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Preventing the overdiagnosis of chest sepsis in children: A quality improvement project
Rebecca Bradford-Duarte1, Valerie Milton2, Jillian McKenna3
1Medway NHS Foundation Trust, Medway Maritime Hospital, Gillingham, UK.
Insights
Many children are unnecessarily treated for chest sepsis, despite interventions. Further efforts are needed to change physician behavior and prevent overdiagnosis of pediatric respiratory infections.
Area of Science:
- Pediatric infectious diseases
- Antimicrobial stewardship
- Clinical quality improvement
Background:
- Respiratory infections are a leading cause of pediatric hospitalizations and sepsis.
- Viral infections are common, yet antibiotic overuse persists, exacerbating antimicrobial resistance.
- Urgent changes in antibiotic prescribing for children are necessary.
Purpose of the Study:
- To evaluate adherence to sepsis guidelines in diagnosing and treating pediatric 'chest sepsis'.
- To identify and implement measures to prevent unnecessary diagnosis and treatment of pediatric sepsis.
- To reduce antibiotic overuse in children with respiratory infections.
Main Methods:
- Baseline audit of pediatric sepsis diagnosis and treatment against National Institute of Clinical Excellence (NICE) guidelines.
- Surveys and focus groups with pediatric doctors to identify barriers and facilitators to preventing overdiagnosis.
- Implementation of interventions including a revised sepsis pathway and awareness campaigns.
Main Results:
- 61% of young children with likely viral infections received intravenous antibiotics.
- 77% had blood tests and 88% had chest X-rays, often not indicated.
- Despite interventions, re-audit showed no significant reduction in overdiagnosis or overtreatment.
Conclusions:
- Initial audits confirmed significant overdiagnosis, over-investigation, and overtreatment of pediatric sepsis.
- Multimodal interventions showed transient improvements but failed to achieve sustained change.
- Further interventions targeting physician behavior are required to address the overuse of antibiotics in pediatric respiratory infections.
Rationale:
Respiratory infections in children are one of the most common causes of hospital attendances and a common cause of sepsis. Most of these infections turn out to be viral in nature. However, the overuse of antibiotics is common and with increasing problems with antimicrobial resistance, changes to antibiotic prescribing practices need to be implemented urgently.
Aims And Objectives:
To test our hypothesis that a significant number of children and young people are diagnosed with and treated for 'chest sepsis' unnecessarily by evaluating adherence to British Thoracic Society and National Institute of Clinical Excellence sepsis guidelines, and to implement measures to prevent overdiagnosis.
Design:
A baseline audit undertaken, stratified patient risk as per NICE sepsis guidelines. Data were analysed to assess adherence to these guidelines following presentation of possible lower respiratory tract infection. Questionnaires were sent to Paediatric doctors in local hospitals and focus groups were held to qualitatively evaluate the barriers and facilitators to preventing overdiagnosis. These informed implemented measures.
Results:
The baseline audit showed 61% of children under two, who are more likely to have a viral chest infection were treated with intravenous antibiotics. Seventy-seven percent of children had blood tests and 88% had chest X-rays (CXRs) which are not routinely recommended. A total of 71% with a normal CXR had been treated with intravenous antibiotics. Barriers to preventing overdiagnosis included the over-sensitivity of the sepsis tool, anxiety and drug prescribing habits. Facilitators included visual cues and team work. Implemented changes including a revised sepsis pathway and raising awareness led to some positive changes. However, upon re-auditing there was no significant change in the number of children being overdiagnosed.
Conclusions:
Initial audit results supported our hypothesis that children were being overdiagnosed, over-investigated and over-treated. Despite multimodal interventions aimed at understanding the drivers underpinning these issues, the re-audit results mirrored the baseline audit despite a transient improvement following our campaign to raise awareness and further work to change physician behaviour is required.
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