SLO 5 – Care for children of all ages in the ED, at all stages of development and children with complex needs

This Speciality Learning Outcome covers paediatric emergency medicine. It includes the fundamentals of evaluation, investigation, decision making, safeguarding, resuscitation and caring for families and loved ones of children attending the ED.

Domain 1: Professional values and behaviours

Domain 2: Professional skills

– practical skills
– communication and interpersonal skills
– dealing with complexity and uncertainty
– clinical skills (history taking, diagnosis and medical management; consent; humane interventions; prescribing medicines safely; using medical devices safely; infection control and communicable disease)

Domain 3: Professional knowledge

– professional requirements
– national legislation
– the health service and healthcare systems in the four countries

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and team-working

Domain 7: Capabilities in safeguarding vulnerable groups

Key EM capabilities

At completion of Intermediate training a trainee will:

  • Be able to gather appropriate information, perform a relevant clinical examination and be able to formulate and communicate a management plan that prioritises the child and where relevant the family’s choices that is in their best interests.
  • Be able to identify the sick child and initiate appropriate management steps
  • Acquire the special skills needed to resuscitate children of all ages, and know that this may differ dependent on developmental age and know how this differs from adult resuscitation
  • Assess children and young people with concerning presentations and know that some of the presenting symptoms could be manifestations of abuse

with Supervisor ‘on call’ from home for queries, able to provide directions via phone and able to attend the bedside if required to provide direct supervision

At completion of higher training a trainee will:

  • Be expert in assessing and managing all children and young adult patients attending the ED. These capabilities will apply to patients attending with both physical and psychological ill health and include concerning presentations that could be manifestations of abuse
  • Be able to lead a multidisciplinary paediatric resuscitation including trauma
  • Be able to assess and formulate a management plan for children and young adults who present with complex medical and social needs

and would be able to manage with no supervisor involvement

Clinical assessment

  • Able to interact with children of different stages of development and their families to elicit the history
  • Able to undertake a careful, sensitive and flexible examination of children of all ages, at different stages of development and with complex needs
  • Aware of the different developmental stages of children and their assessment and how injury and illness can affect this
  • Understand the impact of learning disability and chronic complex health needs on acute presentations
  • Aware of behavioural and developmental issues and learning disabilities in childhood may impact presentations and clinical assessment in the ED, including infection and NAI.
  • Can engage children appropriately in their own decisions and protects the best interests of the child at all times.

Medical, Surgical and Trauma

  • Aware that paediatric life-threatening emergencies are infrequent and therefore prior preparation is essential i.e. successful completion of APLS or equivalent is needed
  • Able to lead a team debrief following a paediatric resuscitation/trauma
  • Acquire the special skills needed to manage the paediatric patient– e.g. airway management, vascular access
  • Know that paediatric trauma is different to adult trauma and be able to apply those differences clinically
  • Know that the interpretation of vital signs and tests is age dependent e.g. ECG, radiology, bloods
  • Be able to safely and appropriately arrange tests such as radiology and blood tests, considering factors such as the ALARA principle and the trauma of unnecessary blood tests 
  • Be able to prescribe safely for children
  • Know when to utilize distraction techniques and play therapists to manage children in the ED
  • able to identify those patients needing urgent specialist attention and know when and how to refer
  • Have an understanding of which patients can be safely discharged home and what follow-up they may need
  • Able to liaise with Paediatric Critical Care Retrieval Services and plan for a time critical transfer
  • Know the local procedure for sudden unexpected death in infants and children (SUDIC)

General

  • Know the immunisation schedules
  • Have a basic understanding of common problems e.g. toddler tantrums, food refusal

Mental Health

  • Have an awareness of the effect of bullying, truancy, and work pressure upon children
  • Understands consent, capacity to take decisions, and confidentiality in relation to children, respects the ethical and legal framework relating to children in the ED and is aware of the issues of parental responsibility
  • Know self-harm in children and adolescents as an expression of distress.
  • Calculate risk stratification score for those with suicidal ideation and refer appropriately.
  • Know how to manage the adolescent refusing treatment for a life – threatening overdose.
  • aware of the presentations of mental illness in childhood including depression, anxiety, OCD, bipolar and schizophrenia
  • Know how to refer to the Child and Adolescent Mental Health Service team.

Safeguarding

  • Knows and understands the ways in which children may present with physical, sexual, emotional abuse and neglect.
  • Know which infants are most at risk
  • Aware of the stresses to the family and the increased risk of NAI, neglect and DV
  • Reliably pick up clues which should give rise to concern
  • Able to recognize patterns of injury or illness which might suggest NAI.
  • Reliably document concerns, conversations with other professionals, and detailed descriptions of history or examination findings as appropriate.
  • Understand the importance of seeking help from experienced colleagues in the assessment of children with possible NAI.
  • Understand the ways in which children might reveal sexual abuse.
  • Understand and recognise the signs and symptoms of sexual abuse.
  • Able to talk with parents and inform them that a social services referral is being made
  • Able to initiate safeguarding children procedures including sexual abuse as per local policy.
  • Know the relevant national documents which underpin the safeguarding children policy in the emergency setting
  • Understand the roles of other systems in protecting children, e.g. Social Services, the Child Protection Plan, Police Child Protection and Domestic Violence Units, SureStart, Childline, Health Visitors, School Nurses, Area safeguarding children Committee, Community Paediatricians
  • 6 months in PEM in intermediate training
  • Completing APLS/EPALS (Optional Neonatal Life Support)
  • Completing Spotting The Sick Child Online Module (In Core when this includes care of children)
  • Completion of Safeguarding Level  1 – 3
  • Relevant RCEM Learning/FOAM modules content
  • In situ sim of PEM resuscitation scenarios
  • Simulation suite feedback of paediatric resuscitation team leadership/ human factors

There is no requirement to record feedback on the care of children in ACCS. Trainees may wish to do so if they provide care for children as part of their time in EM.

Evidence to inform decisions include:

  • Assessment of simulated practice
  • CbD
  • ESLE
  • FEG
  • Mini-CEX
  • MSF
  • RCEM App

During 6 month placement trainees will be expected to seek feedback on patients across the full range of ages and include those with illness, injury and psychosocial presentations. Trainees will be expected to be observed in the resuscitation room and to reflect on receive feedback received about their assessment and management of children there. Trainees are required to record a formative WPBA on a concerning presentation and reflect on the feedback received. There are no absolute numbers required, but is expected trainees need to be observed in some aspect of PEM care on most shifts in their time in PEM.

Evidence to inform decisions include:

  • Assessment of simulated practice
  • CbD
  • ESLE
  • FEG
  • Mini-CEX
  • MSF
  • RCEM App

In HST formative assessment will be appropriate in challenging or complex cases. This will include resucitation cases, and HST trainees are expected to receive feedback on their leadership of paediatric resuscitation cases. Feedback on the assessment and management of concerning presentations is also required.

Evidence to inform decisions include:

  • Assessment of simulated practice
  • CbD
  • ESLE
  • FEG
  • Mini-CEX
  • MSF
  • RCEM App

Entrustment Decisions

End of core training

There is no requirement for an entrustment decision in ACCS. EM trainees may choose to work towards this point by seeking formative feedback in this SLO.

End of intermediate training Level 3

  • A trainee will be entrusted to take a history from a child and their parents, examine children of various ages and elicit key examination findings. They will construct an age appropriate differential diagnosis. Trainees at this point will be entrusted to identify spot the sick child and initiate age appropriate management steps.
  • They will be entrusted to assess a paediatric patient with concerning presentations and refer to social services and inform parents of this referral when appropriate

End of HST Level 4:

At the end of training an EM specialist will be able to deliver the above. In addition they will be entrusted to lead paediatric resuscitation effectively in the ED, including trauma, through to disposal. They will also be able to support the resuscitation team and lead a debrief to enable others to learn.

RCEM examinations

MRCEM 
SBA
OSCE
FRCEM
SBA
MSO

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