Purpose The management of empyema thoracis in children is controversial. Simple effusions can be managed conservatively or with a drain. Complex, empyema with a thick rind/solid components typically requires video assisted thoracoscopic surgery (VATS). However, for loculated effusions there is debate regarding the use of a chest drain with fibrinolysis (CDF) versus VATS. In 2019 in our centre, a protocol was implemented with a focus on increased, standardised use of CDF. The purpose of this study was to assess outcomes for patients post implementation of this protocol. Methodology Retrospective review of all 53 children admitted to the paediatric intensive care unit (PICU) from January 2019 to September 2023 with a diagnosis of empyema. Results Fifty-three children with a mean age of 4.5 years (range 3 months to 16 years) were admitted to PICU with thoracic empyema. Aboriginal and Torres Strait Islander children were over-represented making up 38% (compared to 9% of the North Queensland population). From 2019 to 2023 there has been a progressive decline in the number of children undergoing VATS. From 2019-2021 n=19/34 and 2022-2023 only n=1/19 underwent operative intervention. This has been associated with a significant increase in the number of children managed with CDF. N=25/27 children were successfully managed with CDF and n=2/27 required subsequent operative management. There was no significant difference in the complication rate in children who underwent VATS versus CDF. Conclusion Implementation of an empyema protocol has been associated with a significant reduction in VATS and subsequent increase in use of CDF. CDF was associated with a high success rate and minimal complications.