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Aims To measure the safety, quality and cost-effectiveness of a child and adolescent mental health service (CAMHS) embedded in a paediatric emergency department (PED). Methods A prospective interventional study. Children and young persons (CYP) aged up to 16 years presenting to the PED with a psychiatric emergency during Monday to Friday between the hours of 0800 to 2300 were assessed by a CAMHS clinician based in the department over a 3 month period. Admission, discharge and breach rates were recorded. Qualitative measures on satisfaction were also obtained through the use of a self-reporting questionnaire issued to the CYP and their carer. Staff satisfaction was also obtained through a web-based survey. Results A total of 103 CYP attended during the 3 month period. 49 (47%) presented during the hours of intervention and 41 (84%) of these were assessed by the PED CAMHS service. 34 (83%) assessed by the service were deemed safe for discharge with appropriate follow up plan, and 7 (17%) were admitted to the paediatric ward for further psychiatric assessment. The PED CAMHS service had a 4 hour breach rate of 20%. CYP presenting outside of intervention hours were admitted for CAMHS assessment as per existing pathway. CYP, carer and staff satisfaction was overwhelmingly positive. 96% of CYP reported that they were happy with the service with an overall satisfaction rating by CYP and their carers of 4.45/5 (89%). PED staff reported that they saved 10 hours per shift and 3 hours per patient due to the presence of the embedded service. Cost analysis demonstrated a saving of £12 920 through the avoidance of admissions. There were no serious untoward incidents. Conclusions CYP presenting to PED with acute psychiatric conditions requiring urgent mental health assessments are increasing. This intervention provides evidence to suggest that such a service could be safe and cost effective. The intervention improved the quality of service that CYP and their carers experienced with timely assessments and interventions. Establishing a comprehensive service within PED may reduce the disparity between physical and mental health provision for CYP in psychiatric crisis in addition to improving their long term outcomes.

Background A&E is a critical entry point for crisis-based health visits with 1 in 6 presentations resulting from injuries, and 1 in 3 abused children presenting with fractures. The role of A&E personnel is therefore crucially impportant in identifying and initiating safeguarding measures. Aims To analyse the incidence of fractures in children presenting to A&E with any fracture and identify those with suspected non-accidental injury (NAI). To identify whether appropriate safeguarding measures had been followed and identify potential barriers if not. To provide recommendations to improve safeguarding procedures. Methods This analysis took the form of a re-audit of all children under the age of 3 years with an A&E discharge diagnosis of any fracture. Electronic case notes were reviewed along with the minutes of weekly psychosocial safeguarding meetings to ensure that all suspected cases of NAI were identified and analysed. Results of the initial audit carried out over a 6 month period in 2009 were compared to the same 6 month interval in 2014. Standards of safeguarding procedures were taken from Benger and Pearce (2002). Following initial audit, safeguarding procedures and education were improved with casualty card checklists and all infants being seen directly by paediatric speciality. A re-audit was undertaken to ascertain whether further improvement was necessary. Results In 2009, 73 cases were reviewed with an incidence of suspected NAI of 1.3%. No fractures identified in children under 9 months were referred for further paediatric opinion, and there was limited documentation of consideration of NAI. In 2014, 56 cases were identified. The safeguarding checklist was used in 57%, delay in presentation was documented in 9% and inconsistent history in 14%. 28% of cases were discussed with the paediatric team and 12.5% discussed directly with social services. 80% of fractures identified in under 9 month old children were referred for further safeguarding assessment with social services. Although further multidisciplinary follow up was carried out, no cases of NAI were identified. Conclusions Whilst there has been improvement in documentation of safeguarding consideration and onward referral through safegarding pathways, documentation is still limited in some cases. Following presentation of these results, funding for an additional liaison health visitor was secured to review all case notes.

The populations of most resource-poor countries live in remote rural areas far from hospitals where presentations are to health centres with limited facilities without doctors and often without health officers; however, the majority of research in such countries has focused on validating triage tools within hospital settings. Simple effective triage is particularly important where primary healthcare is limited or non-functional but validated triage tools have not included health promotion or extended programme immunisation (EPI) screening. Implementation of a multi-faceted triage system incorporating both EPI screening and health promotion was assessed in Southern Ethiopia. Over two months all children under 5 presenting to a Medecins Sans Frontieres supported health centre in Chire in the rural highlands of Southern Ethiopia were triaged using the South African Triage Scale (SATS) by nurse supervisor. Prior training was given on recognising the sick child, SATS triage, EPI schedule and focused health education. Patients were triaged and either treated directly by triage nurse or sent to OPD for health officer/OPD nurse consultation. In addition, all children including siblings were screened for vaccine eligibility as per EPI schedule and offered this. Common illness health promotion (diarrhoea and dehydration management, malnutrition, pneumonia, and vaccinations) ran alongside with health educator. Data was recorded for total number presenting to health centre, number OPD consultations, mortality and hospital referral rates, and number receiving EPI. From May to June 2013, there was reduction in total number presentations from 1342 to 1170 (87%). Of those presenting, 723 (62%) were referred for OPD consultation. Top morbidities were respiratory infection 29%, skin diseases 22%, and diarrhoeal diseases 12%. Mortality rose from 1 case (0.07%) to 3 (0.26%) although more critical cases presented within rainy season. Hospital referrals reduced from 2 cases (0.15%) to 1 (0.09%). EPI uptake improved with oral Polio (124%) and Penta (170%). The results of this intervention demonstrate that SATS triage system can be used safely and effectively in rural settings reducing high consultation numbers. Integrating immunisation screening significantly increased EPI uptake. Longer follow up would allow for more careful analysis of the effect of health promotion on disease presentation and mortality.