients w/o AMROF
Recommendations and Tips
Test measurement tool thoroughly
 insures that the data collection process will
produce the information you are seeking
Recommendations/Tips
“Measurement is for learning, not for judgment”
“Use data to generate light not heat!”
 Use data to learn where your process is failing
 Data collection should be frequent, small samples
Measurement Tool
Medication Reconciliation Worksheet: Admission & Discharge Reconciliation (Contra Costa Regional Medical Center)
MRN:
Admit Date:
Unit:
Patient Name:
Discharge Date:
Reviewer:
Patients selected for audit must
have at least 1 pre-admit med.
Do not mark an herbal as
unreconciled upon admission
(not continued, per policy).
ADMISSION RECONCILIATION
Pre-Admit (HX) Meds
If MROF used, no need to list
drugs (just do summary). If no
MROF, list all pre-admit drugs,
including OTCs, vitamins,
herbals & supplements
Step 1:List Meds on MAR on
day of d/c with exceptions:
No
No
No
No
No
No
PRNs
Insulin sliding scale
Heparin SQ
antibiotic ointments
IV Chemo
one dose only drugs
Step 2: Does documentation
specify that each drug is C, DC,
M upon discharge? If not, it's
unreconciled.
DISCHARGE RECONCILIATION
Meds Pt is Taking Day of D/C
Audit Inclusions: Any admission to the service; A least one pre-admit med in hx.
C
DC
M
Med order to
C, DC, M on
discharge?
C
DC
Med NOT
Reconciled
Med order to
C, DC, M on
admission?
Med not rec; but
clinically obvious
Drug
Discharge
Med NOT
Reconciled
Audit Instructions
Med not rec; but
clinically obvious
Admission
Comments
Data Summary
M
Was Admit MROF
Used?
Total # of PreAdmit Meds
Total # of PreAdmit meds NOT
reconciled on
admission
Total # of PreAdmit meds NOT
reconciled on
discharge
Was DMOF Used?
Does DMOF
contain all at
home meds?
Total # of predischarge Meds
Total # of predischarge meds
NOT reconciled on
discharge
Did any med order consist of "continue preadmit meds" or "continue home meds"
without detailing the specific medication?
(Y/N)
Admission Reconciliation
Paper process
• Originally: Admitting provider hand-wrote the list of
medications patient was taking at home on AMROF.
• Now: Admitting provider prints an eAMROF form
which is pre-populated with the current med list and
uses same form to order medications on admission.
• Process being used >99% of the time.
Our paper
Admission
Medication
Reconciliation
Order Form
(AMROF)
Our electronic
Admission
Medication
Reconciliation
Order Form
(eAMROF)
Page 1
Pearls
Use “What’s-In-It-For-Me” (WIFM) approach in
workflow design
 Admitting MD  new process was less work
 Admitting MD  eAMROF was less work (prepopulated list meant less writing)
 Admitting RN  new process was less work (stopped
capturing a med list from scratch)
 Pharmacy  ?
Pearls
Customize where necessary; Standardize where
possible
 Allows for unique workflows
 Promotes buy-in from staff
Examples  OB (currently), and Psychiatry and
PES units for about 2 years post
implementation
Manual
Admission and
Discharge
Medication
Reconciliation
Order Form
For L&D
Pearls
Make it easy for staff to use the new process &
difficult or impossible to use the old process
 Key for achieving high compliance with use of
the process
Example  Attached Admission Med Rec form as page 1 of all
admit order forms already in use & Removed the medication list
part of H&P, to have prescriber comply with the standards.
Transfer Reconciliation
• Electronically printed form contains list of all
active meds as of that moment in time.
• Provider uses form to order medications on
transfer within the facility.
• Process being used >99% of the time.
Our Transfer
Medication
Reconciliation
Order Form
(TMROF)
Pearls
Use “What’s-In-It-For-Me” (WIFM) approach in
workflow design
 Receiving RN  Less work (no more “continue
previous meds)
Harness Informal Champions
 Receiving RN  Constant reminders to
physicians who didn’t use the new process
Create a Pharmacy-Nurse liaison to educate the
Medical as well as the Nursing staff
Discharge Reconciliation (DMROF)
• Electronically printed form contains list of all
pre-admit meds and active inpatient meds as
of discharge.
• Provider uses form to order discharge meds
• Patient is provided with a “patient friendly”
list of discharge medications.
• Copy of list is sent to next provider of care.
Our Discharge
Medication
Reconciliation
Order Form
(DMROF)
Page 1
Our Discharge
Medication
Reconciliation
Order Form
(DMROF)
Final Page
Our [electronically
generated]
“patient friendly”
Discharge Medicine
List
Pearls
Use “What’s-In-It-For-Me” (WIFM) approach in
workflow design
 Discharging MD  Less work (home &
inpatient meds print on a report)
 Patient  Now has a concise med list
Remember: Make it easy for staff to use the
new process & difficult or impossible to use
the old process
Discharge Reconciliation:
Who Does What…….
• MD
– Reviews and sign the DMROF. Updates RXM as
needed
– Generates prescriptions in RXM
Discharge Reconciliation:
Who Does What…….
• Nursing Staff
– Print Patient Home Medicine List from RXM (aka Patient
Friendly Med List)
– Complete the STOP medication section on the Med List
– Review Patient Home Medicine List with patient (aka Pt
Friendly), make a copy for the chart.
– Indicate on Patient Home Medicine List, the time the next
dose of any medication is due.
– Write Patient Home Medicine list if not generated from RXM
Importance of Patient Education…
Discharge Reconciliation:
Who Does What…….
• Clerk
– Fax prescriptions (DMROF) to Retail Pharmacy of
choice
OR
– CCRMC Pharmacy
Discharge Reconciliation:
Who Does What…….
PHARMACY: Closed the service for all
discharged meds in March, 2007
Exclusion criteria: Injectables, PES, and psych
units
• TECHs: enter the order into RXM, pull meds
and prepare
• Pharmacists: Checks techs’ work and Dispense
Where We are today and where we are Going…
Future Conversion
to EPIC, Go live
7/2012
Meditech
2011
ED visit
Inpatient Admission
(Admit, Transfer, Discharge)
Pt friendly
form
Electronic prescribing to
Retail or CCRMC
Pharmacies vs printed
copy (RXM)
Outpatient Visit
Pt friendly
form
Measurement
ORIGINALLY
1) Outcome Measures
• % unreconciled meds (Goal = 0%)
• % of patients with ALL meds reconciled (Goal = 100%)
2) Process Measure
• % Compliance with use of the forms/process (Goal = 100%)
NOW
1. % compliance: Med Rec Form (DMROF) Matches Home Med
List
2. whether or not D/C’d meds at the Discharge are noted on
patient friendly list
3. % compliance with Med list being provided for the next level
of care (SNF, rehab…)
Results
• We’ve reduced our rates of unreconciled home
medications…
…from 26% to 0.6% on ADMISSION
…from 23% to ~7% on DISCHARGE
• We’ve reduced our rates of unreconciled
medications…
…from 12% to 4% on TRANSFER
• Improvement has been sustained with slight
variations for 5 years.
Medication Reconciled on Admission
100%
80%
60%
40%
20%
0%
Measurement (IHI website)
Medication Reconciliation at the Discharge
by Month (Feb and March of 2011)
100%
100%
100%
94%
90%
80%
60%
40%
20%
0%
#N/A
Feb
Mar
2011
% Med Rec Form Matches Home Med List
% of Meds Discontinued on Discharge that are Noted on Patient's List
% Med List was Provided to the Next Level of Care
94%
Medication Reconciliation, a continuous improvement
process
Examples of Admission challenges:
•
Incomplete data collection despite one’s best attempt, poor historian and a new
patient, etc... (Much less of a problem in a closed system for majority of pts)
Examples of Transfer challenges:
•
•
When an order is printed and faxed to the RX early, while additional orders are
actively being written for the same floor prior to the actual transfer
When the stop date on a time sensitive medication is not cited and the pt is
transferred with prolonged treatment period, erroneously
Examples of Discharge challenges:
•
•
CII’s are written on a Blank by law. However, RXM (i.e., Meditech) is not updated
electronically 100% of the time throughout the system (time consuming and
burdensome)
MD may accidentally forget to DC duplication of therapy. Example: Pt comes in
with a Med (documented on AMROF). The dose gets modified during the admit.
Upon discharge, Meditech compiles home med in addition to inpatient meds to
prepare DMROF and if not caught, it may create duplication of therapy. DMROF is
faxed to retail pharmacy and this may or may not be identified as an error outside
the organization
Lessons Learned/Challenges
• Improvements must
resonate with staff
• Make the improvement
easy to do!
• Change should not be
“extra work”
• Short, goal-directed
meetings
• Define your “aim” before
you start
• Set attainable goals, reach
them and then expand
• No room for bias, be honest
• Plan the “spread” wisely
• Identify your metrics earlyyou can’t fix what you can’t
measure
• Conduct small tests of
change
• Collect valid, reliable,
actionable data
• Interdisciplinary teams:
Talent not Title!
• Invaluable: Include a
patient in your team as a
member (FMEA
perspective)
IHI Global Trigger Tool
• Harm vs Error
• What is Harm?
Unintended physical injury resulting from or contributed to by
medical care that requires additional monitoring, treatment or
hospitalization, or that results in death. (Examples: post op
infections, PCN-induced anaphylactic shock, etc… )
“ Less than 4% of all adverse drug events involving use of rescue drugs are
reported.”
Studies of medical services suggest that only 1.5% of all adverse events result
in an incident report.
INCIDENT REPORTING
HARM
How do you measure harm?
1) Random chart sampling after the patient has been discharged 2) Clues
Global Trigger Tools Clues
The National Coordinating Council for Medication Error
Reporting and Prevention (NCC MERP)
E Temporary harm, intervention required
F Temporary harm, initial or prolonged hospitalization
G Permanent patient harm
H Life sustaining intervention required
I Contributing to Death
CCRMC’s Pharmacy’s position
• 100% review of all rescue med use and formal
report to MSC, P&T, PIC, and MEC separate
from the IHI global trigger tool data
“So what?”
• Trend, DUE’s, system redesign or system
changes, departmentally or institution wide, if
and when necessary
What is the significance of Global
Trigger Tools?
* It is used as a strategy to improve system in
multitude of projects.
* This method will help us
• DECREASE preventable hospital-acquired
conditions by the end of 2013, by 40%
AND
• Reduce hospital readmissions by 20% by the
end of 2013
Pledge of support-a CMS initiative
In April of 2011, at the Region IX launch of the Obama Administration new
initiative, the partnership for patient, our organization shared our
accomplishments with public in presence of our Congressman George
Miller,7th District of California Herb K. Schultz, Regional Director, HHS,
Region IX, David Sayen, CMS Regional Administrator, HHS, and Joseph
McCannon, Senior Advisor, Centers for
Medicare & Medicaid Services, HHS
We Pledged that CCRMC and Health Centers
will:
• Decrease by 40%, preventable hospital-acquired conditions by the end of 2013
• Reduce by 20% hospital readmissions by the end of 2013.
Delivery System Reform Incentive
Payments
(DSRIP)
Delivery System Reform Incentive Payments (DSRIP)
• Delivery System Reform Incentive Pool (DSRIP): The waiver
includes the opportunity for public hospitals to receive up to $3.3
billion over five years through the Delivery System Reform
Incentive Pool (DSRIP). This pool will be a subset of the Safety Net
Care Pool.
• The DSRIP is intended to support California’s public hospitals’
efforts to enhance the quality of care and the health of the patients
and families they serve
• CCRMC plan submitted to California Department of Health Care
Services and Center for Medicare and Medicaid Services in Feb
,2011
• Participants: 17 public hospitals
• A copy of all participants’ plans available on California Department
of Public Health website:
Http://www.dhcs.ca.gov/provgovpart/Pages/DSRIP1.aspx
About DSRIP……
Following our mission, we have developed the Delivery System
Reform Incentive Payment Plan (DSRIP) to:
• Accelerate the building of an integrated approach to care that
will improve the patient and caregiver experience
•
Build a coordinated system of care
•
Improve patient safety
•
Reduce harm
•
Increase preventative care services
•
Improve care of at-risk-populations that are most
vulnerable to health problems in our communities.
DSRIP (executive summary)
Improvement Projects (Cateogory 1)
1. Increase Primary Care Capacity
2. Increase Training of Primary Care Workforce
3. Enhanced Interpretation Services and Culturally Competent Care
4. Collection of Accurate Race, Ethnicity, and Language (REAL) Data to Reduce Disparities
Improvement Projects (Category 2)
1. Expand Medical Homes
2. Patient Experience of Care
3. Integrate Physical and Behavioral Health Care
4. Conduct Medication Management (Medication Reconciliation at Discharge)
DSRIP
Improvement Projects (Category 3)
Undefined at the moment. TBA per CMS.
Improvement Projects (Category 4)
1. Improve Severe Sepsis Detection and Management
2. Central Line-Associated Bloodstream Infection (CLABSI) Infection Prevention
3. Surgical Complications Core Processes (SCIP)
4. Hospital-Acquired Pressure Ulcer Prevention
5. Stroke Management
6. Venous Thromboembolism (VTE) Prevention and Treatment
7. Falls with Injury Prevention
DSRIP (Medication Management-MED REC at Discharge)
Contact Information
Shideh Ataii, Pharm.D.
Director of Pharmacy Services
Contra Costa Regional Medical Center and Clinics
Health Services Department
[email protected]
(925) 370-5601
Extra Materials and resources
TJC standards on Med Rec (effective 7/1/2011)
Elements of Performance for NPSG.03.06.01
1. Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient
setting. This information is documented in a list or other format that is useful to those who manage medications.
Note 1: Current medications include those taken at scheduled times and those taken on an as-needed basis. See the Glossary for a definition
of medications.
Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information
from the patient and/or other sources will be considered as meeting the intent of the EP.
Define the types of medication information to be collected in non–24-hour settings and different patient circumstances.
Note 1: Examples of non–24-hour settings include the emergency department, primary care, outpatient radiology, ambulatory surgery, and
diagnostic settings.
Note 2: Examples of medication information that may be collected include name, dose, route, frequency, and purpose.
2. Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital in order
to identify and resolve discrepancies.
Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by the
hospital, does the comparison. (See also HR.01.06.01, EP 1)
3. Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is
discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose).
Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include
only those medications. For more information about communications to other providers of care when the patient is discharged or transferred,
refer to Standard PC.04.02.01.
4. Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an
outpatient encounter.
Note: Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications
are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication
information at all times in the event of emergency situations. (For information on patient education on medications, refer to Standards
MM.06.01.03, PC.02.03.01, and PC.04.01.05.)
Reliabiity
Nolan T, Resar R,
Haraden C, Griffin FA.
Improving the
Reliability of Health
Care. IHI Innovation
Series white paper.
Boston: Institute for
Healthcare
Improvement; 2004.
(Available on
www.IHI.org)
Joint Commission
Resources
(www.jcrinc.com)
AHRQ
Innovation Profile: Low -Tech Medication Reconciliation process
emphasizing standardized, easy to execute roles significantly
reduces rates of unreconcilied medications
Summary
Contra Costa Health Services launched a medication reconciliation process at its county-owned
hospital based on Institute for Healthcare Improvement (IHI) concepts for redesigning work to
achieve a high degree of reliability. Contra Costa Health Services uses a process in which
Providers, Pharmacy, and Nursing staff have standardized, easy-to-understand, and easy-toexecute roles related to medication reconciliation. Before instituting the program, it was
"everyone's job" to collect information on a patient's home medications, which led to
confusion, and often home medication information "fell through the cracks." The program has
allowed Contra Costa Health Services to nearly reach its stated goals of having no unreconciled
medications at transition points (admission, transfer, discharge) and achieving 100 percent
adherence with form usage.
Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics
related to medication reconciliation, with baseline and post-implementation data coming from
chart audits.
Preventing Readmissions
• Focus on preventing readmissions (CHF)
• Using LEAN/Kaizen (many examples
throughout the organization)
• It is NOT: hospital ‘project’
• It is: system way of functioning
• Goal: using best practices for rapid
adaption/adoption in our system
Our Approach
• Bundle of 5 triggered at Dx
– CHF order set
– Patient education process
– Interdiscpilinary teaching plan
– Discharge appts made at time of admission!
– CHF Discharge Nurse
CHF Discharge Nurse
• Twice weekly phone calls to patients
– First call within 72 hours of discharge
• Real time ongoing medication reconciliation
of all meds
• Education
• Transportation assistance
• Triage
CHF Nurse
Ask the patient: Since leaving the hospital.
•How is your breathing?
Do you have worsening chest pain?
Can you lay flat without shortness of breath?
Are you coughing more?
Have you gained weight? If yes, how many pounds
Are you more dizzy or light headed?
Green Zone
All Clear – This zone is your goal. Your systems are under control
You have
•No shortness of breath.
•No weight gain more than 2 pounds (It may change 1 or 2 pounds).
•No swelling of your feet, ankles, legs or stomach.
•No chest pain.
Yellow Zone
Caution: - This zone is a warning.
CALL YOUR DOCTOR’S OFFICE IF:
•You have a weight gain of 3 pounds or more in 1 day or a weight gain of 5 pounds or more in 1 week.
•More shortness of breath.
•More swelling or your feet, ankles, legs, or stomach.
•Feeling more tired. No energy.
•Worsening cough.
•Dizziness.
•Feeling uneasy, you know something is not right.
•It is harder for you to breathe when lying down. You need to sleep sitting up in a chair.
Red
EMERGENCY
Go to the emergency room or call 911 if you have any of the following:
•Struggling to breath. Unrelieved shortness of breath while sitting still.
•Have chest pain that is different or stronger than normal or usual.
•Have confusion or can’t think clearly.
CONTRA COSTA HEALTH SERVICES
CONTRA COSTA REGIONAL MEDICAL CENTER
•
•
•
•
•
•
•
•
•
Congestive Heart Failure (CHF) Nurse Tool
CHF Nurse
Call all new CHF referrals received by fax twice a week on Tuesday and Friday:
Assess Clinical Condition (see attached):

Red Zone
 Advised patient to go to ED and Notified ED (370-5973)

Yellow Zone
 Made appointment within 24 hours ---- OR-- Do green zone assessment below and call medicine dept. on call MD to consult.
Green Zone – Initiate discussion with patient or caretaker
Ask patient “teach back” questions:
What gain is concerning enough that you should report to your doctor?
What foods should you avoid?
Do you know what symptoms to report to your doctor?
Review medications:
“Were you able to get prescribed medications after you left the hospital?”
“Do you have the list of medicines they gave you when you left the hospital?”
“What is the name of your water pill(s)?”
Does patient have medications?
 Yes
 No
 Medications Refaxed /called to __________________________ pharmacy
Does patient administer own medications?
 Yes
 No
Medications reviewed with patient/family member_____________
Reinforced “Daily Activities” (daily wt., law-salt diet, activity as tolerated)
Review Appointment(s):
 Patient/family member aware of follow-up appointment(s) __________________________________
__________________________________________________________________________________
 Referral made to Social Worker (925)370-5480 for transportation issues.
 Appointment with Patient Educator made (next available):___________________________________
Other Intervention:
_________________________________________________________________________________________________________________
Follow up:
 Low Risk Patient: Chart check to make sure patient made follow-up appt.
 High risk Patient (any patient requiring consultation with MD or not clear on any items on patient assessment): Chart check for repeat phone
call 3 to 5 days.
Our paper
Pediatric
Admission
Medication
Reconciliation
Order Form
What’s wrong with just studying
errors?
• “We found that less than 4% of all adverse
drug events involving use of rescue drugs
were reported.”
Schade, Am J Med Qual. 2006 Sep-Oct;21(5):335-41
• Studies of medical services suggest that only
1.5% of all adverse events result in an incident
report.
O'Neil A,. Ann Intern Med 1993;119:370-376
Pearls
Find and tell the stories...share…
….They exist
….They’re powerful
….They’ll engage people
Where we were….
Medication Reconciliation: 2005 - 2007
ED Visits
Inpatient
Admission
Admit  Transfer  Discharge
Outpatient
Visits