Objectives The aim of this project was to test our clinical impression that a significant number of children and young people are diagnosed with and treated for ‘chest sepsis’ unnecessarily.
Our main objectives were thus:
To design a Quality Improvement Project to investigate whether we overdiagnose chest sepsis, over investigate children presenting with signs and symptoms of lower respiratory tract infection and over use IV antibiotics
To evaluate adherence to NICE sepsis and BTS guidelines
To suggest measures to implement to prevent over investigation and unnecessary use of antibiotics in children with chest infections
Method Our QIP used the PDSA (Plan, Do, Study, Act) cycle. Initially, an audit was undertaken within the Paediatric Department in our DGH. Initial data was collected retrospectively from May 2017 to January 2018. Patients were categorised by age and then stratified according to sepsis risk, as per NICE guidelines. The data were then analysed assessing adherence to both guidelines during clinical assessment and management following presentation with signs and symptoms of a LRTI.
Subsequently, we sent questionnaires to Paediatric doctors in local hospitals and held focus groups with our local multi-disciplinary team, in order to understand the barriers and facilitators to preventing overdiagnosis, which enabled us to put some changes in place to try and prevent further overdiagnosis. The implemented changes included posters for visual cues and changes to the local sepsis pathway. Following these changes, we re-audited the data from November 2019 to January 2020.
Results The initial results were presented in the 2018 conference in Copenhagen. Our questionnaire’s and focus groups revealed that barriers to overdiagnosis included the over-sensitivity of the sepsis tool, staff and parental anxiety, imaging for convenience and drug choices made due to habit. The facilitators for preventing overdiagnosis included visual cues and reminders, team work and being able to justify why a pathway wasn’t followed. The re-audit data included 215 patients with 76% being high risk for sepsis on presentation. A large number still had co-existing wheeze on presentation. 80% of patients had blood tests and 84% had a CXR. The majority of children were still treated with IV Ceftriaxone and the oral antibiotic of choice remained as Co-amoxiclav.
Conclusions First phase audit results supported the hypothesis that children presenting with signs and symptoms of a possible LRTI are overdiagnosed and over investigated. We implemented some changes within the Paediatric department to prevent unnecessary investigations, notably CXRs and blood tests and to reduce unnecessary antibiotic use that comes with long term risks for the wider population including posters for visual reminders and changes to the local sepsis pathway. The positive changes included the number of children who were high risk for sepsis receiving their first dose of antibiotic within an hour and improved numbers having a lactate level checked. Unfortunately, there were still a large number of children with wheeze being treated as chest sepsis and the numbers were not significantly different for those who had blood tests or received IV antibiotics.
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