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The benefits of involving patients and the public in medical education are well documented, however there is a need to further explore how this can be translated to the setting of paediatric medical education. This article aims to identify how organisations can facilitate the involvement of paediatric patients and their parents/carers.While involving children in research can present challenges, we describe examples where organisations have successfully involved young people in clinical research and selection of research topics.Involving paediatric patients and their parents/carers in medical education helps develop a patient centred approach to practice for medical students. Participation of paediatric patients in objective structured clinical examination (OSCE) examinations is employed by many medical schools, however allowing them the ability to provide a ‘global score’ may have the potential to assess skills such as communication and empathy in addition to medical knowledge.The Royal College of Paediatrics and Child Health (RCPCH) have provided a framework on how to involve children in health services, addressing practical considerations such as funding and facilities. This framework could be applied by organisations seeking to actively involve children in paediatric medical education. Potential barriers and facilitators are explored in this article.During the COVID-19 pandemic, involving young people and their families in medical student teaching became challenging. We describe virtual bedside teaching sessions which actively involved paediatric patients and their families, which showed that many patients and parents prefer virtual consultations.Involving paediatric patients and their families in medical education is strongly advocated by the General Medical Council (GMC) and RCPCH. Organisations should actively seek out opportunities to become involved in the development of medical education resources as we describe in this paper.

This presentation is from the CIVICA Research Open Science for the Social Sciences workshop on Introduction to Research Data Management and Data Management Plans. Dr Thomas Bourkeprovided participants with an overview on the following topics relating to the management of research data: Data discovery, input and quality control; Data protection and database copyright; Data generation, data processing and ethical use; Managing data during the research project cycle; Data management plans; Repositing and preserving data; and, ICT support and international guidelines.

AimThe early administration of antibiotics in sepsis reduces mortality and improves outcomes. This randomised control trial evaluated the effect of environmental priming (EP) on healthcare student performance in a simulated paediatric sepsis scenario.MethodsMedical and nursing students were randomised into primed and unprimed groups. Primed groups received both direct and virtual priming. Each group completed a standardised simulated sepsis scenario. Time to achieve five key clinical interventions was recorded. Mini focus groups were conducted to explore perceptions of EP.ResultsThere were 26 primed and 26 unprimed groups. The primed students were quicker to complete all five interventions and statistically significantly quicker to achieving intravenous (IV) access (median 350 s vs 373 s, p=0.02), administering IV antibiotics (median 648 s vs 760 s, p=0.045) and seeking senior help (median 703 s vs 780 s, p=0.02). Primed students did not feel that they had gained any specific advantage from being primed.ConclusionsEP can improve clinical performance. Implications for practice include incorporating EP of key clinical areas into local induction, standardisation of resuscitation areas and regular use of in situ simulation.

No examination of a child’s abdomen or gastrointestinal system is complete without an examination of the ’backside' or perineum, however there is often reluctance among paediatricians to perform this examination routinely. This article aims to describe how to use perineal examination in infants and children. It discusses the indications and stepwise approach to performing a per-rectal examination and interpretation of the findings one could expect to encounter. We include four cases encompassing the major conditions, both congenital and acquired, that paediatricians should be aware of and how they were managed in our institution.

Clinical bottom line As a newly appointed Education and Simulation Fellow in a tertiary paediatric hospital, I am interested in using simulation to provide paediatric resuscitation training to staff. I wondered how frequently staff should undergo resuscitation training to ensure optimum retention of cardiopulmonary resuscitation (CPR) skills. Should responders to paediatric arrests ( population ) receive resuscitation training ( intervention ) more frequently than national guidelines recommend ( comparator ) to ensure optimum retention of CPR skills ( outcome )? We searched PubMed using the terms: ‘(frequency OR frequent OR interval OR timing) AND (training OR train OR education OR programme) AND (resuscitation OR CPR OR cardiopulmonary resuscitation OR basic life support training OR chest compression) AND (skills retention OR retain)’. Searches were conducted in September 2020. PubMed yielded 159 results. Studies involving laypeople were excluded. We did not exclude studies that assessed CPR skills on adult manikins given the need for paediatric providers to respond to adolescent emergencies. Thirty-one papers were identified for abstract review and eleven papers underwent …

Background With the launch of the #ChoosePaediatrics Campaign, there is national recognition that recruitment and retention are the biggest issues facing the future of the Royal College of Paediatrics. There has been a 30% decline in applications and the drop-out rate is rapidly rising. Resultant rota gaps, poor work/life balance and burnout in a climate of political uncertainty and under-resourced workforce mean trainees feel underappreciated. Career opportunities are being forfeited to provide the high-quality service expected by the public. However, we too deserve the best! Life passes at such a pace, we find ourselves thinking....what if. As a pivotal part of RCPCH, trainees in Northern Ireland decided to host a careers fair. A fun day showcasing the resources and opportunities available, to prepare and improve our futures academically, physically and mentally. Aims To provide support for all trainees to facilitate a smoother transition through training. To showcase the available opportunities within paediatric training. To provide an enjoyable, networking opportunity for all paediatric affiliations within NI. Methods Designed as a ST1–8 regional teaching day. Recruitment of medical director, school tutors and senior trainees collaborating inspirational and informative discussions on leadership, curriculum, governance, careers and wellbeing. An afternoon funfair theme emulated via career’s stalls featuring paediatric subspecialties, district general hospitals, academia, NI library, BMA and RCPCH, principally creating an opportunity to network. Responses evaluated via online feedback Results NI’s inaugural career’s fair was a huge success. 70% of trainees attended, all rating it as excellent/very good. Highlights included; ‘better understanding of future opportunities’, ‘great networking environment’ and ’the ice-cream’. Further feedback included; ‘inspired to be proactive about my goals’ and a senior-trainee shared ‘I wish I’d attended this earlier’. Participation by trainers was almost 100%, viewed as ‘best thing we have done in years’. Suggested improvements were a larger venue and a two-day event. Conclusions A regional career’s day is an excellent opportunity to boost morale, tailor careers advice and network. It was an uplifting day, taking a step back from workload to promote paediatrics and all it has to offer. We are the future of the RCPCH.... #ChoosePaediatrics!!

Background Paramedics in Northern Ireland are expected to treat unwell children; perform life-saving interventions, in challenging surroundings with limited resources. Surprisingly, Northern Irish paramedic baseline paediatric education is minimal, and reliant on the ‘Joint Colleges Ambulance Liaison Committee Clinical Guidelines’ and personal experience to provide a solid foundation of knowledge. Furthermore, the Northern Ireland Ambulance Service (NIAS) does not offer subsidised study leave. Approached by a paramedic crew, provoked by a number of tough, emotive paediatric call-outs, we conceived, designed and facilitated a collaborative, bespoke paramedic paediatric study day. Aims To improve paramedic confidence in the management of unwell children. To provide an insight into hospital–based management of paediatric emergencies aimed to complement paramedic knowledge. To create a multidisciplinary forum for paramedics and paediatricians to network, improve relations and educate via a shared learning environment. Methods Designed as a regional study day for NIAS members. Recruitment of paediatric intensivists, emergency consultants and senior paediatric trainees to facilitate lectures on emergencies; recognition, interventions and outcomes. Rotating skills stations focused on airway, cardiovascular management and an informative question and answering session. A simulated ‘cot death’ scenario to amalgamate learning objectives. A paramedic led pre–recorded out of hospital neonatal arrest call, streamed and continued in hospital with the emergency team receiving the patient. An actress played the role of the parent for authenticity. Responses evaluated via feedback forms. Results This complimentary course was fully subscribed within five hours of advertisement. Fifty-five paramedics attended, 35 provided feedback; 100% felt more comfortable dealing with the unwell child after the course. Greater than 90% rated the skills station and lectures as extremely useful; simulation, validated by the actress was highlighted as ‘innovative’ and ‘enlightening’. Further feedback read ‘extremely beneficial day’, ‘thoroughly enjoyed and learned so much’ and ‘please, more of these events’. Suggested improvements included a bigger venue and more time. Conclusion The course will run annually to facilitate regular paramedic training and enhance pre and in-hospital working relationships. The collaborative paramedic paediatric study day is a fabulous opportunity for all to progress in a shared learning environment, mutually respectful of the reality and fear of losing a child!

Background In the UK, the proportion of places available in medical school, the total number of foundation doctors, and the number of trainees applying to Paediatrics are falling. The NHS is at ‘breaking point’, exacerbated by workforce shortages, chronic underfunding, increasing service demand and poor job satisfaction within healthcare workers. Paediatrics in is in the midst of this crisis. Issues in recruitment and retention of paediatricians ‘threaten the safety of our children’s health’ according to the Royal College of Paediatrics and Child Health. In 2019, the RCPCH Executive Committee has prioritised a new recruitment and retention campaign as their key strategic priority for the next three years. Aim The aim of this study is to explore what strategies have been described in the literature that have been used to enhance recruitment and retention in Paediatrics. This is the first-known scoping review of the literature exploring specific strategies used globally to enhance recruitment and retention in Paediatrics. Methods A scoping review methodology was conducted, employing a qualitative approach to review the literature on strategies used to improve recruitment and retention in Paediatrics. The studies included were English-language studies. 38 full-text articles were reviewed and analysed by the research team. Study Findings Despite the importance of this issue, there is a paucity of data in the literature that describes evidence-based approaches to improving retention and recruitment in Paediatrics. The most important strategies employed to help are identified and collated using validated PRISMA criteria for systematic reviews. The findings were grouped into six main themes of professional advocacy, workforce diversity, mentorship, improving working conditions, career flexibility and enhancing educational opportunities. The authors propose a strategic modified ‘Paediatric Pipeline’ paradigm of ‘Identify, Engage, Recruit, Retain and Champion.’ Conclusions There appear to be three main elements that are key to recruitment and retention of Paediatricians: personal, professional and systemic factors. Whilst some of the issues encountered share similarities with other medical specialities in difficulty, much of the context and potential remedies within Paediatrics are distinct. A strategic, multi-agency international collaborative approach is required urgently to address the significant issues that face both Paediatrics and the healthcare system itself.

ObjectiveThis practical approach to the use of telehealth aims to offer clinicians a framework for video and telephone interactions with children and families accessing healthcare.DesignUsing a standardised case to illustrate how video and telephone consultations can be used during the COVID-19 pandemic.SettingThe emergence of 2019 novel coronavirus (COVID-19) is having a massive impact on society. Routine face-to-face consultations were reduced to reduce potential spread of the virus. Clinicians still need to provide ongoing safe care, particularly for more complex patients. Telehealth is the delivery of healthcare services across geographical barriers using information and communication technologies to improve health outcomes.InterventionIn this article, we describe a ‘How to’ approach to using virtual consultations based on our experience and a review of expert guidelines.ConclusionVirtual consultations can be more convenient and have the potential to improve access for patients. Many have embraced these technologies for the first time during this pandemic.

Medicine and teaching are intrinsically linked. Traditionally, medical education was an apprenticeship model, where practical experience superseded book learning and the student/teacher relationship was paramount.1 2 In recent years there has been increased professionalisation of medical education at both undergraduate and postgraduate levels. Although this development should be embraced, there is concern that clinical and educational roles are now often seen as separate and, at times, conflicting entities. Leonard H ‘Bones’ McCoy, the chief medical officer of the Starship Enterprise, was known to Star Trek fans for his catchphrase ‘I’m a doctor (Jim), not a…bricklayer/psychologist/coal-miner etc.’ . While the academic lecturer should be clear and enthusiastic about their role as a teacher, the ‘jobbing paediatrician’ can have a more challenging time balancing clinical and teaching responsibilities. In the busyness of the hospital environment it becomes easy to prioritise clinical duties and mirror ‘Bones’ in adopting the attitude that ‘I’m a doctor, not a teacher’ . Despite many recent changes in how medical education is delivered, experiential workplace learning remains crucial.3 4 This article encourages all paediatricians to reconsider their role as both clinician and teacher. ### Professional obligation The importance of the clinical teacher was first outlined within the Hippocratic Oath (box 1). Although this …

You are the paediatric registrar at an epilepsy clinic. A mother of a 9-year-old patient with childhood absence epilepsy asks if he should be taking vitamin D. He is currently prescribed sodium valproate. You wonder if you should prescribe vitamin D supplementation alongside his antiepileptic medication. In children with a clinical diagnosis of epilepsy on antiepileptic drugs (AED) (population), is there evidence to suggest that they should receive supplemental vitamin D (intervention) to improve their bone health (outcome)? We searched OVID MEDLINE in June 2020 with the keywords (Child OR Paediatrics OR Pediatrics) AND (Vitamin D OR Vitamin D Deficiency OR Cholecalciferol OR Calcitriol) AND (Anti-Epileptic Drug OR Anti-Epileptic Medication OR Anti-Convulsant Drug). The search was limited to articles in English from the year 2000. Sixty-five articles were identified. Twenty articles were included after initial scrutiny and four were selected for full-text review. One further study was identified on review of article references. These were graded according to the Oxford level of evidence (table 1).1 View this table: Table 1 Summary of included studies Vitamin D deficiency is common worldwide. Vitamin D is protective for musculoskeletal health. Children treated with AED are known to have problems with bone metabolism and bone mineral density (BMD) loss. Enzyme-inducing AEDs (phenytoin, carbamazepine, primidone and phenytoin) increase vitamin D metabolism due to induction of cytochrome P450. Newer, non-enzyme-inducing antiepileptic drugs (NEIAEDs) can affect bone metabolism in a variety of ways, including stimulation of osteoclast activity, direct action on bone cells, parathyroid hormone resistance, inhibition of calcitonin secretion …

BackgroundIn the UK, the number of junior doctors completing foundation programme, and the number of trainees applying to paediatrics has been in decline in recent years. The NHS is at ‘breaking point’, exacerbated by workforce shortages, chronic underfunding, increasing service demand and poor job satisfaction within healthcare workers. Issues in recruitment and retention of paediatricians ‘threaten the safety of our children’s health’, according to the Royal College of Paediatrics and Child Health.AimTo explore what strategies have been described in the literature to enhance recruitment and retention in paediatrics.MethodsA scoping review methodology was conducted, employing a qualitative approach to review the literature. The studies included were English-language studies. 16 full-text articles were reviewed and analysed.Study findingsThere is a paucity of data in the literature that describes evidence-based approaches to enhancing retention and recruitment in paediatrics. The most important strategies employed to help are identified and grouped into six main themes. These include professional advocacy, workforce diversity, mentorship, improving working conditions, career flexibility and enhancing educational opportunities. The authors have created a ‘paediatric pipeline’ paradigm of ‘identify, engage, recruit, retain and champion’, which allow us to present these themes in a pragmatic way for paediatricians and policymakers.ConclusionsWhile some issues share similarities with other specialties in difficulty, much of the context and potential remedies within paediatrics are distinct. A strategic, multi-agency collaborative approach is required urgently to address the significant issues that face both paediatrics and the healthcare system.

Strong communication, empathy and interpersonal skills are crucial to good clinical practice. Actors trained in interpretations of the Stanislavski system draw on their own life experience to develop the character. We hypothesised that simulation enhanced by trained actors would be an ideal way for our senior trainees to develop advanced communication skills. We developed a communication training course based on challenging situations which occur in paediatrics like child death and safeguarding. Actors were briefed and invited to develop characters that would behave and respond as a parent/carer might do in complex and stressful clinical scenario. Paediatric trainees then participated in simulations, with a focus on communication skills. Feedback and debrief were provided by a multidisciplinary faculty. The impact of the course was evaluated by analysis of data collected in focus groups held after the simulation. Trainees noted the actor’s ability to respond in vivo to emotive situations and felt it was much more effective than their previous experience of simulation with simulated patients without formal training. Actors were able to offer feedback on aspects of body language, tone and use of language from a non-medical perspective. Actors enhanced the realism of the simulations by changing their language and emotional performance in response to the trainee’s performance, improving trainee engagement.

To determine if an intubation drugs pack containing pre-filled syringes can reduce the time to endotracheal intubation compared with standard care during a simulated paediatric emergency. Twenty doctors (10 consultants and 10 registrars) who worked in the paediatric intensive care unit or anaesthetic department of a tertiary paediatric hospital were asked to participate in an in situ simulated emergency paediatric intubation scenario. The participants were instructed to prepare and administer intubation medications. They were randomised to either an intubation drug pack, containing pre-filled syringes or to standard care where each of the drugs had to be individually drawn-up. The mean time to intubation when using the pre-filled syringes of 159.5 s was over three times faster than with standard care of 497.5 s (p

In paediatric practice feeding, eating, drinking and swallowing difficulties are present in up to 1% of children. Dysphagia is any disruption to the swallow sequence that results in compromise to the safety, efficiency or adequacy of nutritional intake. Swallowing difficulties may lead to pharyngeal aspiration, respiratory compromise or poor nutritional intake. It causes sensory and motor dysfunction impacting on a child’s ability to experience normal feeding. Incoordination can result in oral pharyngeal aspiration where fluid or food is misdirected and enters the airway, or choking where food physically blocks the airway The incidence is much higher in some clinical populations, including children with neuromuscular disease, traumatic brain injury and airway malformations. The prevalence of dysphagia and aspiration-related disease is increasing secondary to the better survival of children with highly complex medical and surgical needs. This article aims to outline the indications for performing videofluoroscopy swallow (VFS). This includes the technical aspects of the study, how to interrupt a VFS report and some of the limitations to the study.

Medical handover is one of the most commonly performed actions in the healthcare system today. While it is performed regularly, it is often not done as effectively as it could or should be. 1 Many organisations have implemented systems and structures to improve the quality and impact of their handover process. These include advocating senior presence, introducing validated handover tools and an emphasis on multidisciplinary involvement. 2 A protected handover prioritises safety, enhances communication and encourages improvement in handover effectiveness. Our local pilot and subsequent regional initiative has begun actively addressing this issue using a low-cost, interprofessional, multispeciality quality improvement initiative.

AimDifferences in the gaze behaviour of experts and novices are described in aviation and surgery. This study sought to describe the gaze behaviour of clinicians from different training backgrounds during a simulated paediatric emergency.MethodsClinicians from four clinical areas undertook a simulated emergency. Participants wore SMI (SensoMotoric Instruments) eye tracking glasses. We measured the fixation count and dwell time on predefined areas of interest and the time taken to key clinical interventions.ResultsPaediatric intensive care unit (PICU) consultants performed best and focused longer on the chest and airway. Paediatric consultants and trainees spent longer looking at the defibrillator and algorithm (51 180 ms and 50 551 ms, respectively) than the PICU and paediatric emergency medicine consultants.ConclusionsThis study is the first to describe differences in the gaze behaviour between experts and novices in a resuscitation. They mirror those described in aviation and surgery. Further research is needed to evaluate the potential use of eye tracking as an educational tool.

Clinical bottom line An 8-week-old infant is receiving inhaled nitric oxide (iNO) for secondary pulmonary hypertension (PHT) in paediatric intensive care unit (PICU). The child is postcongenital diaphragmatic hernia repair and is proving difficult to wean from iNO. Given the problem with rebound PHT, you wonder if treatment with enteral sildenafil will aid discontinuation of iNO. In the child with pulmonary hypertension (population), does treatment with enteral sildenafil (intervention) compared with a slow wean from iNO alone (comparison) prevent rebound PHT and allow for discontinuation of iNO (outcome)? We performed an online search using PubMed and Medline (1946 to present) in September 2019. The key terms were (pulmonary hypertension) AND (rebound) AND (sildenafil) AND (nitric oxide) AND (child). We limited the search to include articles written in English. We identified three relevant articles, a randomised controlled trial, a prospective and a retrospective …

A 2-year-old boy attends outpatient clinic with a history of persistent, intermittent non-bilious vomiting from birth. An upper gastrointestinal (UGI) contrast study was arranged, and the radiology report has stated that the duodenal-jejunal flexure is midline and lower than the gastric outlet, suggesting malrotation without volvulus. Should (patient) children with non-bilious vomiting and radiological evidence of malrotation (intervention) undergo a Ladd’s procedure or (comparison) be managed conservatively (outcome) to reduce the risk of volvulus? We performed an online literature search in March 2019 using PubMed. The key terms were ‘malrotation’ and ‘asymptomatic’. The search was limited to full articles written in English and yielded 109 results. On review of titles and abstracts, we excluded all case reports, studies not including children and papers focusing on heterotaxy syndromes. Nine studies were identified along with an expert consensus review commissioned by the American Pediatric Surgical Association (APSA). These articles are outlined in table 1 and are graded according to the Oxford levels of evidence. View this table: Table 1: Summary of included articles During normal fetal development, the bowel undergoes a 270° counter-clockwise turn, resulting in the duodenal-jejunal flexure (DJF) positioning itself to the left of the midline and at the level of the gastric outlet. It is fixed in position by the ligament of Trietz. From there, the remainder of the small bowel continues …

Introduction In September 2015, the UK became the first country in the world to introduce the 4-component meningococcal B vaccine(4CMenB) into the routine vaccine schedule for infants. 4CMenB is known to cause fever in infants. Infants presenting with fever, particularly those under 3 months, have a significant risk of serious bacterial infection(SBI). Method Between September 2015 and January 2016, we performed a prospective audit of management of infants between 30 and 180 days attending the regional paediatric emergency department(ED) in Northern Ireland, within 4 days of receiving 4CMenB. Results 35 ED attendances in infants aged 30–180 days were due to symptoms occurring after primary vaccinations including 4CMenB, representing an estimated 0.8% of the vaccinated population in the catchment area. 86% of infants presented after the first vaccine and parents reported giving paracetamol to 94% of infants. 80% of infants presented with fever. Blood tests were performed in 62% of infants and leucocytosis was present in 73%. All cultures taken were negative and 51% were admitted to hospital. 100% of final diagnoses were vaccine related (diagnosis made by exclusion). Discussion In this study, an estimated 0.8% of the vaccinated population in the catchment area attended ED with symptoms occurring after primary vaccinations including 4CMenB. Infants with fever have a higher risk of SBI, but infants with fever in the post-vaccination period may not have the same risk. Further data are essential to inform national guidelines on investigation and management of fever in infants following vaccination with 4CMenB, possibly incorporating a less-invasive approach.

Acute bronchiolitis is the most common respiratory condition under 1 year of age. In the UK and Ireland, approximately one in three infants will develop bronchiolitis in the first year of life and ~2%–3% of all infants require hospitalisation.1 In severe cases, children are admitted to paediatric intensive care (PICU) for ventilation and supportive treatment. An admission to a critical care unit is an extremely stressful time for children and their families. It also has significant implications on workload and resources. High-flow nasal cannula oxygen (HFNCO) is a treatment where oxygen is delivered at high rates via a tight-fitting nasal mask. This treatment has recently been increasingly used to manage bronchiolitis. Recent evidence has suggested that this may have a role as rescue therapy to reduce the proportion of children requiring high-cost intensive care.2 Prior to this initiative, this treatment option was only available in PICU in our trust. In 2016, our team acquired one HFNCO unit in a bid to introduce this treatment at ward level. These attempts to do so, prior to developing an introductory simulation-based collaborative teaching event, …

Paediatric traumatic brain injury (TBI) is a non-degenerative, acquired brain insult. Following a blow or penetrating trauma to the head, normal brain function is disrupted. If it occurs during the early stages of development, deficits may not immediately become apparent but unfold and evolve over time. We address the difficulties that arise when treating a child with severe TBI.

Background Simulation-based education is now a well-established part of undergraduate and postgraduate healthcare education. However, many healthcare teams still experience challenges with providing this due to limited staff engagement. ‘Play is the highest form of research’ is a well-known quote that has been attributed to Albert Einstein. However, concerns about performing in ‘make-belief’ simulations & peer-critique inhibit participation and impede sim-based education credentials. Summary of project We conceived, designed, facilitated and evaluated N. Ireland’s inaugural ‘Sim-off competition’. This was devised as a fun, educational opportunity to improve knowledge of Paediatric conditions, to aid networking, and act as an inter-speciality and multi-professional event. It was the first national sim-off competition in any speciality across the UK & Ireland. The contest ran as an informal ‘round robin’ competition with 10 competing teams representing hospitals from all 5 NI Healthcare trusts, a University APNP team and a Paediatric EM team from Dublin. Our prestigious judging panel comprised of 5 experienced paediatric clinicians with expertise in clinical education. Several moderate complexity scenarios were designed. Team marks were awarded for both technical and non-technical skills. Summary of results 114 people attended this inaugural event in QUB Riddel Hall on Friday 15th June 2018. There were 44 Paediatric ST1-8 trainees as well as 70 other attendee’s. 26 doctors & 20 nurses formed the 10 competing teams. Feedback was received from 21 participants and 11 observers. 85% of those (27 people) felt that performing simulation as a competition enhanced the educational experience. Some comments included: ‘Extremely enjoyable day- competitive side of sim added to the experience’, and ‘An exemplary day of education. Well done to all involved on an excellent concept!’ Discussion This inaugural ‘sim-off’ contest has provided trainees and sim-enthusiasts an ideal opportunity to engage in an informal competition, enhance perceptions of sim-based education & generate region-wide enthusiasm. It is hoped this will be used as a platform for further similar events in undergraduate intervarsity competitions, and at a postgraduate level within various specialities (such as Anaesthetics, Emergency Medicine) as well as potentially run as a biennial event in Paediatrics.

Background Paediatrics, like many specialties, is experiencing a decline in applications for specialty training.1 Reasons include perceptions of poor flexibility; arduous training programme and lack of adequate career guidance and support.2 The RCPCH suggest strategies to increase recruitment should include exposure to educational opportunities. 2 In the UK, the transition between foundation level training and specialty training is an uncertain and stressful time. We believe that allowing access to high fidelity simulation training affords a unique opportunity to showcase our specialty. Summary of project We designed, delivered and evaluated ‘A Foundation in Acute Paediatrics Simulation’ (FAPS) course aimed at offering junior doctors an introduction into the management of common paediatric conditions. This initiative was approved by the Northern Ireland Medical & Dental Training Agency (NIMDTA). A highly experienced inter-professional faculty provide an insight into a career in paediatrics, their own career perspectives and an opportunity for group discussion and tailored personal career advice. Clinically relevant interactive simulation scenarios offer the candidates an opportunity to work alongside colleagues and encounter common paediatric conditions, potentially developing their clinical acumen and enhancing non-technical skills. Summary of results Since its inception in 2017, 32 Junior doctors (FY1-FY3) have taken part in the annual course. Prior to the course, 22/32 (69%) candidates were unsure whether they would apply to Paediatrics. After the course, all 32 candidates indicated that that they were more likely to apply [mean score- 2.7 before vs 3.9 after; 1-very unlikely, 3-undecided, 5-Very likely to apply]. Subsequently, 31/32 candidates (97%) felt more confident in the assessment of the unwell child. All candidates (100%) recommend this course to peers. Qualitative comments included ‘Excellent concept, relevant scenarios and useful course’ and ‘First exposure to Paediatrics since 4th year medical school. Thoroughly enjoyable.’ Discussion This is the first use of high-fidelity simulation to enhance specialty recruitment that has been reported. It has now become an established part of the academic calendar in Northern Ireland and runs on an annual basis each November. It is endorsed by both the Northern Ireland Foundation School & NIMDTA. This course affords an opportunity to gain access to motivated clinicians while experiencing common paediatric conditions in a safe, simulated learning environment. The tailored career advice may be of use for their future speciality direction. This course actively helps in addressing the current plight of low trainee recruitment and retention in Paediatrics and could be easily replicated in other areas. References Royal College of Paediatrics and Child Health. ST1 Paediatric Deanery/LETB Competition ratios and fill rate 2016. London, 2016. http://www.rcpch.ac.uk/ Jacob H, Shanmugalingam S and Kingdon C. Recruitment and retention in paediatrics. Arch Dis Child December 2 016. doi:10.1136/archdischild-2016-311390

Introduction Time delays in the delivery of emergency treatment in a resuscitation can be detrimental to patient care.1 Multiple factors have been implicated as causes of such delays. These include hospital related factors such as the time taken to access emergency equipment.2 Recommendations have previously been made regarding standardisation of resuscitation trolleys.3 To date there have been no studies evaluating the effect of environmental priming on performance in simulated emergencies. This study aimed to evaluate the effect of environmental priming impact on student performance in a simulated paediatric emergency. Methods Ethical approval for the study was obtained. SimBaby is an inter-professional educational module in which undergraduate nursing and medical students participate in simulated paediatric emergencies. We randomised students participating in SimBaby into primed or un-primed groups. Those in the primed arm received a tour of the sim-suite in advance of the session and had access to an online video tour of the sim-suite. Students then undertook a simulated scenario based on a child with meningococcal septicaemia. The time taken to achieve five of the six key clinical interventions outlined in the Paediatric Sepsis Six protocol were recorded. A selection of groups were then randomly selected to undertake semi-structured interviews with a psychologist. Data was analysed using thematic analysis. Results The primed students were quicker to all five key clinical interventions and significantly quicker to achieving IV access, administration of antibiotics and seeking senior help (p Discussions/Conclusions These findings suggest that familiarity with the clinical environment may improve clinical performance and subsequently impact positively on patient outcomes even if participants are not always aware of the benefit this may confer. This may have implications for considering standardisation of resuscitation areas within healthcare settings. In addition it may highlight the importance of local induction and perhaps helps to promote the use of in-situ-simulation in familiarising staff with the local environment. References Chan P, Krumholz H, Nichol G, et al. Delayed time to defibrillation after in-hospital cardiac arrest. N Engl J Med 2008;358:9–17. Pedley R, Whitehouse A, Hammond S. Improving room layouts for venepuncture, cannulation and ABG equipment on surgical wards. BMJ Quality Improvement Reports 2014; u554.w477 doi: 10.1136/bmjquality.u554.w477 Royal College of Anaesthetists, Royal College of Physicians of London, Intensive Care Society, Resuscitation Council (UK). Cardiopulmonary resuscitation: standards for clinical practice and training. Resuscitation Council (UK).Published October 2004, updated June 2008.

Background Hierarchy and leadership are essential within any multidisciplinary team. However, team leaders can make mistakes irrespective of seniority. It is essential that everyone within the team feels confident in raising concerns to ensure patient safety. This can be particularly challenging for new staff joining established healthcare teams. We aimed to improve the confidence of new children’s nursing staff in raising concerns by introducing teaching on a structured method for raising concerns into their induction simulation session. Summary of education programme New nurses undertook a simulated clinical scenario in which the doctor was deliberately hesitant and reluctant to administer appropriate emergency treatment. Teaching was then provided on the PACE approach for raising concerns. Each nurse then participated again in a similar scenario. Each of the 23 participants completed pre and post questionnaires. Summary of results There was no difference in participants’ confidence between challenging a nurse or doctor (3.4/5) prior to training. Following the initial scenario the nurses reported feeling ‘frustrated’ and ‘scared’. After the session they stated that their confidence in challenging nurses and doctors had increased to 4.3/5 and 4.2/5 respectively. Free text comments included: ‘Hearing from doctors that they would rather be challenged was reassuring.’ ‘Improved my confidence to speak up when querying a decision’ Conclusions/Discussion Nursing staff reported improved confidence in their ability to raise concerns. This can only serve to improve patient safety. We believe that similar training would also benefit new medical staff. Consequentially, we plan to incorporate PACE training into all future medical and nursing induction programmes.

Background In recent years there has been an increasing recognition of the importance of non-technical skills training in medical education. Strong communication and interpersonal skills are crucial to good clinical practice. These are of particular relavence when communicating with team members, parents and patients in challenging situations. We identified a lack of postgraduate training opportunities for paediatric trainees to develop these skills. Our aim was to devise an interdisciplinary training opportunity which would enable senior paediatric trainees to develop their communciation skills by undertaking simualted scenarios based on challenging clinical situations. Summary of education programme Level 3 trainees in our deanery were invited to attend the ACTup course. We recruited a diverse faculty consisting of paediatricians, paediatric nurses, social workers and psychologists. In a unique collaboration, we worked closely with drama students from our local universty. The drama students acted in the role of parents for the simulations. The scenarios focused on challenging clinical encounters which may be seen in paediatric practice. These included safeguarding cases, sudden unexpected death of an infant and discussions around withdrawal of care. Feedback was collected through questionnaires and focus groups conducted by the psychology team. Summary of Results Feedback on the course was excellent. All participants found input from a diverse faculty particularly beneficial. Themes identified on analysis of the focus groups included the importance of the drama students in enhancing the fidelity of the simulations, the necessity of further non-technical skills training in paediatric training and the benefits of debrief following challenging clinical encounters. Conclusions/Discussions This course provided an opportunity for senior paediatric trainees to develop their communication skills in challenging situations. Initial feedback was excellent. We strive to establish this course as a regular training opportunity for paediatric trainees in our deanery. The course has also been adopted as an essential component of the undergraduate drama module entitled ‘Drama, Health and Social Care’ now offered in our local university.

Background Paediatrics, like many specialties in the UK, is experiencing a decline in applications for specialty training1. Reasons include perceptions of poor flexibility, arduous training programme and lack of adequate career guidance and support2. Transition between foundation level training and specialty training is an uncertain and stressful time3.In 2016, only 50% of FY2 doctors reported that they would enter directly into speciality training4. We believe that offering access to high-fidelity simulation course affords a unique opportunity to showcase our specialty, as encouraged by the RCPCH2. Methods We designed, delivered and evaluated ‘A Foundation in Acute Paediatrics Simulation’ (FAPS) course aimed at offering junior doctors an introduction into the management of common paediatric conditions. A highly experienced inter-professional faculty provided an insight into a career in paediatrics and an opportunity for group discussion and tailored personal career advice. This initiative was approved by the Foundation programme director of the Northern Ireland Medical and Dental Training Agency (NIMDTA). This course was specially designed to run in the weeks prior to the opening of the national speciality application process. Results 16 Foundation doctor candidates took part in the pilot FAPS course in November 2017. Prior to the course 11/16 (69%) candidates were unsure whether they were going to apply for paediatrics. After the course all 11 candidates indicated that that they were more likely to apply [mean score- 2.9 before vs 4.0 after; 1-very unlikely, 3-undecided, 5-Very likely to apply]. Subsequently, 15/16 candidates (94%) felt more confident in the assessment of the unwell child. This course will run annually and is now oversubscribed for the next course in November 2018. Conclusions This was the first known use of a high-fidelity simulation recruiter course to enhance specialty recruitment within the UK. This course provides an opportunity to gain access to motivated junior trainees in a safe, simulated learning environment. It was extremely well received by the candidates, the faculty, and the regional training agency. This course actively helps in addressing the current plight of low trainee recruitment and retention in Paediatrics and could be easily replicated in other areas. References Royal College of Paediatrics and Child Health. ST1 Paediatric Deanery/LETB Competition ratios and fill rate 2016. London, 2016. http://www.rcpch.ac.uk/ Jacob H, Shanmugalingam S and Kingdon C. Recruitment and retention in paediatrics. Arch Dis ChildDecember2016. doi:10.1136/archdischild-2016–311390 Pinnock R, Reed P, Wright M. The learning environment of paediatric trainees in New Zealand. J Paediatr Child Health2009;45:529–34 British Medical Association. The state of pre and post-graduate medical recruitment in England September 2017. https://www.bma.org.uk/collective-voice/policy-and-research/education-training-and-workforce/state-of-medical-recruitment

Context Simulation-based education is now a well-established part of healthcare education. However, many healthcare teams still experience challenges with providing this due to limited staff engagement. Often, concerns about performing in ‘make-belief’ simulations and peer-critique inhibit participation and impede sim-based education credentials. Methods We conceived, designed, facilitated and evaluated the region’s inaugural ‘Sim-off competition’. This was devised as a fun, educational opportunity to improve knowledge of Paediatric conditions, to aid networking, and act as an inter-speciality and multi-professional event. It was the first National Sim-off competition in any speciality across the UK and Ireland. The contest ran as an informal ‘round robin’ competition with 10 competing teams representing hospitals from all 5 NI Healthcare trusts, a University APNP team and a Paediatric EM team from Dublin. Our prestigious judging panel comprised of 5 experienced paediatric clinicians with expertise in clinical education. Several moderate complexity scenarios were designed. Team marks were awarded for both technical and non-technical skills. Outcomes 114 people attended this inaugural event in QUB Riddel Hall on Friday 15th June 2018. There were 44 Paediatric ST1–8 trainees as well as 70 other attendee’s. 26 doctors and 20 nurses formed the 10 competing teams. Specialities including General Practice, Anaesthetics, Emergency Medicine and Medical Education were represented in the audience. Feedback was received from 21 participants and 11 observers. 85% of those (27 people) felt that performing simulation as a competition enhanced the educational experience. Some comments included: ‘Extremely enjoyable day- competitive side of sim added to the experience’, and ‘An exemplary day of education. Well done to all involved on an excellent concept!’ Conclusions This inaugural ‘sim-off’ contest has provided trainees and sim-enthusiasts an ideal opportunity to engage in an informal competition, enhance perceptions of sim-based education and generate region-wide enthusiasm. Following its success, or team has been contacted by colleagues who are organising National and European Paediatric and Simulation conferences to recreate this event at their conference. It is hoped this will be used as a platform for further similar events within different specialities and also run as a biennial event in Paediatrics in Ireland.

Aims The objective of this quality improvement project was to increase CSF interpretability by 50% in a 5 month period using an Lumbar Puncture (LP) simulator to enhance trainee technique. LP is a core practical procedure of level 1 RCPCH training. Lack of opportunity, experience and low procedural confidence can make it difficult to achieve this competency. Traumatic punctures causing blood stained CSF can lead to difficulties with interpretation. Methods Prospective data was collected during August 2017 to December 2017 for general paediatric admissions (patient demographics, trainee grade, number of attempts, microscopy results and interpretability). Three half-day simulated procedural training days practicing LP technique, discussing appropriate sedation and clinical cases occurred during this time and their impact was measured. Results 58 LPs were performed during the study period. Participation of junior trainees increased from 8% to 40% in the first 4 months but then decreased to 15% in December. Encouragingly after the second LP course CSF interpretability increased from 47% to 92%. LPs carried out in theatre under general anaesthetic (4 patients) were mostly atraumatic (RBC 0–23). The number of LP attempts also impacted on CSF quality and likelihood of achieving interpretable CSF microscopy Conclusions Simulation-based training is beneficial for trainees to gain experience of procedural skills. This project shows that when trainees are given the opportunity to gain hands-on experience using high-fidelity models it translates to enhanced user confidence, willingness to participate in the clinical setting and increased procedural competence (table 1). During the 5 months CSF interpretability increased from 47% to 69%, nearly achieving our overall project aim.

Aims Time delays in the delivery of emergency treatment can be detrimental to patient care. Multiple factors have been implicated as causes of such delays including the time taken to access emergency equipment. This randomised control trial aimed to evaluate the impact of environmental priming on student performance in a simulated paediatric emergency. Methods We randomised medical and nursing students into primed or un-primed groups. The groups then undertook a standardised simulated scenario based on a child with meningococcal septicaemia. Those in the primed arm had received a tour of the sim-suite in advance of the session and had access to an online video tour. The time taken to achieve five of the six key clinical interventions outlined in the Paediatric Sepsis Six protocol were recorded. Groups from each arm were then randomly selected to undertake focus groups with a psychologist. Results The primed students were quicker to all five key clinical interventions and significantly quicker to administration of the first fluid bolus, administration of antibiotics and seeking senior help (p Interestingly students participating in the focus groups suggested that they did not feel that they had gained any specific advantage from being primed, perhaps displaying a degree of cognitive dissonance. Un-primed students did not feel disadvantaged by not being primed. Conclusions This study suggests that familiarity with the clinical environment improves clinical performance. It may be possible to address this through standardising the layout of resuscitation areas, by ensuring familiarisation with key areas during local induction and through the use of in-situ simulation in clinical settings.

Aims Clinicians collect, prioritise and respond to visual cues when making decisions about patient care. This is of particular importance in the resuscitation environment where they are required to absorb and process large volumes of complex visual information in a time critical manner. Eye tracking technology allows for the measurement of an observer’s point of gaze based on where their pupil is focused. Eye tracking technology has been used in aviation and surgery to describe differences in the gaze behaviour between experts and novices. The aim of this study was to describe the gaze behaviour of clinicians from different training backgrounds during a simulated paediatric emergency. Methods Twenty-seven clinicians from different clinical areas within a tertiary children’s hospital undertook a standardised, six minute, high fidelity simulated paediatric emergency. Participants wore SMI Eye Tracking Glasses. We measured the number of times participants looked at predefined key areas (fixation count) and the duration of time spent looking at each of these areas (dwell time). The time taken to key clinical interventions was also recorded. Results Participants from all groups looked more frequently and for longer at the patient (chest and airway) than any of the other key areas of interests. Paediatric Intensive Care Unit (PICU) consultants focused longer on the chest and airway than any other groups. The gaze behaviour of paediatric consultants and trainees was similar. Both groups spent longer looking at the defibrillator and algorithm (51,180 ms and 50,551 ms respectively) than the PICU consultants and consultants in paediatric emergency medicine (19,804 ms and 28,095 ms respectively). The PICU consultants were quickest to perform key clinical interventions. Conclusions This study is the first to describe differences in the gaze behaviour between clinicians from different backgrounds during a simulated paediatric emergency. Differences observed between experts and novices are similar to those described in aviation and surgery. Further research is needed to evaluate the potential use as an educational tool in the resuscitation setting.

Aims In recent years there has been an increasing recognition of the importance of non-technical skills training in medical education. Strong communication and interpersonal skills are crucial to good clinical practice. These are of particular relavence when communicating with team members, parents and patients in challenging situations. We identified a lack of postgraduate training opportunities for paediatric trainees to develop these skills. Our aim was to devise an interdisciplinary training opportunity which would enable senior paediatric trainees to develop their communciation skills by undertaking simualted scenarios based on challenging clinical situations. Methods Level 3 trainees in our deanery were invited to attend the ACTup course. We recruited a diverse faculty consisting of paediatricians, paediatric nurses, social workers and psychologists. In a unique collaboration, we worked closely with drama students from our local universty. The drama students acted in the role of parents for the simulations. The scenarios focused on challenging clinical encounters which may be seen in paediatric practice. These included safeguarding cases, sudden unexpected death of an infant and discussions around withdrawal of care. Feedback was collected through questionnaires and focus groups conducted by the psychology team. Results Feedback on the course was excellent. All participants found input from a diverse faculty particularly beneficial. Themes identified on analysis of the focus groups included the importance of the drama students in enhancing the fidelity of the simulations, the necessity of further non-technical skills training in paediatric training and the benefits of debrief following challenging clinical encounters. Conclusions This course provided an opportunity for senior paediatric trainees to develop their communication skills in challenging situations. Initial feedback was excellent. We strive to establish this course as a regular training opportunity for paediatric trainees in our deanery. The course has also been adopted as an essential component of the undergraduate drama module entitled ‘Drama, Health and Social Care’ now offered in our local university.

Aims Acute Paediatrics is a stimulating and challenging training programme. The Royal College of Paediatrics and Child Health (RCPCH) provide a comprehensive curriculum for trainees during these years. In Level 1 Training (ST1–3), there are a number of core practical procedures trainees are expected to perform prior to progression to Level 2 training. These skills include Neonatal Intubation, Lumbar Puncture (LP) and Intraosseous (IO) Access. 1 Often it may be difficult for trainees to gain significant experience in these skills and achieving competence can be challenging. Reasons for this include lack of opportunity, lack of experience, and low procedural confidence. The RCPCH advocates the delivery of Simulation and Technology Enhanced Learning (TEL) including in the area of technical skills training. 2 By creating a technical skills simulation training day, we aimed to increase trainee exposure and confidence to core college procedures. Methods We created a simulation training day for Level 1 Regional Training focused on 3 core procedures. We asked Paediatric ST1–3 trainees about previous teaching, experiences and confidence levels with these skills. Results 24 ST1–3 trainees were surveyed. Prior to the teaching, 2 (8%) trainees felt their Intubation skills were adequate, 12 (50%) described their LP skills as satisfactory and 4 (16%) trainees labelled their IO access skills as acceptable. Following the training session, 23 of the 24 trainees (96%) felt significantly more confident in approaching all 3 of the core practical skills. All 24 Trainees (100%) felt that simulated practice helped improve their technical skills and all (100%) felt it would be useful in their daily job. Conclusion Simulation-based training for procedural skills has been shown to be effective for trainees and has been widely used in many training programs. 3 By integrating this into the Deanery’s Regional teaching programme, we have presented junior trainees the opportunity to gain vital hands-on experience on high-fidelity models, which has improved procedural exposure, enhanced user-confidence and may potentially develop procedural competence.We hope to extend this programme to higher level trainees and incorporate other core procedural skills in a bid to further promote a safe, trainee-friendly, patient-centred simulated learning environment. References . Curriculum for Paediatric Training. General paediatrics: Level 1, 2 and 3 training August 2016. http://www.rcpch.ac.uk/training-examinations-professional-development/postgraduate-training/general-paediatrics-training/ge#curriculum . Strategy- Simulation and TEL. Royal College of Paediatrics and Child Health January 2015. http://www.rcpch.ac.uk/training-examinations-professional-development/postgraduate-training/simulation-and-technology-enh . Barsuk JH, Cohen ER, et al. Simulation-based education with mastery learning improves residents’ lumbar puncture skills. Neurology2012;79(2):132–7.

Serious adverse incidents (SAIs) are events in healthcare that justify a heightened level of response as their impact on patients, staff or systems is so great.1 The National Health Service has a framework for reporting of SAIs, never events and near misses.2 Individual healthcare trusts are responsible for investigating these incidents and delivering recommendations to staff to avoid recurrence.1 These recommendations typically include education and training of staff. Immersive, in situ simulation is an effective interprofessional educational model3 that can lead to improvements in patient safety,4 and we believe it is the ideal tool to learn from SAI investigations. The aim of this project was to develop a more robust and educationally sound system to rapidly disseminate interprofessional learning, to minimise the risk of recurring errors. A multidisciplinary team including paediatric surgery, paediatric anaesthesia, theatre nursing, medical education and clinical governance managers was convened. Review was undertaken of SAIs reported over 5 years from the operating theatres at a tertiary referral children’s hospital. The team identified recurring themes and high-risk cases amenable to in situ simulation. Each simulation was based on an …

This study demonstrates the feasibility of using quantitative real time PCR to measure genomic bacterial load in the nasopharynx of children with invasive meningococcal disease and shows that these loads are exceptionally high (median 6.6 × 10(5) (range 1.2 × 10(5)-1.1 × 10(8)) genome copies of Neisseria meningitidis per swab).

In our tertiary paediatric centre, we carry out frequent unannounced in situ simulations. While conducting simulations on acute wards, we have encountered a variety of latent safety threats (LSTs) and barriers to effective patient care. There are numerous off-ward areas in the hospital in which children are assessed and may receive treatment. Some of these areas are difficult to access and are located in parts of the hospital with which staff may be unfamiliar. We designed a project to determine how prepared staff working in these areas would feel if required to manage an unwell child in an emergency. We explored this further using simulation to detect any potential barriers to the effective management of emergencies and to initiate a process by which these could be addressed. The aim of the project was to develop systems to improve patient safety and ensure efficient care could be delivered throughout the entire hospital. The project was registered with the Standards, Quality and Audit Department and our Service Manager was consulted. We conducted surveys in five off-ward areas. We asked staff about their previous resuscitation training and whether they had any previous experience of managing emergencies in the area in which they work. We also asked if there was an agreed process for managing emergencies in their area. The departments included were the electroencephalogram (EEG) department, …

Bronchiolitis is a seasonal viral lower respiratory tract illness common in infancy and a major cause of hospitalisation in this age group. The course is often self-limiting. Mainstay of management is supportive care to maintain oxygenation and hydration. We developed local guidelines for the management of bronchiolitis based on recommendations from NICE and Bronchiolitis of Infancy Discharge Study (BIDS). Key messages being: minimal handling and suctioning, rare pharmacological treatment in selected cases and permissive approach to patients with saturations>90% (BIDS). This guidance was implemented using a robust teaching program for all staff including nurses and junior doctors. We aimed to audit current management of bronchiolitis and compliance with new guideline. We also compared outcomes with practice before implementation of new guideline. Methods An audit proforma was designed and the new trust guideline – 2015/2016 was used as gold standard. Data was collected using clinical coding, case notes, electronic case records. Data on 30 patients admitted with bronchiolitis between October 2014 to December 2014 was collected. The new guideline was implemented in December 2015. We collected data on infants admitted with bronchiolitis between 1st January and 31st March 2016 in RBHSC. A total of 29 patients were included in this cohurt. Results Suctioning was reduced from 83% to 34%, so as the use of hypertonic saline nebulisers. There was a slight increase in the use of antibiotics. No change was seen with regards to duration of stay. 1 patient was readmitted in 2016 compared with 5 patients in 2014. Conclusion Compliance to the new guideline was good and minimal handling and suctioning did not prolong the stay or readmission.

Aims The Royal College of Paediatrics and Child Health (RCPCH) provides a comprehensive curriculum for paediatric trainees. It details the knowledge, skills and behaviours expected from a trained paediatrician and highlights the core competences required of trainees. Achieving these competencies can be difficult for more uncommon conditions which trainees do not routinely encounter in clinical practice. We sought to address this by offering senior paediatric trainees the opportunity to participate in inter-professional, high-fidelity, simulated scenarios based on rare but important clinical conditions. Methods We surveyed all level three paediatric trainees (ST6– ST8) in our deanery. We listed the acute presentations as outlined in the RCPCH for general paediatrics and asked them to identify conditions which they had either never experienced or had only had very limited exposure to in clinical practice. We incorporated routine simulation teaching, focusing on these rare cases, into the postgraduate education programme in the deanery’s tertiary paediatric centre. Trainees who participated were asked to complete an online questionnaire to explore their experience of these teaching sessions. Results Trainees identified a number of conditions with which they lacked clinical experience. Table 1 highlights some of the conditions trainees mentioned. Feedback on these sessions was very positive. Comments included: ‘These sessions enabled me to develop my confidence in the management of conditions which I rarely see in clinical practice.’ ‘Rare case simulation training allows me to meet curriculum competencies which I have not previously been able to achieve.’ ‘Challenging and educational.’ Conclusions Simulation training focusing on rare cases allows trainees to develop their confidence in managing uncommon conditions and address areas of the curriculum which they have previously struggled to achieve. After a successful local pilot we have now also embedded rare case simulation training into the deanery’s regional paediatric teaching programme.

Aims Hierarchy and leadership are essential within any multidisciplinary team. However, to err is human and team leaders can make mistakes irrespective of seniority. It is important that everyone within the team feels confident in raising concerns to ensure patient safety. This can be particularly challenging for new staff joining established healthcare teams. The Advanced Paediatric Life Support (APLS) Group recommend the PACE approach as a structured method for raising concerns. We aimed to improve the confidence of new children’s nursing staff in raising concerns by introducing teaching on this topic into their induction simulation session. Methods New nurses undertook a simulated clinical scenario in which the doctor was deliberately hesitant and reluctant to administer appropriate treatment. Teaching was then provided on the PACE approach. Each nurse then participated again in a similar scenario. Using pre and post questionnaires we asked the 23 participants to suggest on a Likert scale how confident they would feel in challenging a nursing colleague or doctor if they had concerns about their practice before and after the session. During the debrief of the first scenarios we asked participants how they had felt. Results There was no difference in participants’ confidence between challenging a nurse or doctor (3.4/5) prior to training. Following the initial scenario the nurses reported feeling ‘ frustrated ’ and ‘ scared ’ . One stated ‘ this is my worst fear. ’ After the PACE teaching and subsequent scenarios nursing staff stated that their confidence in challenging nurses and doctors had increased to 4.3/5 and 4.2/5 respectively. Free text comments included: ‘Hearing from doctors that they would rather be challenged was reassuring.’ ‘Improved my confidence to speak up when querying a decision’ Conclusion Nursing staff reported improved confidence in their ability to raise concerns. This can only serve to improve patient safety. We have subsequently embedded PACE training within all our medical and nursing induction programmes.

­ A 9-month-old boy presented to the emergency department with acute wheeze. He had a background of cleft lip repair at 4 months and was awaiting palatoplasty. He had mild eczema but had never had a previous wheezy episode, and was awaiting cardiology follow-up for a small patent ductus arteriosus (PDA). He had been at the child minder when symptoms began abruptly with no witnessed event. On assessment, the wheeze had resolved, saturations were 98% breathing air, respiratory rate was 34 breaths per minute and he was afebrile. He was discharged home with safety net advice. He represented 2 days later with cough, wheeze and shortness of breath. On examination, he had subcostal recession and there was reduced air entry on the right. There was no wheeze, crepitations or obvious organomegaly. Oxygen saturations were 98% breathing air, respiratory rate was 38 breaths per minute and he was afebrile. Oral amoxicillin was given. Questions Given the history what is the likely diagnosis? Bronchiolitis Congestive heart failure Foreign body aspiration Pneumonia Reactive airways disease Which investigation would be most useful at this stage? Bronchoscopy Chest X-ray CT chest Echocardiogram Point-of-care respiratory strip What is the next step in the management? Intravenous ceftriaxone/clarithromycin Intravenous diuretics Needle thoracocentesis Oral steroids and inhaled bronchodilator Rigid bronchoscopy What are the long term complications of an undiagnosed foreign body? Answers can be found on page 2.

One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. A small proportion will have other rare, but important, diagnoses such as foreign body aspiration, anaphylaxis, gastro-oesophageal reflux, congenital anatomical abnormalities or other chronic lung diseases. Clinical assessment should try to classify children into either episodic viral wheeze or multiple trigger wheeze phenotypes. In clinical practice children rarely fit neatly into either category and the phenotype may change overtime. Clinical examination may well be normal in a child presenting with chronic symptoms. Urgent outpatient review should be considered for symptoms present from early infancy, chronic wet cough, failure to thrive or systemic involvement. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy. Children with high-risk features on assessment should be treated immediately with inhaled bronchodilator therapy. Those with intermediate risk should be treated immediately with bronchodilator therapy and reassessed 15-30 minutes later. Intermediate-risk children who respond and low-risk children can be managed at home with bronchodilator therapy via a spacer device.

A healthy 15-month-old girl presented to the emergency department with a 24-hour history of fever and rash. The initial blanching rash developed into non-blanching areas with associated leg swelling. She had received no recent medications, had no known drug allergies and no unwell contacts.On examination, she was feverish at 38.6°C, capillary refill time was2 s with warm peripheries, heart rate 169 bpm and blood pressure 94/59 mm Hg. A palpable purpuric rash was evident on all four limbs and face (figure 1) although the trunk was spared. Her legs were tense and oedematous to the knee.edpract;103/1/25/EDPRACT2016311782F1F1EDPRACT2016311782F1Figure 1Rash at presentation.Initial investigations: Haemoglobin level: 131 g/L, white cell count: 16.6×10What is the diagnosis? Henoch-Schonlein purpura (HSP)Meningococcal septicaemiaAcute haemorrhagic oedema of infancy (AHOI)Vasculitic urticariaGianotti-Crosti syndromeWhat further investigation is required? Check viral serology including Epstein-Barr virus and hepatitis B virusComplement levels and autoimmune screenSkin biopsyLumbar puncture and audiologyNo further investigationHow should this child be managed? Complete 7 days of ceftriaxone treatmentOral aciclovirOral steroidsRegular follow-up with urinalysis and blood pressure monitoringStop antibiotics if cultures were negative at 48 hours and discharge

Needle cricothyroidotomy is a simple but potentially life-saving emergency airway manoeuvre used to provide oxygenation during a ‘cannot intubate, cannot ventilate’ (CICV) emergency.1 ,2 The procedure involves inserting a large bore cannula through the cricothyroid membrane and can be performed in patients of all ages.3 It is, however, only a short-term oxygenation solution prior to insertion of a definitive airway.1 The procedure is taught on Advanced Paediatric Life Support (APLS) courses where focus is on needle cricothyroidotomy insertion and not subsequent airway utilisation.3 This along with the rarity of this emergency means practical experience is lacking. Problems, such as equipment availability and poor assembly, would likely arise when the manoeuvre is required, which could be disastrous during this time-critical emergency. In this study, we show that introduction of a simulation-based training bundle improves: 1. Successful simulated patient oxygenation 2. Time taken to oxygenation 3. APLS provider confidence Invited APLS providers within a tertiary paediatric hospital were given the same hypothetical CICV scenario where a simulated patient has a needle cricothyroidotomy airway in situ. The project was registered with the local trust governance department. Candidates were asked, within a maximum time of 10 min, to collect and assemble suitable equipment to oxygenate or ventilate the patient. Candidates were then shown a standardised video tutorial on needle cricothyroidotomy and introduced to a procedure pack containing all necessary equipment used within the …