Measuring non-administration of ordered medications in the pediatric inpatient setting.

OBJECTIVE: Medication compliance in inpatient settings shows some significant gaps for adult patients. In pediatric settings prescribing and other administration errors have been studied but missed doses have not been specifically studied in the pediatric inpatient setting. We intended to apply health information technology and data processing methods to study the medication compliance for pediatric patients at our institution. STUDY DESIGN: We collected medication ordering, dispensing, and administration data spanning 42 months (7/1/2010 through 12/31/2013) for pediatric inpatients admitted to a major tertiary pediatric hospital. We analyzed the orders for which either the corresponding administration record was missing or the records indicated non-administration. RESULTS: There were only 596 medication orders without corresponding administration records, accounting for less than 0.05% of 1.6 Million orders for 56,000 patients. There were 40,999 orders with corresponding administration records indicating non-administration (or less than 3% of all orders). Overall order compliance of the nursing staff was 97.35%, with another 2.6% of orders having a documented reason for non-administration The top two medication classes comprising the missed and non-administered orders were "Alimentary tract and metabolism drugs" and "Nervous system drugs". CONCLUSION: Measurement of medication compliance is an important quality measure of patient safety and quality of care. Our study found a small proportion of non-administered medication orders and discovered corresponding reasons illustrating how health information technology can help to measure the quality of the medication process from ordering and dispensing to administration at a major healthcare institution.

Code status and resuscitation options in the electronic health record.

AIM: The advance discussion and documentation of code-status is important in preventing undesired cardiopulmonary resuscitation and related end of life interventions. Code-status documentation remains infrequent and paper-based, which limits its usefulness. This study evaluates a tool to document code-status in the electronic health records at a large teaching hospital, and analyzes the corresponding data. METHODS: Encounter data for patients admitted to the Medical Center were collected over a period of 12 months (01-APR-2012-31-MAR-2013) and the code-status attribute was tracked for individual patients. The code-status data were analyzed separately for adult and pediatric patient populations. We considered 131,399 encounters for 83,248 adult patients and 80,778 encounters for 55,656 pediatric patients in this study. RESULTS: 71% of the adult patients and 30% of the pediatric patients studied had a documented code-status. Age and severity of illness influenced the decision to document code-status. Demographics such as gender, race, ethnicity, and proximity of primary residence were also associated with the documentation of code-status. CONCLUSION: Absence of a recorded code-status may result in unnecessary interventions. Code-status in paper charts may be difficult to access in cardiopulmonary arrest situations and may result in unnecessary and unwanted interventions and procedures. Documentation of code-status in electronic records creates a readily available reference for care providers.

Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue of the salivary glands: a population-based study from 1994 to 2009.

BACKGROUND: Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) arising from the salivary glands is rare. METHODS: Five hundred seven cases were available for frequency/incidence analysis, and 712 for relative survival and regression analysis in the Surveillance Epidemiology and End Results (SEER) database. RESULTS: Of the total patients, 72.98% were women, 80.47% were white, and 74.75% were ≥50 years old. The parotid gland was involved in 80.87% of cases. Ann Arbor stage at diagnosis was 53.85% IE, 18.54% IIE, and 10.06% IIIE/IV. Overall, 15-year relative survival was 78.40%. Relative survival was worst among blacks and those with advanced-stage disease. No difference was noted between those treated with surgery, radiation, or both. Statistically significant poor prognosticators included black race (hazard ratio [HR], 2.3961; 95% confidence interval [CI], 1.54-3.72; p = .0001) and stage IIIE/IV (HR, 2.3677; 95%CI, 1.36-4.11; p = .0022). CONCLUSION: Early-stage salivary gland MALT lymphoma disease may be amenable to unimodality treatment. Even patients with advanced disease have relatively high survivals.

Demographics and survival trends of sinonasal adenocarcinoma from 1973 to 2009.

BACKGROUND: The purpose of this work was to study the demographics and survival of patients diagnosed with sinonasal adenocarcinoma (SNAC) within the time period of 1973 to 2009 using the Surveillance, Epidemiology, and End Result (SEER) database. METHODS: A retrospective cohort study using the U.S. National Cancer Institute's SEER registry was performed to study the demographics and survival for SNAC from 1973 to 2009. Analysis was conducted based on race, gender, and stage. RESULTS: In total, 1270 cases of SNAC were analyzed for demographics and survival. Males accounted for 51.6% of cases, while females accounted for 48.4% of cases, amounting to a male to female ratio of 1.06:1.00. Disease specific survival at 5, 10, 15, and 20 years was 65.2%, 50.9%, 40.9%, and 36.5%, respectively. When analyzed by gender, females had higher survival than males, although this difference was not statistically significant. When analyzed by race, the category of other, which encompasses American Indian, Asian, Hispanic, and unknown or unspecified race, was shown to have the best survival, followed by whites and blacks, respectively. CONCLUSION: SNAC is a rare tumor classically associated with occupational exposure and carries a variable prognosis. This is the first dedicated large-scale, retrospective analysis of a North American SNAC population. SNAC appears to affect both males and females equally and predominantly affects whites. Patients categorized as other had significantly better survival outcomes, while gender appeared to have no significant effect on survival.

Epidemiology of sinonasal squamous cell carcinoma: a comprehensive analysis of 4994 patients.

OBJECTIVES/HYPOTHESIS: To examine the incidence and survival of patients with sinonasal squamous cell carcinoma (SNSCC) between the years of 1973 and 2009 using the Surveillance, Epidemiology, and End Result (SEER) database. STUDY DESIGN: Retrospective cohort study using a national database. METHODS: The SEER registry was utilized to calculate incidence and survival trends for patients with SNSCC between 1973 and 2009. Patient data were then analyzed according to age, sex, and race. RESULTS: A total of 4,994 cases of SNSCC were identified, composed of 64.44% males and 35.56% females. Incidence trend analysis revealed a significant decrease in yearly rates from 1973 to 2009 for the overall population, females, whites, blacks, and "others" (P < .05). Overall 5-, 10-, and 20-year survival for SNSCC was 52.95%, 44.67%, and 29.37%, respectively. No significant differences (P > .05) were found when comparing survival between the last three decades. Differences in long-term survival were noted between whites, blacks, and "others," with whites displaying the highest 20-year survival. Males and females were found to have similar long-term survival curves, with 20-year survival of 30.68% and 26.35%, respectively. CONCLUSIONS: The overall incidence of SNSCC is declining. However, survival has not significantly improved in the last 3 decades. Race seems to influence the overall survival of this tumor. Future studies need to be conducted to investigate these dynamic trends related to SNSCC.

Demographic trends and disease-specific survival in salivary acinic cell carcinoma: an analysis of 1129 cases.

OBJECTIVE/HYPOTHESIS: Acinic cell carcinoma (AciCC) is a rare salivary gland malignancy that most commonly arises in the parotid gland. Characteristics of AciCC are slow growth and a long clinical course. As a rare tumor, population-based studies are limited. We analyzed the incidence and survival for AciCC using a national population-based database. STUDY DESIGN: Retrospective analysis. METHODS: The United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was utilized to calculate incidence and disease-specific survival trends for AciCC between 1973 and 2009. Patient data were stratified according to age, gender, race, grade, and extent of disease. Incidence trends were studied across the last 30 years and long-term disease-specific survival outcomes were compared across the different demographic parameters. RESULTS: A total of 1,129 cases of AciCC were identified, comprising of 672 (59.52%) females. Incidence trend analysis revealed significant changes in yearly incidence rates from 1973 to 2009 for male gender and white and "others" races. Overall 5-year survival was 97.15%, 10-year survival was 93.81%, and 20-year survival was 89.74%. Significant differences in survival outcomes were noted for extent of disease. Patients exhibiting distant metastasis displayed the worse long-term prognosis at 21.99% 20-year disease-specific survival. Hazard ratios demonstrated a significant increase in mortality in patients with poorly differentiated, undifferentiated, and metastatic disease. CONCLUSION: Trends in incidence of AciCC are influenced by gender, race and age. Long-term survival of this rare malignant tumor is influenced by gender, grade, race, and extent of disease. Future studies need to be conducted to investigate these dynamic trends related to AciCC.

Trends in resource utilization associated with the inpatient treatment of neonatal congenital heart disease.

INTRODUCTION: While neonates account for a significant proportion of health care expenditures related to inpatient care for congenital heart disease, key drivers of resource utilization among this population are poorly defined. METHODS: Data from 2005 through 2011 were extracted from the Pediatric Health Information System for patients assigned a discharge All Patient Refined Diagnosis Related Group of 630 (neonates with birthweight >2499 g undergoing a major cardiovascular procedure). Mortality risk adjustment for patients undergoing operative interventions was performed with the Risk Adjusment in Congenital Heart Surgery (RACHS-1) score. RESULTS: A total of 13 156 cases were included in the analysis. Despite only a 3% increase in case mix index and no significant change in operative acuity over the study period (RACHS classifications of 3 or greater 67% in 2005 vs. 66% in 2011, P = .64), there were inflation-adjusted increases in both total estimated cost per case of (50% to $151 760 in 2011, P < .001), and mean charge per case (33% to $433 875 in 2011, P < .001). Pharmacy charges increased by 16% (P < .001), with agents including chlorothiazide and albumin accounting for the highest patient charges over the study period. Imaging charges increased by 42% (P < .001), with an average of 5.7 echocardiograms and $6517 in associated charges per case by 2011. While the proportion of patients receiving nitric oxide remained consistent, mean duration of administration increased by 25% to 6.6 days by 2011, accounting for average charges of $52 141 per patient exposed. CONCLUSIONS: Among neonates with serious congenital heart disease, increases in both institutional costs and charges to the patient are associated with relatively consistent utilization practices in recent years. Multiinstitutional collaboration may prove useful in aligning evidence-based reductions in practice variation with limitations in resource utilization without compromising the quality of care.

Incidence trends and long-term survival analysis of sinonasal rhabdomyosarcoma.

PURPOSE: Sinonasal rhabdomyosarcoma (SNRMS) is a rare malignancy which often presents with nasal obstruction, rhinorrhea and epistaxis. It is the most common sarcoma in children. In this study, we analyze the incidence and long-term survival for SNRMS using a national population-based database. METHODS: The United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was utilized to calculate incidence and survival trends for SNRMS between 1973 and 2009. In addition, data were grouped by age, gender, race, and histopathological subtype. RESULTS: A total of 181 cases of SNRMS were analyzed for incidence trends, showing a 1.23:1 female to male ratio. While the overall incidence of SNRMS increased by 1.02% annually over the last 20years, this pattern was not equal amongst gender and racial groups. The incidence in males has increased, while in females incidence has decreased. An increase in incidence was noted in white and "others," but decreased in blacks. Using a total of 314 cases for survival analysis, we found that the rate in the white population has been consistently highest with a 5-year survival of 49.45%, 10- and 20-year survival of 48.81%. Survival rates in cases of embryonal SNRMS were also consistently higher than in cases of alveolar SNRMS. CONCLUSION: Overall incidence of SNRMS is increasing. Histologic subtype and race are important considerations in the long-term prognosis of SNRMS. Future studies will further elucidate gender and race related trends.

Sinonasal adenoid cystic carcinoma: comprehensive analysis of incidence and survival from 1973 to 2009.

OBJECTIVES/HYPOTHESIS: Sinonasal adenoid cystic carcinoma (SNACC) is a rare malignancy that most commonly arises in the maxillary sinus. Characteristics of SNACC are slow growth, perineural invasion, and long clinical course. Because it is a rare tumor, population-based studies are limited. We analyzed the incidence and survival for SNACC using a national population-based database. STUDY DESIGN: Retrospective cohort study using national cancer database. METHODS: The United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was utilized to calculate incidence and survival trends for SNACC between 1973 and 2009. Patient data were then analyzed according to age, sex, and race. Incidence trends were studied for the last 30 years, and survival outcomes were compared across the different demographic parameters. RESULTS: A total of 412 cases of SNACC were identified (57.52% female). Incidence trend analysis revealed a significant decrease in yearly rates from 1973 to 2009 for the overall population, females, whites, blacks, and "others." Overall 5-year survival for SNACC was 68.80%, 10-year survival was 48.03%, and 20-year survival was 22.39%. Significant differences in survival outcomes were noted between whites, blacks, and "others." "Others" had the best 20-year survival outcomes. CONCLUSIONS: The overall incidence of SNACC is declining. Sex and race seem to influence the overall survival for this rare tumor. Future studies need to be conducted to investigate these dynamic trends related to SNACC.

Constitutive expression of MMP9 in intestinal epithelium worsens murine acute colitis and is associated with increased levels of proinflammatory cytokine Kc.

Inflammatory bowel disease (IBD), which includes ulcerative colitis and Crohn's disease, is a chronic inflammatory disease associated with an increased risk for colon cancer. Matrix metalloproteinases (MMPs) are the predominant proteinases expressed in the gut mucosa during active IBD. Our laboratory has previously demonstrated that epithelial-derived MMP9 is absent in normal colonic tissue but is upregulated during IBD. In this study MMP9 transgenic mice (Tg-villin-MMP9) are generated specifically to overexpress MMP9 in intestinal epithelium to examine the role and underlying mechanism by which it modulates the pathogenesis of acute colitis. Dextran sodium sulfate (3% DSS)- and Salmonella typhimurium (S.T.)-induced colitis models were used to study gut inflammation in Tg-villin-MMP9 and wild-type littermates (WT). Colonic tissue was analyzed via Western blot, histology, myeloperoxidase (MPO) assay, and quantitative PCR. Tg-villin-MMP9 mice expressed significantly increased MMP9 mRNA and protein expression at basal level. There was a significant decrease in the goblet cells, but a significant increase in proliferation and apoptosis were observed among Tg-villin-MMP9 mice compared with WT mice. There was also a significant increase in the proinflammatory chemokine Kc among Tg-villin-MMP9 compared with WT mice. Tg-villin-MMP9 exhibited a severe inflammatory response than WT mice in both DSS- and S.T.-induced colitis models as evident by greater weight loss and higher clinical score, histological score, and MPO activity, which correlated with relative levels of Kc mRNA. MMP9 expressed by intestinal epithelial cells mediates inflammation in colitis with simultaneous increase in proinflammatory cytokine Kc.

That's nice, but what does IT do? Evaluating the impact of bar coded medication administration by measuring changes in the process of care.

Health information technology (IT) is widely endorsed as a way to improve key health care outcomes, particularly patient safety. Applying a human factors approach, this paper models more explicitly how health IT might improve or worsen outcomes. The human factors model specifies that health IT transforms the work system, which transforms the process of care, which in turn transforms the outcome of care. This study reports on transformations of the medication administration process that resulted from the implementation of one type of IT: bar coded medication administration (BCMA). Registered nurses at two large pediatric hospitals in the US participated in a survey administered before and after one of the hospitals implemented BCMA. Nurses' perceptions of the administration process changed at the hospital that implemented BCMA, whereas perceptions of nurses at the control hospital did not. BCMA appeared to improve the safety of the processes of matching medications to the medication administration record and checking patient identification. The accuracy, usefulness, and consistency of checking patient identification improved as well. In contrast, nurses' perceptions of the usefulness, time efficiency, and ease of the documentation process decreased post-BCMA. Discussion of survey findings is supplemented by observations and interviews at the hospital that implemented BCMA. By considering the way that IT transforms the work system and the work process a practitioner can better predict the kind of outcomes that the IT might produce. More importantly, the practitioner can achieve or prevent outcomes of interest by using design and redesign aimed at controlling work system and process transformations.

A human factors framework and study of the effect of nursing workload on patient safety and employee quality of working life.

BACKGROUND: Nursing workload is increasingly thought to contribute to both nurses' quality of working life and quality/safety of care. Prior studies lack a coherent model for conceptualising and measuring the effects of workload in healthcare. In contrast, we conceptualised a human factors model for workload specifying workload at three distinct levels of analysis and having multiple nurse and patient outcomes. METHODS: To test this model, we analysed results from a cross-sectional survey of a volunteer sample of nurses in six units of two academic tertiary care paediatric hospitals. RESULTS: Workload measures were generally correlated with outcomes of interest. A multivariate structural model revealed that: the unit-level measure of staffing adequacy was significantly related to job dissatisfaction (path loading=0.31) and burnout (path loading=0.45); the task-level measure of mental workload related to interruptions, divided attention, and being rushed was associated with burnout (path loading=0.25) and medication error likelihood (path loading=1.04). Job-level workload was not uniquely and significantly associated with any outcomes. DISCUSSION: The human factors engineering model of nursing workload was supported by data from two paediatric hospitals. The findings provided a novel insight into specific ways that different types of workload could affect nurse and patient outcomes. These findings suggest further research and yield a number of human factors design suggestions.

Effects of mental demands during dispensing on perceived medication safety and employee well-being: a study of workload in pediatric hospital pharmacies.

BACKGROUND: Pharmacy workload is a modifiable work system factor believed to affect both medication safety outcomes and employee outcomes, such as job satisfaction. OBJECTIVES: This study sought to measure the effect of workload on safety and employee outcomes in 2 pediatric hospitals and to do so using a novel approach to pharmacy workload measurement. METHODS: Rather than measuring prescription volume or other similar indicators, this study measured the type and intensity of mental demands experienced during the medication dispensing tasks. The effects of external (interruptions, divided attention, and rushing) and internal (concentration and effort) task demands on perceived medication error likelihood, adverse drug event likelihood, job dissatisfaction, and burnout were statistically estimated using multiple linear and logistic regression. RESULTS: Pharmacists and pharmacy technicians reported high levels of external and internal mental demands during dispensing. The study supported the hypothesis that external demands (interruptions, divided attention, and rushing) negatively impacted medication safety and employee well-being outcomes. However, as hypothesized, increasing levels of internal demands (concentration and effort) were not associated with greater perceived likelihood of error, adverse drug events, or burnout and even had a positive effect on job satisfaction. CONCLUSIONS: Replicating a prior study in nursing, this study shows that new conceptualizations and measures of workload can generate important new findings about both detrimental and beneficial effects of workload on patient safety and employee well-being. This study discusses what those findings imply for policy, management, and design concerning automation, cognition, and staffing.

Matrix metalloproteinase-9 functions as a tumor suppressor in colitis-associated cancer.

There is a well-documented association of matrix metalloproteinase-9 (MMP-9) and receptor Notch-1 overexpression in colon cancer. We recently showed that MMP-9 is also upregulated in colitis, where it modulates tissue damage and goblet cell differentiation via proteolytic cleavage of Notch-1. In this study, we investigated whether MMP-9 is critical for colitis-associated colon cancer (CAC). Mice that are wild type (WT) or MMP-9 nullizygous (MMP-9(-/-)) were used for in vivo studies and the human enterocyte cell line Caco2-BBE was used for in vitro studies. CAC was induced in mice using an established carcinogenesis protocol that involves exposure to azoxymethane followed by treatment with dextran sodium sulfate. MMP-9(-/-) mice exhibited increased susceptibility to CAC relative to WT mice. Elevations in tumor multiplicity, size, and mortality were associated with increased proliferation and decreased apoptosis. Tumors formed in MMP-9(-/-) mice exhibited expression of p21(WAF1/Cip1) and increased expression of beta-catenin relative to WT mice. In vitro studies of MMP-9 overexpression showed increased Notch-1 activation with a reciprocal decrease in beta-catenin. Notch and beta-catenin/Wnt signaling have crucial roles in determining differentiation and carcinogenesis in gut epithelia. Despite being a mediator of proinflammatory responses in colitis, MMP-9 plays a protective role and acts as a tumor suppressor in CAC by modulating Notch-1 activation, thereby resulting in activation of p21(WAF1/Cip1) and suppression of beta-catenin.

Comparison of the pulse oximetric saturation/fraction of inspired oxygen ratio and the PaO2/fraction of inspired oxygen ratio in children.

BACKGROUND: Although diagnostic criteria for acute lung injury (ALI) and ARDS are clear, invasive arterial sampling is required for computation of Pao(2)/fraction of inspired oxygen (Fio(2)) [PF] ratios. The pulse oximetric saturation (Spo(2))/Fio(2) (SF) ratio may be a reliable noninvasive alternative to the PF ratio for identifying children with lung injury. METHODS: We electronically queried blood gas measurements from two tertiary care pediatric ICUs (PICUs). Included in the analysis were corresponding measurements of Spo(2), Pao(2), and Fio(2) charted within 15 min of each other when Spo(2) values were between 80% and 97%. Computed PF and SF ratios were compared to identify threshold values for SF ratios that correspond to PF criteria for ALI (< or = 300) and ARDS (< or = 200). Data from one PICU were used for derivation and validated with measurements from the second PICU. RESULTS: From the 1,298 observations in the derivation data set, SF ratio could be predicted by the regression equation SF = 76 + 0.62 x PF (p < 0.0001, R(2) = 0.61). SF ratios of 263 and 201 corresponded to PF ratios of 300 and 200, respectively. The ALI SF cutoff of 263 had 93% sensitivity and 43% specificity, and the ARDS cutoff of 201 had 84% sensitivity and 78% specificity. Applying these values to the 1,845 observations in the validation data set yielded a sensitivity of 86% and specificity of 47% for ALI and a sensitivity of 68% and specificity of 84% for ARDS. CONCLUSION: SF ratio is a reliable noninvasive marker for PF ratio to identify children with ALI or ARDS.

Promoting adherence to ventilator management and ventilator weaning protocols.

Studies have shown that ventilator weaning protocols have resulted in a reduction in duration of mechanical ventilation, ventilator-associated pneumonia, and the rate of re-intubation when compared to weaning directed by a physician. This project continuously monitors weaning status and provides feedback on each patients status. The specific aim of this project is to improve the adherence to ventilator management and ventilator weaning protocols.

Closing the loop in practice to assure the desired performance.

A closed loop control process assures that a system performs within control limits. In closed loop control, the system's output feeds back directly to change the system's inputs. We describe an approach to planning and monitoring care that uses closed loop control to assure the desired performance using examples from Vanderbilt University Medical Center's ventilator management initiative. The approach has three components: an explicit end-to-end plan; a record of what is done as it is done; and an instant display of the status of each patient against their plan. The status display provides process control by showing the clinical team where correction is needed while they have time to act prospectively. Plans, displays and performance evolve together iteratively until the desired performance is achieved.

Matrix metalloproteinase-9 regulates MUC-2 expression through its effect on goblet cell differentiation.

BACKGROUND & AIMS: We recently demonstrated that epithelial-derived matrix metalloproteinase (MMP) 9 up-regulated during inflammatory bowel disease is a critical mediator of tissue damage during colitis. MMP-9 null mice (MMP-9(-/-)) develop dramatically reduced inflammatory response to luminally administered colitic agents in the face of intact systemic immune response and inflammatory cell recruitment, suggesting protected epithelial barrier in these mice. In this study, we sought to address the role and mechanism by which MMP-9 influences barrier protective function. METHODS: Wild-type and MMP-9(-/-) mice were used for in vivo studies, and the goblet cell line HT29-cl.16E and the enterocyte cell line Caco2-BBE were used for in vitro studies. RESULTS: Compared with wild-type mice, MMP-9(-/-) mice had an increased number of goblet cells and MUC-2 expression. In addition, KLF-4 and Elf-3, transcription factors involved in terminal differentiation of goblet cells were up-regulated, whereas notch intracellular domain (NICD; activated Notch-1) was down-regulated in MMP-9(-/-) mice. These findings suggest altered epithelial cell differentiation in MMP-9(-/-) mice. Temporal expression of MMP-9 inversely correlated with MUC-2 expression during maturation of goblet cells. MMP-9 over expression inhibited goblet cell differentiation in vitro. Conversely, MMP-9 gene silencing in Caco2-BBE cells resulted in a change in their phenotype toward goblet cells. Finally, MMP-9 over expression or silencing in goblet cells increased or decreased Salmonella typhimurium adherence, respectively. CONCLUSIONS: MMP-9 regulates goblet cell differentiation in colon. The effect of MMP-9 on goblet cells could contribute to alteration in mucosal defense leading to inflammation. Together, our data uncover a novel function of MMP-9 in intestinal epithelial cells.

The effect of implementing computerized provider order entry on medication prescribing errors in an emergency department.

Medication errors are a major concern in the Emergency Department (ED). We examined medication prescribing errors among consecutive adult ED patients during two 10-day periods before and during one 9-day period after implementing computerized provider order entry in an adult ED. 2,073 patients had 5,950, orders. Before (after) implementation there were 3.7 (2.8) potential adverse drug events, 222.0 (21.0) medication prescribing errors, and 5.1 (0) rule violations per 100 orders.