Overall, 26 clinicians (20 GPs and six practice nurses) were interviewed from 24 practices (range of one to two clinicians per practice) and 13 CCGs (Table 1). Ten clinicians (eight GPs and two practice nurses) were interviewed from eight practices during the pilot phase. Findings are presented for each of the NPT constructs, illustrated with anonymised quotations (pilot interview quotations are indicated).
Collective action (using CHICO in practice)
Most clinicians liked the intervention and used it as a supportive aid in consultations. It was a way of reassuring themselves and carers of the appropriateness of treatment decisions:
‘It’s very reassuring for the professional and, of course, when you’ve printed out the leaflet that is the scoring we have done; it is very reassuring for parents as well.’
(GP 16)
Launching CHICO
During the pilot phase, clinicians were reminded to use the intervention via an electronic patient record system ‘pop-up’, which was triggered for all children under the age of 10 at the start of the consultation. Following feedback, this was modified for the main trial, with clinicians having the choice of the early pop-up or of launching it later in the consultation when typing in ‘cough’. In the main trial, some practices retained the pop-up to help remind clinicians to use the intervention:
‘It seems the hard pop-up was useful, but it comes up too early. So, it comes up before you know what’s actually wrong with the child.’
(Nurse 8, pilot)
‘We’ve kept the automatic launch on, even though it is a bit annoying … We thought the best way to try and get people to use it and remember it for the whole year was to keep it as automated.’
(GP 13)
Prognostic algorithm
Most clinicians liked the signs and symptoms template, which they found easy to use without adding any more time to consultations:
‘I think that’s quite straightforward … I thought it was good, it was easy to use.’
(Nurse 6, pilot)
However, some clinicians felt the template did not capture all the required information, meaning that they needed to make additional entries in the patient’s record or ‘moving between two screens’ (GP 11), which could be problematic:
‘I found I either use the template and then probably it was a bit sketchy history, or I had to then go into the patient’s note or save the template, and then do a history or presenting complaints, and I found that made it a bit more disjointed.’
(GP 19)
Clinicians liked that the template helped to elicit carer concerns, which were important but could easily be forgotten:
‘I suppose I wouldn’t necessarily ask “what are you particularly worried about?” directly.’
(Nurse 17)
The usefulness of the prognostic algorithm depended on the severity of the child’s symptoms. It was most useful with children who were ‘borderline’ cases for hospitalisation or prescribing antibiotics:
‘I personally would [have] used it [prognostic algorithm] more for the borderline ones.’
(GP 14)
Letter/advice leaflet
The carer advice leaflet was reported to be the most useful intervention component and clinicians liked it as a ‘good safety netting tool’ (GP 19), a way of facilitating conversations with carers, and reinforcing the clinician’s decision not to prescribe antibiotics:
‘That [advice leaflet] was quite helpful to feel you give the parents a little bit more understanding and information of what they’re looking out for before perhaps they worry or to help reduce their anxiety over their children’s coughs.’
(Nurse 6, pilot)
‘So, if there was a feeling that it was going to be a difficult consultation to try and steer them [parents] away from antibiotics based on the clinical assessment, then that would be a really good adjunct tool for that.’
(GP 25)
GPs and nurses felt that carers were more satisfied with being given a leaflet that explained the clinician’s decision and having information they could take away with them:
‘I think that it makes patients feel more satisfied that they’re not going away empty handed. They’ve been given something, and I feel kind of what I’ve said to them had been enhanced by going away with a leaflet.’
(GP 11)
Nurses found being able to give the carers the leaflet particularly useful, as they felt they faced increased scrutiny and pushback from carers if they did not prescribe antibiotics:
‘What we find quite often as an ANP [advanced nurse practitioner] is, if we refuse them antibiotics, then they go and make an appointment with the doctor and get antibiotics. So, you know, you’re always aware in the back of your mind that that kind of thing is going to rumble on … they’ll just go and keep seeing people until they get what they want … I would say that it gave us that extra back-up to say no.’
(Nurse 24)
As with the prognostic algorithm, the advice leaflet was seen to be more useful for children considered to be ‘borderline’ for hospitalisation or prescribing antibiotics:
‘Especially when there is a borderline whether to go to the hospital or not and the score is a bit on the lesser side and parents are not keen to go to the hospital and at that time, this has particularly helped. The leaflet you’re giving them the clear-cut advice of when to go and when to seek advice.’
(GP 23)
Challenges with CHICO in practice
Several challenges were highlighted that led to reduced use of the intervention or selective use of some of its components. Clinicians reported difficulties aligning the intervention with their usual consultation practice. The use of the algorithm to support decision making and providing carers with the letter and advice leaflet required clinicians to engage with the computer and patient record throughout the consultation. However, some would usually complete the record at the end of the consultation or after the patient had left as they liked to focus on the patient during the consultation. This led some clinicians to stop using the intervention; however, in some cases, clinicians did provide carers with pre-printed non-personalised advice leaflets:
‘I do my typing up at the end of the consultation so it [intervention] doesn’t alter my thought processes, “am I going to prescribe them antibiotics or not?” I have already made that decision from taking the history and doing the examination … It doesn’t actually give you the scoring until you click ‘save’ so that pop-up comes right up right at the end.’
(GP 3, pilot)
‘Most of us find that it gets in the way of our consultation and so, therefore, we don’t use it, but we like the leaflet, and we give that out.’
(GP 11)
‘Unfortunately, the leaflet thing probably got a little bit overlooked because you do the whole template, finish the consultation with the patient and then they would go and then you’d finish writing up your notes … and then up comes the “would you like to print a leaflet?” and it’s “oh, I’ve forgotten to do that”.’
(Nurse 17)
Some practices conducted their consultations remotely, which meant assessing the clinical symptoms required for the prognostic algorithm was challenging. This was more of an issue with telephone consultations because some symptoms could still be assessed using video where the child could still be seen and heard:
‘Can assess using video, can see the child … breathlessness, wheezing.’
(GP 18)
‘We do a lot of video consultations as well, then you can see whether the child’s running around and what they’re doing, so yes it could easily be adapted I would have thought.’
(Nurse 20)
It was also difficult to provide carers with personalised printed leaflets in some practices, either because of the remote consultation or because of printing issues. However, some clinicians had found ways around this, including using non-personalised pre-printed versions of the leaflet provided by the study team, saving a pdf version that could then be printed off without using the intervention, and emailing or texting the leaflets to carers:
‘Often, I would just give them a nice … they were very attractive leaflets and a bit more striking than the black and white paper printout.’
(GP 19)
‘We’ve started to email the leaflet to patients … using a text messaging service … So, we have used the leaflets via telephone consultation as well, so you can do that so that bit is good.’
(GP 22)
Frequency of use
How often clinicians used the CHICO intervention was variable, with some reporting frequent use early on, but reduced use over time. This could depend on clinicians remembering to use it, how busy the practice was, and increased familiarity with the algorithm outcomes:
‘In the latter months we sometimes would forget to do the CHICO template … The more you use it, the more you get used to it, and you get a feel of what the score might be and what the outcome might be.’
(GP 14)
Perceived impact on prescribing behaviour
Some clinicians believed the intervention influenced their prescribing behaviour. However, others believed that it supported rather than changed their prescribing decisions, and did not change their behaviour:
‘I’m not sure it massively did [affect prescribing]. Perhaps not directly I would say … We probably went on the history and the physical examination.’
(Nurse 17)
‘The main thing we used it for was safety netting and we do that anyway, so it’s really just enhancing. Not like we’re saying “okay, we are going to ignore everything in front of us because CHICO is telling us to do this”. It really just fits in with what we do anyway.’
(GP 11)
Use during the COVID-19 pandemic
Changes in practice pathways, such as increased use of remote consultations and nurse triaging, and the use of COVID-19 protocols, led to reduced use of the CHICO intervention during the pandemic. Anyone presenting with a cough was assessed for potential COVID-19 infection and referred for a COVID-19 test:
‘COVID took over, I think that completely took over … and also cough just took on a whole new meaning.’
(Nurse 17)
The need to conduct consultations in restricted spaces with no computers meant that clinicians were unable to use the CHICO prognostic algorithm and they could not print out the personalised letters or use pre-printed leaflets:
‘The problem was that we were seeing patients with coughs and temperatures in a red room. So, we’d cleared everything from that clinical room … so we didn’t have the leaflets readily available and also we weren’t logging onto that computer … so, I don’t think we’d probably used it quite as much during COVID.’
(GP 19)
‘Part of the reason that we wouldn’t use it during COVID is that we’re seeing our patients … outside in the car park, so we don’t have our computer in front of us.’
(GP 15)
The increased use of remote consultations during the COVID-19 pandemic further highlighted the challenges discussed. However, having used the intervention during remote consultations during this period, clinicians did perceive some benefits to using it remotely, including less need to focus on a face-to-face consultation:
‘It fits more naturally with remote working because it’s easier to get whatever you need on the [computer] screen, and you’re not worried about eye contact and body language.’
(GP 25)
There were also fewer children presenting with respiratory illnesses, which reduced the opportunity to use the CHICO intervention during the pandemic:
‘We get a lot of virally coughs and colds and things in children but since lockdown and since COVID, there’s been hardly any and I suppose that’s because people aren’t going out and they’re not going to nurseries are they, and they’re not picking it up … we haven’t hardly any children in now.’
(Nurse 20)
Reflexive monitoring (appraisal of CHICO)
When appraising the CHICO intervention and making recommendations for future implementation, participants suggested expanding the template to encompass more information (for example, ‘physical examination findings like heart rate, respiratory rate’ [GP 13]). This could help overcome issues with having to record information in multiple places and switching screens:
‘I think if you’re filling in a template, especially when we’re busy in the winter, it would be good if we could record all the information in that template and then not have to go back into the notes to record things that we think is important to record.’
(GP 19)
Clinicians also recommended adapting the intervention to be more conducive to remote consultations. This could include informing carers about how to assess symptoms and having carer-reported criteria rather than having the clinician-assessed criteria. However, some clinicians worried about relying on carer-reported symptoms because these could be less accurate:
‘I think the tool is little bit reliant on the clinical aspect as well, which you may not have, so it’s difficult to judge on chest signs and symptoms, and respiratory distress, and that sort of thing, wheeze, based on a conversation with a parent, and even temperature. They may not have a temperature probe so you may not be able to get particular aspects of it but then some bits you will be able to get. But if it can be tweaked to amend for things that may not happen on remote working then that may obviously help.’
(GP 25)
Some participants valued the CHICO intervention and said they would use it in the future:
‘I would have no problem with starting to use it again now because I feel you know, now we’re gonna start getting back to normal and coughs will just be coughs and colds, and it would be really useful to have that back again.’
(Nurse 24)
