Objectives Our group has previously shown in a study presented at the Preventing Overdiagnosis 2018 conference (DOI: 10.1136/bmjebm-2018-111070.47) that lower respiratory tract infections (LRTIs) in paediatric patients are not only over diagnosed, but also over and inappropriately investigated and treated. The next stage of our projected, presented here, focuses on:

1. Understanding the factors driving this overdiagnosis to prevent unnecessary investigations, notably Chest X–rays (CXRs) and blood tests, and reduce inappropriate antibiotic use

2. Applying lessons learnt using a Plan, Do, Study, Act (PDSA) cycle prior to fully implementing a change of practice and re–auditing

Method A mixed quantitative-qualitative analysis was conducted involving Paediatric departments across South East England involving multidisciplinary team (MDT) members. Using triangulation, data was collected using the following methods:

1. Questionnaires (sent out via SurveyMonkey) to assess use of investigations and antibiotic prescribing practices of doctors in cases of suspected LRTI, and adherence to local and national guidelines

2. Multiple focus groups including staff from Paediatrics, Accident and Emergency (A&E), Microbiology, and Pharmacy departments to consider factors driving overdiagnosis and over management, as well as to identify barriers and facilitators in preventing overdiagnosis

3. Further focus groups to gather views on the full range of proposed interventions

4. Re–audit of local sepsis pathway following changes made based on focus group discussions

Focus group data was analysed using Framework analysis to identify common themes.

Results Preliminary data gathered from questionnaires suggest that doctors are more likely to follow local guidelines for the management of LRTI, but that not every hospital has these. Over half of clinicians reported they would order blood tests in a child with suspected LRTI, and some would order CXRs. The majority of survey respondents said they would rely on a CRP result to decide if antibiotics are required, particularly intravenous (IV) antibiotics, and almost half would sometimes prescribe antibiotics if a parent or patient insists on it. Following the focus group discussions, the local sepsis pathway was identified as being ‘over-sensitive’, and thought to result in the over treatment of children with IV antibiotics. The pathway was therefore modified and audit data from before and after these changes will be presented. Other perceived barriers and facilitators to preventing overdiagnosis which emerged from the thematic analysis will also be presented.

Conclusions This quantitative-qualitative analysis has highlighted some of the factors driving the overdiagnosis and over management of LRTIs in children. Findings suggest that faster availability of infection marker results, better clinical guidelines, regular antibiotic prescription audits, and educational sessions involving senior staff who influence junior prescribing habits would be useful in guiding management of suspected LRTI in children. As a result, the following interventions are being considered: 1) Auditing local sepsis tools and changes to current pathways 2) Discouraging unnecessary investigations by using posters in doctors’ offices, paediatric assessment units and A&E 3) Updating local guidelines to reflect national ones 4) Encouraging nurses to decline ordering CXRs if patients have not been assessed by doctors 5) Educational sessions on investigation and antibiotic choices We hope that implementing these changes will results in fewer unnecessary investigations and help promote better antimicrobial stewardship. We plan to fully re-audit at a future date.