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OBJECTIVES Panel management processes have been used to help improve population-level care and outreach to patients outside the health care system. Opportunities to resolve gaps in preventive care are often missed when patients present outside of primary care settings but still within the larger health care system. We hypothesized that we could design a process of “inreach” capable of resolving care gaps traditionally addressed solely in primary care settings. Our aim was to identify and resolve gaps in vaccinations and screening for lead exposure for children within our primary care registry aged 2 to 66 months who were admitted to the hospital. We sought to increase care gaps closed from 12% to 50%. METHODS We formed a multidisciplinary team composed of primary care and hospital medicine physicians, nursing leadership, and quality improvement experts within the Division of General and Community Pediatrics. The team identified a smart aim, mapped the process, predicted failure modes, and developed a key driver diagram. We identified, tested, and implemented multiple interventions related to role assignment, identification of admitted patients with care gaps, and communication with the inpatient teams. RESULTS After increasing the reliability of our process to identify and contact the hospital medicine team caring for patients who needed action to 88%, we observed an increase in the preventive care gaps closed from 12% to 41%. CONCLUSIONS A process to help improve preventive care for children can be successfully implemented by using quality improvement methodologies outside of the traditional domains of primary care.

Supplemental Digital Content is available in the text., Introduction: Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative. Methods: There were 3 study periods: baseline (April 2009–March 2010), improvement (July 2012–December 2013), and operational (January 2014–December 2018). All patients undergoing RSI were eligible. We collected data using a structured video review. We compared key processes and outcomes with statistical process control charts. Results: We collected data for 615 of 643 (96%) patient encounters with RSI performed: 114 baseline (12 months), 105 improvement (18 months), and 396 operational (60 months). Key characteristics were similar, including patient age. Statistical process control charts indicated sustained improvement of all 6 key processes and the primary outcome measure (oxyhemoglobin desaturation) throughout the 5-year operational period. Conclusions: Improvements in RSI safety were sustained 5 years after a successful improvement initiative, with further improvement seen in several key processes. Further research is needed to elucidate the factors contributing to sustainability.

Improving population health requires a focus on neighborhoods with high rates of illness. We aimed to reduce hospital days for children from two high-morbidity, high-poverty neighborhoods in Cincinnati, Ohio, to narrow the gap between their neighborhoods and healthier ones. We also sought to use this population health improvement initiative to develop and refine a theory for how to narrow equity gaps across broader geographic areas. We relied upon quality improvement methods and a learning health system approach. Interventions included the optimization of chronic disease management; transitions in care; mitigation of social risk; and use of actionable, real-time data. The inpatient bed-day rate for the two target neighborhoods decreased by 18 percent from baseline (July 2012-June 2015) to the improvement phase (July 2015-June 2018). Hospitalizations decreased by 20 percent. There was no similar decrease in demographically comparable neighborhoods. We see the neighborhood as a relevant frame for achieving equity and building a multisector culture of health.

Objectives Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine. In a video-based study of RSI in a paediatric emergency department (ED), we reported a high degree of process variation and frequent adverse effects, including oxyhaemoglobin desaturation (SpO2

BACKGROUND Recent national guidelines recommend use of narrow-spectrum antibiotic therapy as empiric treatment for children hospitalized with community-acquired pneumonia (CAP). However, clinical outcomes associated with adoption of this recommendation have not been studied. METHODS This retrospective cohort study included children age 3 months to 18 years, hospitalized with CAP from May 2, 2011 through July 30, 2012. Primary exposure of interest was empiric antibiotic therapy, classified as guideline recommended or not. Primary outcomes were length of stay (LOS), total hospital costs, and inpatient pharmacy costs. Secondary outcomes included broadened antibiotic therapy, emergency department revisits, and readmissions. Multivariable linear regression and Fisher exact test were performed to determine the association of guideline-recommended antibiotic therapy on outcomes. RESULTS Empiric guideline-recommended therapy was prescribed to 168 (76%) of 220 patients. Median hospital LOS was 1.3 days (interquartile range [IQR]: 0.9–1.9 days), median total cost of index hospitalization was $4097 (IQR: $2657–$6054), and median inpatient pharmacy cost was $91 (IQR: $40–$183). Between patients who did and did not receive guideline-recommended therapy, there were no differences in LOS (adjusted −5.8% change; 95% confidence interval [CI]: −22.1 to 12.8), total costs (adjusted −10.9% change; 95% CI: −27.4 to 9.4), or inpatient pharmacy costs (adjusted 14.8% change; 95% CI: −43.4 to 27.1). Secondary outcomes were rare, with no difference in unadjusted analysis between patients who did and did not receive guideline-recommended therapy. CONCLUSIONS Use of guideline-recommended antibiotic therapy was not associated with unintended negative consequences; there were no changes in LOS, total costs, or inpatient pharmacy costs. Journal of Hospital Medicine 2015;10:13–18. © 2014 Society of Hospital Medicine

A study was performed to evaluate use of quality improvement techniques to decrease the variability in turnaround time (TAT) for radiology reports on emergency department (ED) radiographs. An interdepartmental improvement team applied multiple interventions. Statistical process control charts were used to evaluate for improvement in mean TAT for ED radiographs, percentage of ED radiographs read within 35 minutes, and standard deviation of the mean TAT. To determine if the changes in the radiology department had an effect on the ED, the average time from when an ED physician first met with the patient to the time when the final treatment decision was made was also measured. There was a significant improvement in mean TAT for ED radiographs (from 23.9 to 14.6 minutes), percentage of ED radiographs read within 35 minutes (from 82.2% to 92.9%), and standard deviation of the mean TAT (from 22.8 to 12.7). The mean time from when an ED physician first met with the patient to the time a final treatment decision was made decreased from 88.7 to 79.8 minutes. Quality improvement techniques were used to decrease mean TAT and the variability in TAT for ED radiographs. This change was associated with an improvement in ED throughput.

The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) was established by the Joint Council on Congenital Heart Disease to dramatically improve the outcomes of care for children with congenital heart disease (CHD) through a national collaborative network of multidisciplinary clinical teams and families, working together to collect longitudinal data, use improvement science methods and conduct research intended to accelerate the development and translation of new knowledge into practice. The initial project selected for this learning network is focused on care processes and outcomes of the initial interstage period for infants with hypoplastic left heart syndrome. A practice-based registry is being used to understand variation in care and outcomes of infants and children with complex CHD. The NPC-QIC has effectively recruited and engaged a large number of U.S. centers caring for infants with complex CHD and provides the infrastructure needed to support the implementation of practice changes across the collaborative that will ultimately improve outcomes in this high-risk group of patients. We describe here the development and early years of NPC-QIC as well as the challenges this collaborative faces moving forward.

There is an urgent need to improve the quality of health care delivery in emergency department (ED) settings. Given that nearly 27% of ED patients are children, 92% of which are seen in non–children's hospitals; the responsibility to improve the quality of emergency care for children applies to all systems, hospitals, EDs, and providers. In this article, we present an acute care model to frame quality improvement work in emergency care. This model will allow all EDs, not just children's hospital EDs, to adopt a common language and improve 4 integrated components of acute care: segmentation, diagnostic accuracy, therapeutic reliability, and disposition. Importantly for EDs, the acute care model can be used to improve ED flow. Furthermore, the model is supported by 4 critical competencies that enable the model to be used as a tool for improving acute care delivery. These include segmentation of patients, appropriate and rigorous use of evidence, reliable care systems, and leadership that encourages a culture of improvement.

OBJECTIVES: Despite its high prevalence, pain often is poorly managed in the emergency department. We used improvement science and quality-improvement methods to reduce delays associated with opioid delivery for children presenting to the emergency department with clinically apparent extremity fractures. METHODS: On the basis of a review of the literature, interviews with key stakeholders, expert consensus, and reviews of isolated examples of patients receiving timely analgesics, a multidisciplinary improvement team identified a set of operational factors, or key drivers, believed to be critical to the performance of appropriate initial pain management for children presenting to the emergency department with acute extremity injury. These key drivers focused the development of an intervention. RESULTS: The intervention, termed the orthopedic evaluation process, addressed all 4 identified key drivers simultaneously by standardizing triage decisions, activating necessary health care providers, aligning the care delivery need with necessary resources, and allowing parallel-task completion between physicians and nursing staff. After implementation of this process, 95% of the patients with long-bone extremity fractures treated with intravenous opioids received a first dose within 45 minutes of arrival, compared with a preintervention baseline average of 20%. CONCLUSIONS: By applying quality-improvement and process improvement methodology, we identified key drivers for the rapid delivery of systemic opioids to patients with clinically apparent extremity fractures and significantly improved the timeliness of analgesic delivery for this subgroup of patients.

Background An important expectation of pediatric education is assessing, resuscitating, and stabilizing ill or injured children. Objective To determine whether the Accreditation Council for Graduate Medical Education (ACGME) minimum time requirement for emergency and acute illness experience is adequate to achieve the educational objectives set forth for categorical pediatric residents. We hypothesized that despite residents working five 1-month block rotations in a high-volume (95 000 pediatric visits per year) pediatric emergency department (ED), the comprehensive experience outlined by the ACGME would not be satisfied through clinical exposure. Study Design This was a retrospective, descriptive study comparing actual resident experience to the standard defined by the ACGME. The emergency medicine experience of 35 categorical pediatric residents was tracked including number of patients evaluated during training and patient discharge diagnoses. The achievability of the ACGME requirement was determined by reporting the percentage of pediatric residents that cared for at least 1 patient from each of the ACGME-required disorder categories. Results A total of 11.4% of residents met the ACGME requirement for emergency and acute illness experience in the ED. The median number of patients evaluated by residents during training in the ED was 941. Disorder categories evaluated least frequently included shock, sepsis, diabetic ketoacidosis, coma/altered mental status, cardiopulmonary arrest, burns, and bowel obstruction. Conclusion Pediatric residents working in one of the busiest pediatric EDs in the country and working 1 month more than the ACGME-recommended minimum did not achieve the ACGME requirement for emergency and acute illness experience through direct patient care.

Objective The aim of this study was to determine if race/ethnicity and socioeconomic status (SES) were associated with the provision of anxiolysis and/or sedation among children undergoing laceration repair. Methods A 1-year cross-sectional sample of children undergoing laceration repair in an urban tertiary-care pediatric emergency department was analyzed. Primary outcomes included the use of nonpharmacologic anxiolysis (presence of a child life specialist), pharmacologic anxiolysis, and procedural sedation. Predictors included race/ethnicity (Caucasian vs minority) and SES (represented by insurance status: private vs none/public). Bivariable analyses provided unadjusted odds ratios (ORs) for the association between predictors and outcomes, and logistic regression was used to obtain adjusted ORs for the provision of anxiolysis and sedation (adjusted for age, gender, acuity, provider type, length of laceration, complexity of repair, time of day, use of a topical anesthetic, and body site of laceration). Results In the unadjusted analysis, a higher proportion of Caucasian children than minority children received nonpharmacologic anxiolysis and sedation, and a higher proportion of children with high SES received nonpharmacologic anxiolysis compared with children of low SES. However, these associations were not statistically significant once potential confounders were controlled in the adjusted analysis. Conclusions A very small proportion of children undergoing laceration repair at this single institution received pharmacologic anxiolysis and/or procedural sedation. We did not demonstrate racial/ethnic or socioeconomic disparities with respect to the management of procedure-related anxiety in children.

BACKGROUND AND OBJECTIVE:A national evidence-based guideline for the management of community-acquired pneumonia (CAP) in children recommends blood cultures for patients admitted with moderate to severe illness. Our primary aim was to increase ordering of blood cultures for children hospitalized with CAP from 53% to 90% in 6 months. The secondary aim was to evaluate the effect of obtaining blood cultures on length of stay (LOS).METHODS:At a tertiary children’s hospital, interventions to increase blood cultures focused on 3 key drivers and were tested separately in the emergency department and inpatient units by using multiple plan-do-study-act cycles. The impact of the interventions was tracked over time on run charts. The association of ordering blood cultures and LOS was estimated by using linear regression models.RESULTS:Within 6 months, the percentage of patients admitted with CAP who had blood cultures ordered increased from 53% to 100%. This change has been sustained for 12 months. Overall, 239 (79%) of the 303 included patients had a blood culture ordered; of these, 6 (2.5%) were positive. Patients who had a blood culture did not have an increased LOS compared with those without a blood culture.CONCLUSIONS:Quality improvement methods were used to increase adherence to evidence-based national guidelines for performing blood cultures on children hospitalized with CAP; LOS did not increase. These results support obtaining blood cultures on all patients admitted with CAP without negative effects on LOS in a setting with a reliably low false-positive blood culture rate.

Objectives The objective was to determine whether several measures of emergency department (ED) crowding are associated with an important indicator of quality and safety: time to reevaluation of children with documented critically abnormal triage vital signs. Methods This was a retrospective cross-sectional study of all patients with critically abnormal vital signs measured in triage over a 2.5-year period (September 1, 2006, to May 1, 2009). Cox proportional hazard analysis was used to determine rate ratios for time to critically abnormal vital sign reassessment, when controlled for potential confounders. Results In this 2.5-year sample, 9,976 patients with critically abnormal vital signs in triage (representing 3.9% of 253,408 visits) were placed in regular ED rooms with electronic alerts prompting vital sign reassessment after 1 hour. Overall, the mean time to reassessment was 84 minutes. The rate of vital sign reassessment was reduced by 31% for each additional 10 patients waiting for admission (adjusted odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.98 to 0.99), by 10% for every 10 patients in the lobby (adjusted OR = 0.94; 95% CI = 0.93 to 0.96), and by 6% for every additional 10 patients in the overall ED census (adjusted OR = 0.97; 95% CI = 0.97 to 0.98). Conclusions Emergency department crowding was associated with delay in the reassessment of critically abnormal vital signs in children; further work is needed to develop systems to mitigate these delays. Resumen Objetivos Determinar si diversas medidas de la saturacion del servicio de urgencias (SU) se asocian con un indicador importante de calidad y seguridad: el tiempo para la revaloracion de ninos con inestabilidad hemodinamica documentada en el triaje. Metodologia Estudio retrospectivo de analisis transversal de todos los pacientes con inestabilidad hemodinamica identificada en el triaje durante un periodo de 2,5 anos (1 de septiembre de 2006 hasta 1 de mayo de 2009). Se utilizo un analisis de riesgos proporcionales de Cox para determinar la razon de tasas para el tiempo hasta la revaloracion de la inestabilidad hemodinamica una vez controlado el modelo por los potenciales factores de confusion. Resultados En esta muestra de 2,5 anos, 9.976 pacientes con inestabilidad hemodinamica en el triaje (representaron un 3,9% de las 253.408 visitas) fueron situados en habitaciones comunes del SU con una alerta electronica que origina una revaloracion de las constantes vitales tras una hora. Del total, la media de tiempo hasta la revaloracion fue de 84 minutos. La frecuencia de revaloracion de las constantes vitales se redujo un 31% por cada 10 pacientes adicionales esperando para el ingreso (odds ratio ajustada [OR] 0,98; IC 95% = 0,98 a 0,99); un 10% por cada 10 pacientes en la recepcion (OR ajustada 0,94; IC 95% = 0,93 a 0,96); y un 6% por cada 10 pacientes adicionales en el censo global de SU (OR ajustada 0,97; IC 95% = 0,97 a 0,98). Conclusiones La saturacion del servicio de urgencias se asocio con un retraso en la revaloracion de la inestabilidad hemodinamica en los ninos; sera preciso trabajar en el futuro para desarrollar sistemas que mitiguen estos retrasos.

OBJECTIVES: Procedures are common in pediatric emergency departments and frequently cause distress from pain and/or anxiety. The objective of this study was to describe the incidence, types, and magnitude of long-term behavior changes after procedures in the emergency setting. METHODS: This is a descriptive pilot study to determine if children display negative behavioral changes after a minor emergency department procedure (abscess drainage or laceration repair). Behavior change was measured at 1 week by telephone follow-up using the 27-item Post Hospitalization Behavior Questionnaire, a well-validated instrument that measures behavior changes across 6 categories: general anxiety, separation anxiety, anxiety about sleep, eating disturbances, aggression toward authority, and apathy/withdrawal. Significant behavior change was defined as 5 or more negative behavior changes on the 27-item questionnaire. RESULTS: Twenty percent of children who underwent abscess drainage (n = 30) and 20% who underwent laceration repair (n = 30) displayed significant negative behavior change at 1 week. Children who displayed significant negative behavior change tended to be younger (3.6 vs 5.9 years) and trended toward being more likely to have received anxiolysis or sedation (16.7% vs 8.3%). Separation anxiety, sleep difficulties, and aggression toward authority were the most common behavior changes. CONCLUSIONS: In this pilot study, a significant percentage of children undergoing common emergency procedures exhibited an appreciable burden of negative behavior change at 1 week; these results demonstrate the need for further rigorous investigation of predictors of these changes and interventions, which can ameliorate these changes. Language: en

Although interventions to improve outcomes for children with congenital heart disease may be designed and tested, the rarity of any one specific defect presents a barrier to using traditional statistical methods to measure the effects of these interventions. The purpose of this report is to describe the innovative statistical approach taken by the Joint Council on Congenital Heart Disease (JCCHD) National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) to measure outcomes for infants with hypoplastic left heart syndrome—a relatively rare disease. We report our experience with the application of statistical process control methods to generate measures capable of identifying statistically significant change in the incidence of early growth failure—a clinically important outcome in this relatively small patient population.

OBJECTIVE: In August 2011, the Pediatric Infectious Disease Society and Infectious Disease Society of America published an evidence-based guideline for the management of community-acquired pneumonia (CAP) in children ≥3 months. Our objective was to evaluate if quality improvement (QI) methods could improve appropriate antibiotic prescribing in a setting without a formal antimicrobial stewardship program. METHODS: At a tertiary children’s hospital, QI methods were used to rapidly implement the Pediatric Infectious Disease Society/Infectious Disease Society of America guideline recommendations for appropriate first-line antibiotic therapy in children with CAP. QI interventions focused on 4 key drivers and were tested separately in the emergency department and on the hospital medicine resident teams, using multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed weekly to determine the success of prescribing recommended antibiotic therapy. The impact of these interventions on our outcome was tracked over time on run charts. RESULTS: Appropriate first-line antibiotic prescribing for children admitted with the diagnosis of CAP increased in the emergency department from a median baseline of 0% to 100% and on the hospital medicine resident teams from 30% to 100% within 6 months of introducing the guidelines locally at Cincinnati Children’s Hospital Medical Center and has been sustained for 3 months. CONCLUSIONS: Our study demonstrates that QI methods can rapidly improve adherence to national guidelines even in settings without a formal antimicrobial stewardship program to encourage judicious antibiotic prescribing for CAP.

Background Provision of medications in-hand at discharge improves adherence with recommended therapy. Objectives Among patients discharged from our emergency departments(ED)/urgent cares(UC) with an acute asthma exacerbation, we aimed to provide oral corticosteroid (OCS) in-hand so families did not have to fill a prescription after discharge. Methods Our multidisciplinary team created a key driver diagram to make explicit our theory for improvement. Key drivers included effective decision support, readily available medication with standard dispensing process, and provider education. Multiple plan-do-study-act cycles were conducted to address key drivers. Our primary outcome was provision of OCS in-hand at time of discharge and our secondary outcome was change to dexamethasone as preferred OCS in ED. Proportion of patients with a return visit within 7 days who required additional OCS was tracked as a balancing measure to ensure there were no unintended consequences. Results Statistical process control charts illustrated special cause variation in both our primary (2% to 96%, figure 1) and secondary (17% to 95%, figure 2) outcome measures. Our balancing measure remained was stable demonstrating only common cause variation (figure 3). Conclusions Using improvement methodology, we increased the proportion of patients seen in the ED/UC who received OCS in-hand at discharge from 2% to 96% without any increase in 7 day returns requiring additional OCS. This practice change within one division had a ripple effect across multiple care sites, including inpatient change to dexamethasone and a standardized process for outpatient follow-up. Future work will focus on standardization of key decisions across ED/UC in collaboration with all key stakeholders.

The study goal was to evaluate interstage growth variation among sites participating in the National Pediatric Cardiology Quality Improvement Collaborative registry caring for infants with hypoplastic left heart syndrome and to identify nutritional practices common among sites achieving best growth outcomes.This was a retrospective analysis of infants in the registry who had presented due to their superior cavopulmonary connection (SCPC) and whose surgical site had enrolled ≥ 4 eligible patients in the registry. The primary outcome variable was weight-for-age z-score (WAZ) change between Norwood discharge and presentation for SCPC (interstage period). Blinded, structured interviews were performed with each site regarding site-specific nutritional practices. Practices common among sites with positive interstage WAZ changes were identified.Sixteen centers enrolled 132 infants from December 2008 through December 2010. Median age at SCPC was 5 months (2.6-12.6), and median interstage WAZ change was -0.29 (-3.2 to 2.3). Significant variation in WAZ changes among sites was demonstrated (P.001). Sites that used standard feeding evaluation prior to Norwood discharge and that closely monitored for specific weight gain/loss red flags in the interstage period demonstrated significantly better patient growth than those that did not use these practices (P = .002).Considerable variation exists in interstage growth among patients receiving care at these 16 surgical sites. Standardization of interstage nutritional management with focus on best nutritional practices may lead to improved growth in this high-risk population of infants.

Objectives The objectives of this study were: (1) to determine the incidence of embedded earrings as a chief complaint among children presenting to a pediatric emergency department (ED), (2) to describe the age distribution of children presenting to the ED with embedded earrings, and (3) to describe local experience with the evaluation and treatment of these children. Methods We performed a retrospective chart review at Cincinnati Children's Hospital Medical Center ED for children presenting with a chief complaint of an embedded earring from 2000 to 2005. Demographic data, removal technique, presence of infection, and antibiotic administration were recorded. Results A total of 100 patients met criteria for inclusion in the study. The overall incidence was 25 per 100,000 patient visits. Most of the patients were girls (n = 81) with a median age of 8 years. Sixty percent of the cohort were younger than 10 years. Locations for embedded earrings included: lobule (n = 87), tragus (n = 2), and pinna (n = 11), with the majority having the posterior portion of the earring embedded (n = 68). Thirty-five percent of the patients had an infection at the embedded earring site. Local anesthesia was used in the most of the patients (n = 72); none required procedural sedation. Conclusions Embedded earring is an uncommon complaint among children presenting to a pediatric ED. Young children are likely overrepresented in the occurrence of this problem, which supports the American Academy of Pediatrics recommendation to postpone ear piercing until self-care is achievable.

Objectives To determine the effect of point-of-care testing (POCT) for influenza on the physician management of febrile children who are at risk for serious bacterial illness (SBI) on the basis of age and temperature and who are presenting to a pediatric emergency department (ED) during an influenza outbreak. Methods Patients 2–3 months of age with temperature of ≥38°C and patients 3–24 months of age with temperature of ≥39°C who were presenting to a pediatric ED during an influenza outbreak were enrolled into a prospective, quasi-randomized, controlled trial. Influenza testing was performed on enrolled patients by either the POCT or the standard-testing (ST) methods. The two groups were compared in terms of laboratory testing, chest radiography, antibiotic use, visit-associated costs, pediatric ED lengths of stay, inpatient admission, and return visits to the pediatric ED. Similar analyses also were performed on the resulting subgroups of patients on the basis of method of testing (POCT or ST) and test result (positive or negative). Results Of 767 eligible patients, 700 (91%) completed the study. No significant differences were demonstrated between the POCT and ST groups with respect to laboratory tests ordered, chest radiographs obtained, antibiotic administration, inpatient admission, return visits to the pediatric ED, lengths of stay, or visit-associated costs. In the subgroup analysis, the adjusted odds ratios (ORs) for blood culture in influenza test–positive to –negative patients were 0.59 and 0.71 in the POCT and ST groups, respectively (p = 0.088). The adjusted ORs for urine culture in influenza test–positive to –negative patients were 0.46 and 0.67 in the POCT and ST groups, respectively (p = 0.005). Conclusions When using a strategy of performing influenza testing on all patients at risk for SBI who presented to a pediatric ED during an influenza outbreak, the method of testing (POCT or ST) did not appear to significantly alter physician management, cost, or length of stay in the pediatric ED. However, if the interaction of the method of testing and the test result (positive or negative) were considered, a positive POCT for influenza was associated with a significant reduction in orders for urinalyses and urine cultures.