Welcome to Respiratory Futures, Dr Julian Legg. We are keen to hear more about the publication of the BTS Paediatric Pneumonia Quality Improvement Toolkit. How did this project come about?
The BTS first published guidelines for Paediatric Community Acquired Pneumonia in 2002 and these were subsequently updated in 2011. Running in parallel, the BTS has run frequent national audits since 2002. In 2017, an audit was performed for the fifth time and was the most comprehensive to date with over 7000 individual patients from 144 institutions included.
Collecting data of this kind is particularly useful as it allows a snapshot view of current provision for paediatric pneumonia and helps us to identify trends over time. We were interested in assessing aspects of care that were working well, as well as those areas with identifiable deficiencies. Analysis of this large data set has enabled us to design a quality improvement (QI) toolkit which we hope will help institutions plan and implement a robust QI programme.
Analysis of the large data set revealed that, whilst there had been improvements in many areas between audit periods, there was still a significant number of children that had unnecessary investigations and management that were not indicated by national guidelines.
Who was involved in developing the toolkit?
The toolkit was put together by a small committee chaired by myself. The committee members were Malcolm Brodlie and Matthew Thomas (both respiratory paediatricians from the Great North Children’s Hospital in Newcastle), Catherine Crocker (a respiratory specialist nurse from Southampton Children’s Hospital) and Rahul Chodhari (a consultant paediatrician from the Royal Free Hospital in London). We also consulted widely amongst healthcare professionals in the community and within emergency and paediatric hospital departments.
You mentioned the BTS Pneumonia Guideline, but is other national guidance relevant too?
During our analysis of the 2017 BTS audit, it became rapidly evident that the investigation and management of children with pneumonia is directed by both the BTS guideline and the National Insitute for Health and Care Excellence 2016 sepsis guideline (NICE, 2016). The NICE guideline provides clinicians with an evidence-based approach to both identify and begin treatment for suspected sepsis. We were very aware that any improvement objectives we published in the toolkit should address the significant overlap between the BTS and NICE guidelines, while also recognising local pathways that may exist for treating sepsis.
24%
children given antibiotics prior to attending hospital
BTS National Audit 2017
What were the key findings from the BTS national audit which underpin the resource?
The key findings that we identified from the audit were:
- that 24% of children were given antibiotics prior to attending hospital and 60% of these children were given oral amoxicillin.
- that the most common organism identified was respiratory syncytial virus (36% of organisms).
- that there had been an overall reduction compared to previous audits in the number of blood investigations (45% in 2016/17 compared to 63% in 2012/13) and chest x-rays (73% in 2016/17 compared to 88% in 2012/13) that were performed.
- that, in comparison to previous audits, more children had been prescribed oral amoxicillin as first line treatment (33% of prescribed oral antibiotics in 2016/17 compared to 25% in 2012/13) and fewer children had been prescribed intravenous antibiotics (31% in 2016/17 compared to 51% in 2012/13)
Using the collected data, was it possible to identify areas of concern?
Absolutely. Analysis of the large data set revealed that, whilst there had been improvements in many areas between audit periods, there was still a significant number of children that had unnecessary investigations and management that were not indicated by national guidelines. The 4 principal areas identified were:
- Blood Investigations for CAP
Successive audits have found that many children undergo tests which are painful and potentially avoidable (45% of children had a blood test during the 2016/17 audit). The audit data demonstrated that these can be avoided in many cases though adherence to the BTS and NICE guidelines.
- CXRs for CAP
The most recent BTS audit data showed that 73% of patients underwent CXR, yet the BTS CAP guideline recommends that chest radiography should ‘not be considered a routine investigation’.
- Intravenous antibiotics for CAP
The BTS CAP guideline recommends that IV antibiotics should only be used “when the child is unable to tolerate oral fluids or absorb oral antibiotics (eg because of vomiting) or presents with signs of septicaemia or complicated pneumonia”.
Despite this recommendation almost one third of children included in the 2017 BTS paediatric CAP audit were treated with IV antibiotics.
- Hospital follow up after an admission for CAP
The BTS CAP guideline suggests that follow up is arranged for patients with severe pneumonia, complications (empyema or lung abscess), round pneumonia or collapse. The 2017 BTS audit found that 24% of patients had a hospital follow up after an admission with CAP despite specific indications being significantly lower (e.g. 1% of patients developed an empyema).
How did these findings translate into your final recommendations?
As a result of the audit’s findings, we were able to recommend 4 key national improvement objectives:
- children with community acquired pneumonia should not undergo blood investigations (e.g. white cell count or CRP) that are not indicated by either the BTS Community Acquired Pneumonia or NICE Sepsis Guidelines.
- children with community acquired pneumonia should not have a CXR performed where there is no clinical evidence of severe or complicated pneumonia.
- children with community acquired pneumonia who are able to tolerate oral fluids should not receive intravenous antibiotics where there is no evidence of septicaemia or complicated pneumonia.
- children with community acquired pneumonia should only have hospital follow-up where there is evidence of severe pneumonia, complications, round pneumonia or lung collapse.
Having identified key areas for improvement what were your next steps?
When putting together the QI toolkit, we felt that our overarching aim should be to try and put together a collection of easily accessible resources to try and enable busy clinicians to run a practical QI project, adhering to best practice, without having to start from scratch. Once the goals were set, we worked as a group to individually examine each improvement objective and provide tailored QI resources for each area.
One of the key drivers for this QI toolkit was to help clinicians direct scant resources to the areas that are most appropriate and of most benefit to patients.
There is an interesting theme in the toolkit around potentially reducing the number of investigations and procedures that are carried out.
That is true. One of the principal findings of the 2017 audit, was that children with CAP frequently had investigations and treatments that were not indicated by national guidelines. The large data set allowed us to identify those areas of management where there was significant divergence from the guidance. The areas for improvement that we identified (as mentioned previously) involved excessive investigations and treatment in 4 principal areas.
When putting together the QI toolkit, we felt that our overarching aim should be to try and put together a collection of easily accessible resources to try and enable busy clinicians to run a practical QI project, adhering to best practice, without having to start from scratch.
QI can be daunting, particularly if people have not been involved in similar projects previously. What advice would you give to get people started?
I think it is important to ensure any activity you plan is achievable, with clear measurable outputs. QI often starts with small, clearly defined steps rather than wide ranging department wide changes. It is vital that adequate resources and staff time are allocated to ensure the project can be completed, including evaluation. Appropriate leadership is key to establish and maintain the momentum.
I would also say that people should not be deterred if the first proposal they put forward to improve care does not go to plan. There are many reasons why a project may need to be adapted and reassessed and a project may not deliver results for many reasons, e.g. lack of communication with all involved.
The toolkit focusses people to think about several key principles:
- Process
- Demand, flow and capacity
- Choosing the tools to bring about change
- Evaluating the impact and measurement of change
A vital first step is the development of a process map of the patient pathway which, by providing a visual of the whole patient journey, will help to identify improvement opportunities.
Also, it’s important to make use of data that is already available to you. For example, data on demand and flow of patients is collected routinely by many hospitals so there is no need to replicate this.
What do you see as the main challenges for people embarking on a QI project?
Reducing investigations and treatment may initially be perceived negatively by colleagues and also patients and carers, but all patients should be treated in line with evidence-based recommendations. Communication is one of the main challenges and it’s essential that the project is outlined clearly at the outset to all those who may be affected. This will likely require multiple routes of communication including email, posters, departmental meetings etc. Having everyone on board with the project will undoubtedly maximise the chances of success.
What are your main hopes for the QI toolkit?
I am hopeful that the toolkit will prove a useful resource for those wishing to start a QI project. We are very keen to hear from people using the toolkit and how it has been implemented. Any feedback regarding its practical application will be essential to inform future iterations of the toolkit.
We're sure it will be most useful! Thanks very much for talking to us Julian.
The Paediatric Community Acquired Pneumonia Quality Improvement Tool can be found here on the BTS website.