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Aim Low‐value care (LVC) is common. We aimed, using infants presenting to a major tertiary paediatric hospital with bronchiolitis between April 2016 and July 2018, to: (i) assess rates of chest X‐ray (CXR) and medication use; (ii) identify associated factors; and (iii) measure the harm of not performing these practices. Methods We extracted data from the electronic medical record for all children aged 1–12 months given a diagnosis of bronchiolitis in the emergency department. Factors potentially associated with LVC practices were extracted, including patient demographics, ordering physician characteristics, order indication, medications prescribed and admission ward. To assess for harm, a radiologist, blinded to CXR indication, reviewed all CXRs ordered over the winter of 2017 for infants with bronchiolitis. Results A CXR was ordered for 439 (11.2%) infants, most commonly to rule out consolidation and collapse (65%). CXRs were more likely to be ordered for admitted infants (40.9% admitted to the general medical ward), and 62% were ordered by emergency department staff. Salbutamol was prescribed for 9.3% (n = 199). Amongst those who had a CXR, 28% were prescribed an antibiotic compared to 2.1% for those who did not. In an audit of 98 CXRs ordered over the winter of 2017, there were no CXR findings that meaningfully affected patient outcomes. Conclusion Using electronic medical record data, we found that CXR and medication use in bronchiolitis were higher than expected given our hospital guideline advice. Future research needs to understand why and develop interventions to reduce LVC.

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Aim To evaluate changes in in‐hospital mortality rate following implementation of a comprehensive electronic medical record (EMR) system. Methods Before and after study of 355,709 hospital discharges, over an 8‐year period, at a paediatric teaching hospital. The major outcome measures were crude number of in‐hospital deaths, deaths per 1000 discharges, and standardised mortality ratio. Results Primary analysis of data from 2 years before and 2 years after EMR go‐live showed a reduction in absolute mortality of 33 deaths, a reduction in the mortality rate of 0.48 per 1000 discharges (95% CI 0.09, 0.88 per 1000): and a relative 22% decrease (95% CI: 4%, 36%, P = 0.02) in deaths per 1000 discharges from 2.20 to 1.72. There was also a reduction in standardised mortality ratio of 47% (95% CI: 18%, 66%, P = 0.004). Post‐hoc analysis of mortality rates for an additional 2‐year pre‐intervention period indicated that these changes in the mortality rate were not part of a pre‐existing downward trend. Further analysis of an additional 20‐month post‐intervention period suggests that the reduced mortality rate has been sustained. Conclusion We documented evidence of a clinically important decrease in in‐hospital mortality rate following the implementation of a modern comprehensive EMR system in an Australian paediatric teaching hospital. The study does not prove a causal relationship, and it is possible that other factors explain some, or all, of this difference, but no changes in the hospital population or other major interventions were identified as alternative explanations for this observed change.