Context This project looked at management of Paediatric Community Acquired Pneumonia (CAP) within a District General Hospital and how the Paediatric Team could improve this.
Problem The British Thoracic Society (BTS) produced guidance in 2011 as to the management of Community Acquired Pneumonia.
Within our hospital it was noted that there was variation in management of CAP, both in terms of its investigation and treatment.
This project aimed to improve the management of CAP using the BTS Guidance as the gold standard.
Assessment of problem and analysis of its causes Initial assessment involved audit of investigation and treatment of CAP.
Investigation The BTS suggests “Chest radiography (CXR) should not be considered a routine investigation” and that “acute phase reactants (C Reactive Protein (CRP), White blood cell count (WCC)) … should not be tested routinely.” It also states that “Microbiological diagnosis should be attempted in children with severe pneumonia sufficient to require paediatric intensive care admission, or those with complications of CAP.” It should “not be considered routinely in those with milder disease.”
With reference to this the audit found that, like hospitals throughout the UK, we were over investigating.
In children with CAP seen between 1 November 2012–31 January 2013 we found:
59% had a blood culture (national 51%)
73% had a WCC (national 63%)
71% had a CRP (national 62%)
98% had a CXR (national 90% (in year 2011/12))
Treatment The BTS suggests “Antibiotics administered orally are safe and effective for children presenting with even severe CAP” provided they can tolerate oral fluids, absorb oral antibiotics and do not have evidence of septicaemia or complicated pneumonia.
Yet despite these rather strict criteria we gave IV antibiotics (IVABx) to 63% of children with CAP despite only 39% requiring IV fluids.
A key issue identified in both investigation and treatment was differences in practice between clinicians.
Intervention A new Guideline was written for the management of CAP within the Trust. This was in line with the BTS National Guidance with particular emphasis on investigation and antibiotic treatment.
Strategy for change Presentations were made to both Trainee and Consultant Paediatricians with emphasis on the audit results and the new Guideline. The evidence for when investigation is needed and when it is appropriate to give oral antibiotics was discussed.
The new Guideline was uploaded to the Trust’s intranet.
Measurement of improvement Management of CAP was re-audited approximately six months after the implementation of the new Guideline.
Effects of changes Improvements were seen across all areas.
Investigation In children with CAP seen in December 2013 we found:
18% had a Blood culture (59% in previous year)
29% had a WCC (73% in previous year)
29% had a CRP (71% in previous year)
76% had a CXR (98% in previous year)
Treatment IV Antibiotic use fell to 24% (from 63%) and IV fluid use to 12% (from 39%).
All this suggests the Trust is now managing CAP considerably closer to the BTS Guidance.
Also with decreased investigation and IV treatment, the cost of CAP to the Trust should be reduced.
Lessons learnt This project has shown how an audit cycle can bring positive change both for improved patient care and in terms of financial savings for the Trust.
Next time it would be helpful to look more closely at quantifying these financial savings.
Message for others There are two key messages:
The first is that Health Professionals need to know why a change is being made. Here the combination of discussing the audit and the evidence behind the Guideline was key to changing practice.
The second is that despite national guidance being available it needs to be brought to people’s attention for a change to be effected.
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