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THE PRINCE CHARLES HOSPITAL CHILDREN’S EMERGENCY

DEPARTMENT

PAEDIATRIC EMERGENCY MEDICINEORIENTATION & ACCREDITATION

PROGRAM

Paediatric emergency Medicine Orientation and Accreditation ManualTPCH Children’s Services revised Dr MZ Pandie Jan 2017- review date Feb2017 v3.0 (MCQ and pre-reading updated June 2017)

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Orientation and Accreditation

CONTENTS PAGE

Introduction: The PEM Team, ED Processes 3

The PEM Team 4The PEM Consultants 5Children’s ED Senior Registrars 6CED Registrars 7Children’s Services Night Team 8CED Residents and Med students 9NEAT targets Key Performance Indicators 10

Home discharge planning 13‘When to come back to ED’ 14

Roster related Matters – Rules and Leave Requests 15

Mandatory PEM Term Requirements 18

Other PEM Courses 21

Registrar Education 23

Work Unit Guidelines 28

Clinical Practice Guidelines 29

Resuscitation Calculation 30

ISBAR handover tool 31

CED MCQ mandatory Competency Package 32

Registrar PEM log for block rotation 39


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Introduction

Welcome to The Prince Charles Hospital Children’s Emergency Department (CED). We hope you thoroughly enjoy your time with us and have collated this orientation and accreditation package to help your transition to the world of Paediatric Emergency Medicine (PEM). If at any time you need help during your PEM term, please do not hesitate to ask – we have a team of dedicated Paediatric Emergency Medicine (PEM) Physicians, Emergency Physicians (FACEM’s), Paediatricians and Senior Children’s ED nurses who are there to support you in providing world class care to children with acute care needs.

This guide should be used in conjunction with: The Adult & Children’s Emergency Department website – tpched.org Prince Charles Hospital Junior Doctor Orientation handbook


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THE PAEDIATRIC EMERGENCY MEDICINE TEAM

The ‘Paediatric Emergency Medicine (PEM) Team’ is composed of:

The Director of Paediatric Emergency Medicine (Dr Zaahid Pandie)

The Directors of Paediatric Emergency Medicine Training (Dr Alaa Ibrahim &

David Wood)

The NUM of CED (Amanda Smith)

The CNC of CED (Tanya Mountford)

The PEM ED Consultant (PEM, FACEM)

The CED Senior Registrar (usually 3 or 4 SR’s)

The PEM Registrar (ED or PEM or PAEDS)

The CED Nursing Team – CN or RN or EN

The CED Nurse Practitioner (roster permitting)

The PEM ED or CED SHO – an SHO training in PEM, ED or Paeds.

The PEM Resident/s (RMO or SHO or JHO)

The PEM Medical Student

The PEM team is supported by a team of other health professionals

The General Paediatric Consultants and Registrars

The paediatric ward nurses

The Adult Emergency consultants, registrars and nurses working in a

combined resuscitation zone

The Paediatric pharmacist, dietician and physios


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THE CLINICAL DIRECTOR OF PAEDIATRIC EMERGENCY MEDICINE

The Clinical Director of PEM for the Children’s Emergency Department (CED) is responsible for the overall administrative, academic, organizational and clinical functioning of the CED. The Director is responsible to the Director of The Prince Charles Hospital Emergency Services and functions in the capacity of a Deputy Director of the Emergency Service.

*The Director of PEM is available 24/7 on Ext 6945 or via Switch for administrative emergencies within the CED, Children’s SSU or Ward.

THE NURSE UNIT MANAGER FOR CED

The NUM is responsible for all administrative and clinical nursing duties that arise from the Children’s Emergency Department.

CLINICAL NURSE CONSULTANT OF CED

The CED Clinical Nurse Consultant provides clinical expertise and leadership in the acute clinical area. They manage complex situations, providing support and direction to the staff.

The PEM CED CONSULTANT

The CED team will be led by the ‘Paediatric Emergency Medicine (PEM) Consultant’. This consultant may be drawn from the Paediatric Emergency Medicine stream or the Emergency Medicine stream.

The PEM CED Consultant will drive the care delivered to children in CED.

Our aim is for all patients to be seen within 20 minutes of triage (with category 1 & 2 patients seen immediately) – the PEM CED Consultant will often delegate or allocate patients to registrars or juniors as workload and work flow requires. All PEM patients should be discussed with the PEM consultant or Senior Registrar. This consultation is to occur early in the patient journey, at the latest – by 90 minutes – this is the EARLY SENIOR REVIEW POLICY of the CED.

The PEM ED Consultant usually carries the ‘Dect Phone’ and is available 24/7 for consultation ON #6956 or after hours through the switch board (dial “9”).

‘DAY’ Children’s ED PEM Consultant (0800-1800) – Responsibilities #6956 Supervision: Of all doctors (residents or registrars)

Patient Flow: In Children’s Acute, Fast Track areas, SSU and combined Resuscitation area in General ED

Clinical Duties: Member of the paediatric resus team. Responsible for admissions to Children’s SSU, the SSU ward round and assists the registrar/RMO in the review of these patients. Functions as a clinical and administrative supervisor of the department but may have a clinical load.


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The ‘Senior Doctor’ icon in EDIS should reflect all patients seen, reviewed or discussed by the PEM Consultant.

EVENING Children’s ED consultant 1300-2300 and on call for the service #6956Upon commencement at 1300 Duties include :

Provides lunch relief for Day consultant at 1300

reviews ‘Did not wait’ patients

Supervises Teaching of Residents and Med students Mon & Tue at 1400-1430.

Performs CSD when not needed for additional support to resus team or on the Floor.

Formally takes over clinical Duties and supervision at 1700 (for further information see PEM ED Duty consultant responsibilities above)

The Children’s ED Senior Registrar (CED SR)The CED SR will function as the second senior decision maker on the clinical floor in CED & SSU – their role is to complement the CED Consultant.

SR Duties include:

Early Senior Review.

Driving the efficient assessment of patients by providing an Early Senior Review within 20 min and allocating patients to residents and med students with: Cat 1 & 2 patients to be seen immediately, and Cat3-5 patients to be seen within 20 min (case load, casemix and staffing dependent)

Disposition Plan at 90 min.

Aiming that all patients have a management / disposition plan by 90 min.

SSU 0700 ward round. The Night CED Reg and morning SR should coordinate the discharge of patients suitable for an early morning discharge.

Co-ordinate the care of patients by allocating patients to residents and medical students, and proceeding to complete a focussed history and examination with the CED resident / med student.

Supervise residents according to the Supervision Guide (see later) All patients seen by residents or med students and supervised by SR’s are

to be physically seen and assessed by the Senior Registrar SR’s should maintain their own patient load depending on department

workload and case-mix. CED Resident Teaching 1400-1430.

E1400-2400 shift – SR’s will commence with their resident team for the evening shift and generally start with a Teaching session for residents on Mon & Wed 1400-1430. See detailed Website 10 week Program.

In Situ Simulation – SR's will assist with facilitation and debriefing of the in situ simulation program which take place every Tuesday 1400-1500.


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Medical Student Clinical Examination Program. Thursday 1400-1500. (bed side tutorials) on Thursdays 1400-1500, concentrating on history and examination skills focussing on systems examination in children. Discuss with Dr Pandie and Dr Lisa Gotley for more info.

JEDI Program – Junior Doctor Initiative – ED SHO Teaching – Thursday 1400-1500.the SR will be involved in teaching on the ED SHO program - 1400-1500 on Thursdays ( see Drs Pandie and Rule for more info – review website program)

Audit responsibilities – The SR is usually assigned to review the documentation for CED – but may be allocated other audits as per the Audit Consultant’s request (Drs Linda Symington / CED SR Portfolio)

Medical Student Supervision – the SR is chiefly responsible for allocating patients to the med student to review and then manage. A med student is allocated on most shifts.

SR Portfolio – SR's will be allocated a non clinical portfolio for the 6 month term. The portfolio will be allocated by the DEMTs and CED Director considering peopls interest areas and other commitments.

THE PEM REGISTRAR, GENERAL PAEDIATRIC REGISTRAR, PEM RESIDENT & PEM MEDICAL STUDENT

The PEM Team will aim to attend to all unwell patients (ATS 1 or 2) immediately.

The PEM Team will aim to see patients triaged with ATS 3,4 or 5 within 20 minutes.

The PEM Team will aim to have a PEM Consultant or Senior Reg review within 90 minutes of the patient’s arrival at Triage.

These internal targets will be dependent on workload, case mix, the state of the department and staffing numbers on a given shift.

The rationale behind these aims is that children often will present well initially and may deteriorate rapidly.

THE PEM REGISTRAR

The ‘PEM registrar’ will be responsible for the timely assessment and management of patients in the CED as per the above aims.

‘DAY’ PEM Registrar Children’s ED – 0800-1800 ‘MID’ PEM Registrar 1000-2000 or 1100-2100‘EVENING’ PEM Registrar 1300-2300. Dect Phone #6955 MUST DIVERT

Clinical load: The PEM Registrar will generally carry their own patient load.Patients presenting to the children’s service in all areas – Waiting room, acute, resus and SSU with the supervision of the PEM consultant. Member of the resus and MET team for


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children’s emergencies (however please note that at night with reduced staffing only one of the two night registrars should go). Supervision: Where directed by the consultant, assist in supervising the RMOs in the service

Administrative Duties: Follow up of pathology and radiology tests as clinical load allows

Consults: the PEM Consultant or Senior Reg for clinical assistance

General Paediatric registrar Children’s Service #6979 Clinical load: Primary doctor responsible for the ward patients requiring review or admission to the paediatric ward. Member of the MET team for external children’s emergencies (however please note that at night with reduced staffing only one of the two night registrars should go)Primary assessment of patients presenting to the children’s service in all areas after hours– FT, acute, resus and SSU in conjunction with the evening ED registrar - shares clinical load between the two.

Consults: the PEM ED Consultant on call or Paediatric Consultant on call, as required for clinical or critical care support after hours. Should be involved in care of sick children and early review of babies <3/12 at all hours.

Night PEM Reg 2200-0830 Dect phone #6955 Gen Paeds Dect phone #6979.

The Children’s Services Night Team – The PEM registrar & Gen Paeds Reg

1. Attend combined CED & Gen Paeds handover at 2200hrs

2. After handover between 2200-2300hrs

Paeds Ward Registrar conduct a “walk around ward round” With the Ward TL Visualise the patients, check charts for vital signs, CEWT scores, ensure

fluids and medications are correctly ordered and complete and there are no new problems identified.

CED Registrars:Review SSU patients Visualise the patients, check charts for vital signs, CEWT scores, ensure

fluids andmedications are correctly ordered and complete and there are no new

problems identified.

3. From 2300hrs Ward and CED Registrar to be based in CED overnight UNLESS required on the Children’s Ward.

4. The Ward and CED registrars will be responsible for seeing and managing patients in CED overnight.


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5. Unstable ward patients may require both CED and Gen Paeds registrars to be in attendance.

6. The CED Registrar is expected to assist on the ward as required by workload.

7. Over-night, Registrars will be accountable to both the On-call Paediatrician (for ward admitted patients) and the On-call CED Consultant for patients seen in CED and admitted by to SSU.

8. At 0630hrs the Registrars (Ward and CED Reg) conduct another brief “walk around ward round” of ward and SSU.

9. 0700hrs attend the nursing hand over round & convene with 0700 Senior Reg to facilitate SSU discharge round of appropriate patients.

10. 0700hrs Resident to see new CED patients presenting / as directed by senior reg.

11. 0800hrs attend the joint CED / Paediatric official handover.

THE PEM RESIDENT

The ‘Paediatric Emergency Resident’ will be allocated / directed to see appropriate patients by the Senior Registrar or Consultant. This may include paediatric as well as adult patients in Adult ED - AS THE NEED ARISES if directed to by the consultant.

The PEM resident will generally be allocated to a senior registrar for a given shift and will present patients to this SR.

Should discuss all cases with the PEM ED Consultant / SR BEFORE instigating investigations, discharge or referral of the child.

The D0700 resident is to see new patients arriving in the early morning to assist the night team complete their ward rounds os ssu and Gen ward.

The E1400 resident will commence their shift at teaching on a Monday and Tuesday as designated on the roster.

The Da0700 resident will commence in Adult ED at 0700 and report to the Night Senior Reg in Adult ED to be allocated early morning duties. The resident will remain in Adult ED unless directed otherwise by the ED Consultant.

THE PEM MEDICAL STUDENT

The ‘PEM Medical Student’ is required to ‘shadow’ the Senior Reg or PEM Registrars OR CONSULTANTS during their rotation in order to grasp basic concepts and work flow processes.


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Students are expected to form part of the team, document notes, see patients under supervision, and plan management with registrars or consultants. All documentation needs to be signed by supervising registrars or consultants.

Residents are not to supervise students.

PEM WORK PROCESSES – Meeting KPIs and Early Discharge Planning

For children presenting to the Children’s Emergency Department (CED)

All children will be triaged by the triage nurses according to the ATS

Early Senior Review by the PEM Consultant or Senior Reg

Patients may have Early Senior review and rapid assessment by a Consultant or Senior Registrar before assessment by the resident or registrar – the child may then be allocated to a junior team member for further evaluation, or management completed by the Consultant or SR if possible.

CED Response Times / Waiting Times

Registrars and residents are required to see patients well within their triage waiting times – if patient load is an issue, the PEM Consultant or SR should be notified.

Cat 1/2 ‘Resus team response activated’ Resus team leader notified and assembles team (combination of adult and Paediatric resus team) for Resus. Generally occurs in the combined General ED Resus area. Patient arrives and resuscitated by team until ‘step down’ de-escalation by team leader - single doctor and nurse then remain responsible for ongoing care.

Cat 2 – Resident /Reg / Senior Reg / Consultant -Aim to see immediately if possible. Must be seen within 10 mins. Triage notifies consultant or Senior Reg that a Cat 2 has arrived. Triage allocates an acute bed - Observations done by nurse on arrival, chart brought in by AO to acute area.

Cat 3,4,5 – Aim to see within 20 min - workload, case-mix and staffing permitting.

Cat 3 – Must be seen within 30min. Doctors log onto patient on EDIS; Chart brought in by AO to acute area (or if appropriate left in waiting room for fast track review.)

Cat 4/5 – Must be seen within 60min. Doctors/nurse practitioners/physios log onto patients and review patients in the FT or acute rooms where clinically relevent– patients returned to waiting room ASAP to keep rooms clear. Note FT area has no nursing staff allocated to the area.

Senior Review at 90 min


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Note: All children to have a PEM ED consultant or Senior Reg Assessment, management and Disposition plan at 90 min where feasible.

Default Location = Waiting Room

Due to a premium on space in CED, once an assessment is completed, all children should be moved back to the waiting room if they do not require continuous monitoring.

Rounding

Ideally, the PEM consultant, SR, PEM registrar and shift co-ordinator should be ‘rounding’ every 2 hours to assess the progress of the PEM team, identify potential admissions or discharges as early as possible and facilitate communication with parents. This may not always be possible due to resuscitation, procedural and other workload commitments.

Children’s department handover – combined PEM CED / Paediatric Ward

Occurs at 0800,1700 and 2200 in the Children’s service meeting room. Outgoing staff handover care of existing patients in Children’s ED and SSU to the incoming team using the SBAR format (See Appendix 4).All staff attending handover should sign a “Handover Registration” sheet to verify attendance

A brief plan and name of the doctor taking over care should be documented on EDIS.

Guidelines on tpched.org - Evidence Based Paediatric Emergency Medicine

PEM patients should be managed according to current recognised evidence based guidelines which are available in the department on the ‘tpched.org’ website or as physical ‘flipcharts’ in the PEM area. Registrars and residents should be practicing within the boundaries of these guidelines, in consultation with the PEM ED Consultant.

Clinical judgment and expertise by PEM ED or Paediatric Consultants always takes precedence over generic guidelines for individual patients.

A review of the guidelines used in the department form the core of this competency PEM package, along with a basic MCQ test of the relevant guideline documents.

Imaging for PEM patients All CXR, AXR & C-spine XR imaging needs to be discussed with and approved bythe PEM ED consultant or Senior PEM Reg. This is to reduce unnecessary imaging in paediatric patients (particularly in asthma and bronchiolitis).

Pathology for PEM patients


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Cannulation or venesection in children is painful and traumatic –patients who may require further lab investigation beyond simple BSL, urine and Peak Flow tests should be discussed with the PEM ED consultant or Senior PEM Registrar.

Clinical notesPEM patients should have their notes written in the password protected area in EDIS. Clinical notes must be printed and put in the chart once documentation has been completed.

NEAT Targets, admissions & the ‘4 hour rule’

The majority of children managed in the PEM Service at CED will either be discharged or admitted to the Short Stay Unit for observation.

Patients should be assessed in a timely fashion and referral of obvious admissions should be made within 2 hours of arrival to ED.

Early senior intervention and review at 90min should make this possible.

Children admitted to SSU: Should have fluids, medications and instructions written up and signed on the

SSU admission form on the back of the medical Proforma / on SSU Documentation.

Clinical responsibility for SSU patients is the emergency doctor who admitted the patient to SSU, with oversight from the PEM ED Consultant or SR.

At handover, SSU patients should be allocated on EDIS to the new team member assigned to the patient. (See Children’s SSU WUG for further details)

Criteria Led Discharge – There is currently a trial for a number of common conditions for criteria led discharge by senior nurses on the ward. Please discuss the case with the Consultant or Senior registrar to ensure patient is appropriate for criteria led discharge before completing the criteria led discharge paperwork. Further education will be provided on the floor about this process.

Children admitted to the Children’s ward TPCH:

Will be referred to the General Paediatric registrar (24/7) and will be reviewed in CED where possible.

If inpatient review is delayed or if the patient is likely to breach 4 hours in ED, patients should be discussed with the Consultant Paediatrician

Early transfer to the ward should be discussed with the paediatric registrar or consultant once they have had a chance to review the patient, and if deemed suitable. The full admission paperwork and documentation can thus be completed in the inpatient ward if deemed suitable.

Handover of clinical responsibility for the patient occurs at the time of acceptance of the admission, however outstanding procedures at the time of acceptance may be performed by either team, according to clinical load or expertise.

Children requiring acute admission to paediatric subspecialty medical or surgical units: Paediatric emergency Medicine Orientation and Accreditation ManualTPCH Children’s Services revised Dr MZ Pandie Jan 2017- review date Feb2017 v3.0 (MCQ and pre-reading updated June 2017)

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Children requiring Paediatric medical subspecialty referral should be discussed with the TPCH Paediatric team prior to referral where practicable.

Children requiring Paediatric subspecialty surgical referral should be discussed with the PEM ED consultant or delegate (registrar) after hours and referred via the relevant subspecialty registrar at the receiving hospital.

Various WUGs for TPCH exist to guide this process to various subspecialty units – please see the TPCH intranet and folders in the Fish bowl area for details

Transfer and retrieval procedures are available to guide these processes.

4. CHILDREN REQUIRING OUTPATIENT REFERRAL (children’s service WUGs can help guide this process – see intranet and folders)

General Paediatric outpatient referral Review and/or discuss with the Paediatric Consultant for follow up in Children’s outpatients if a cat 1 (within 1 month) referral is required. If follow up required in longer than 1 month then refer back to the general practitioner for referral to TPCH Children’s OPD.

Subspecialty outpatient referral – subacute (within a week) Will need to be discussed with the subspecialty registrar at RCH or MCH and acute review organised and approved. Give parent directions form (available on intranet)

Subspecialty outpatient referral – routine: refer back to GP for onward referral.

5. CHILDREN WHO ARE DISCHARGED HOME – EXPERT DISPOSITION PLANS

90% of PEM patients seen in the CED will be suitable for discharge. This predicates the need for ‘EXPERT DISPOSITION’. Parents and carers should have appropriate discharge information, scripts and letters for communication of their child’s presentation for the general practitioner, follow up review in CED or public or private Paediatric Consultant review in Outpatients.

Discharge letters Clear discharge letters need to given to parents/carers or faxed to the GP when discharged – most children with acute illness will need review by their GP or rarely in the CED within 24-48 hrs, as per clinical guidelines or consultant discretion.

In most cases the letter should be formed from the back of the medical proforma, photocopied and sent to the local doctor, or simply a copy of the patients notes typed.

In complex cases it may be appropriate to do a separate typed letter but this should be the exception. .

Expert ED follow-up within 24hours

Most patients can be reviewed by their GP as follow up.However, some PEM patients may require review by the PEM Team within a 12-24 hour period. Please endeavor to plan this with the PEM & Triage team and ensure adequate communication of the plan.


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Fill out the EDIS expects screen Provide the patient’s carer with documentation to reflect this follow up

plan.

Discharge Parent information Queensland Health or TPCH endorsed information sheets, or RCH

Melbourne information sheets. Links to a lot of these handouts are available on the ED website. If you are unsure of what to give to parents, discuss it with the PEM ED consultant.

Good discharge counselling forms part of Expert Disposition Planning. ‘To Come Back Information’ needs to be clearly outlined to parents.

TO COME BACK’ INFORMATION: Most children should return to ED urgently if the following is present:

A. Noisy Breathing – stridorB. Fast breathing or Difficulty breathing C. Lethargy (especially in the absence of fever)D. Drowsiness or Confusion or not responding normallyE. A new rash or a marked change in a previous rashF. Persistent vomiting or inability to tolerate oral fluids

ROSTERING PRINCIPLES FOR CED

1. LEAVE REQUESTS, LEAVE LOG and the REQUESTING WINDOW PERIOD


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CED will give registrars and residents the opportunity to request leave within a ‘requesting window period’ – this window period will allow doctors to request leave via the email: [email protected] This is then entered on the leave log covering 3 months of the roster.

7 weeks prior to the next 3 month roster, the window period will open for 1 week ONLY. Regular texts and emails will be sent as a reminder regarding this window. Requests outside of this period will be considered on a case by case basis.

THE LEAVE LOG – viewing of the leave log available with Kim The CED can generally only guarantee 2 registrars and 2 residents on leave at any given time – the leave log will be transparent to allow registrars/residents to view exactly where in the calendar leave is available.

PLEASE CONSULT THE LEAVE LOG BEFORE REQUESTING LEAVE SO THAT YOU ARE APPLYING FOR LEAVE IN SLOTS THAT ARE AVAILABLE.

2. HOW LEAVE IS PRIORITISED AND ALLOCATED

FIRST PRIORITY – EXAM LEAVE1 -2 weeks of leave will be quarantined prior to ACEM or RACP exam dates to allow exam candidates to access leave equitably. Where more than one registrar requires exam leave, this period will be shared amongst respective candidates. Study leave is regarded as the first priority with leave requests.At the discretion of the roster team, the DEMT or the CED Director, additional training days may be offered in lieu of leave if leave is not available, in keeping with the above policy.SECOND PRIORITY - EMERGENCY FAMILY LEAVEWill be considered on a case by case basis.THIRD PRIORITY – FIRST COME FIRST SERVED FOR ANNUAL LEAVE REQUESTSGenerally 2-3 week periods of leave will be available in a 6 month period or term. If leave is available on the leave calendar log – longer periods may be approved. Leave is also approved based on how much leave has already been taken by individuals during a 6 or 12 month period across both kids and adult ed. ROSTERED DAYS OFFRostered days off are requests for single days or 2-3 days (like weekends) only. If you would like a week off you will need to plan it as annual leave as rostered days off are not guaranteed.CHRISTMAS AND NEW YEAR / RELIGIOUS FESTIVALSPeak periods of the year such as Christmas and New Year will not be open to annual leave requests via the leave log. In general, either 1 of these holidays can be rostered as ‘OFF’ and staff will be asked to nominate one or the other.

3. ON CALL

Each day of the roster is covered by 2 ‘on call’ doctors – a resident is first on call, a reg is second on call. Thursdays are covered by 2 of the (T) training doctors.


mailto:[email protected]

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CED staff will not be recalled unless absolutely required to avoid unnecessary overtime and fatigue penaltiesAs part of the roster medical officers will be rostered for a 24h period of on call duty, providing essential cover for unexpected staffing issuesThe on call medical officer may be required to cover any shift during the 24h period of on call, including night duty.The on call medical officer must be available at all times to respond within one hour of a request to attend.The on call medical officer will be allocated to either GED or CED but may be requested to work in either department if directed by the supervising consultant or senior registrar (after 2300h).The on call medical officer may be requested to attend to cover sick/urgent leave or when there is need for more staff in either sections of the emergency department.

4. SWAPPING SHIFTS

Medical officers of the same level may arrange to swap shifts with each other.Any swaps must be submitted in advance to the roster management team (Kim

Charlouis) at least one week in advance.An AVAC form should be completed, signed and submitted to ESO CED.

5. SICK (OR OTHER URGENT) LEAVE

The medical officer must follow the sequence below:1. Notify the CED duty consultant (or senior registrar) on 6956

2. Contacts the AO on 6285 – On the weekend please leave a voice message so sick leave can be documented correctly

3. Once returned to work, the medical officer must complete an AVAC for all days not worked.

If the period of sick leave has been for 3 consecutive days or more a medical certificate must be provided. The CED registrar will be responsible for providing timely notice of their sick leave.

AVAC APPROVED OVERTIME PROCESS: 1. Overtime needs to be requested or approved by the ed consultant or the Senior reg in kids ed. Please print this persons name clearly in the description of details in your AVAC. 2. The authorizing consultant or senior reg needs to countersign the AVAC. 3. A short description of the reason for overtime as well as the ur number of patients cared for during the overtime is required. 4. Overtime work is greatly valued and appreciated by the TPCH team but in order for approval it needs to be CLINICAL work conducted in the care of patients.


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If any problems with any of the above please discuss with Dr Pandie. All AVAC's are signed off by Dr Pandie or a delegate of the Director of Children's ED if he is on leave.

MANDATORY PEM REQUIREMENTS during a term in CED

The following mandatory requirements apply to all Consultants, Registrars, Residents and medical students working in or due to rotate through CED.

KEY REQUIREMENTS – PLS REVIEW ON WEBSITE TAB – PEM TERM MANDATORY REQUIREMENTS

1. Orientation package and mcq intro competency (wk1-2)2. Complete the TPCH resuscitation trolley checklist including

worksheet and pemsoft calculator backup (wk1)3. Complete online resucitation modules – rmdpp a and rmdpp c


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4. Read all guidelines and work unit guidelines (wk2-3)5. Procedural sedation package (see demt and website)6. Child safety online course

(http://qheps.health.qld.gov.au/csu/edumodule.htm

7. Critical airway management package (see demt and website)8. Paediatric trauma course online (pact) and trauma workshop

(DEMT’s to notify) 9. Asthma competency (see website for details)10.Bronchiolitis package (see website for details)

ORIENTATION MANUAL

ALL CONSULTANTS, REGISTRARS, RESIDENTS & MEDICAL STUDENTS ARE REQUIRED TO HAVE READ THE DOCUMENTS AND GUIDELINES RELATED TO THIS ACCREDITATION PACKAGE.

Tour of CED & Orientation to the PEM area, work processes, EDIS etcOrientation to the Electronic systems should have formed part of your general hospital orientation. If you have issues with any of the electronic systems used in CED please approach the CED consultant for info.

Children’s Service layoutThe Children’s ED 12 Acute Bays 3 Clinic/FT rooms Procedure/procedural sedation room Plaster room and Eye/ENT room 5 Shared resuscitation beds (including trauma room) all stocked for children’s

emergencies

Children’s Ward and SSU 20 Bed ward SSU - 12hour, Ward multiday stay

Children’s OPD 8 clinic rooms and waiting area

CED - Tour key points On your first day in CED, one of the staff should take you through this tour

CS Meeting room and admin offices

Handover registration sheet, EDIS and computer, handover checklist

CS tea room, toilets, lockers, library

Balcony, drinks for sale, single day use lockers


http://qheps.health.qld.gov.au/csu/edumodule.htm

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CS Acute Fishbowl ID board –everyone to have current phone number note need to divert phones, note nursing names

CS Acute Computer – quick overview of EDIS in operation, how to find various different icons

CS Acute Lampson tubes –blood forms & sending bloods – do not use large bore tube – pathology to be sent from gen ED acute until fixed

CS Acute Forms, protocols, Procedures and WUGs, distraction box, Blue orientation folder

CS Acute Doctor team leader and nurse team leader stationCS Acute Central monitoring –ability to trace back in timeCS Acute Fax machine and photocopier –all computers in acute link to hereCS Acute Results black trays –checking processCS Acute Admitting officer desk –chasing old notes, getting information from other

hospitalsCS Acute CS Acute Cubicle 1-12CS Acute Equipment trolleys, ISTAT, fluid and blanket warmerCS Isolation Used for infectious isolation,CS Plaster room

Equipment, plaster trap, check cupboards

CS Procedure and procedural sedation room

Resuscitation equipment, whiteboard, Dressings, suture materials. Open cupboards. Quantiflex machine.

CS Acute Patient toilets and beverage bay for parentsCS Waiting room and triage

Instruct on where to find notes, bringing patients into fast-track or acute and making sure that department map is up to date and nursing staff in agreement,

CS Fast track rooms

No nursing support for these rooms. If need nursing duties performed talk to shift co-ordinator

Corridor behind triage

Cosycot Resuscitaire and neonatal resuscitation equipment

Resuscitation shared

Resus 1-4 with 5 and trauma being built

Resuscitation Resus 4 as the largest cubicle –try to keep free for major cases; Note radiology viewer on wall opposite Resus 4. Point out location of different equipment trolleys especially the Paediatric resus trolley and areas. Note radiology system is portable and no overhead gantry except in trauma room

Resuscitation Blood gas analyser – talk about training; portable gear for transfer, Ultrasound machine and Combined Adult and paediatric MET packs – note two which are identical and are also used for transfers

Resuscitation Write up area and board to write up Children’s Resus team after each handover

Sim area, Transfer Equipment room

Manequins, Equipment and where to wait prior to Thursday morning Sims

Corridors down to back of adult ED

Office corridor pointing out secretary office, main education rooms, Door to main cafe, toilets and change room

Radiography Work room –where to find radiographers, ordering an Xray, inbox forforms and radiology reporting room to find Radiologist for requests

CS SSU and ward

Write up area, beds, charts, beds equip, Staff station, Ward resus trolley

The End Should have completed full circle –Any questions!

Guidelines, Work Unit Guidelines

Clinical Practice Guidelines (CPGs) & Work Unit Guidelines (WUGs) The CPGs in the orientation blue or red folders in CED fish bowl and the contents of the WUG folder are to have been read prior to or within 2 weeks of commencing rotations through CED. This needs to be signed by Director of PEM Training or


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Director of PEM as part of Mandatory requirements. (see appendix 1 and 2 for list of WUGs and Clinical procedures (use blue folder))

PEM Accreditation and MCQ Program

A short set of MCQ’s (with relevant referenced pertinent articles and guidelines) is required to be completed before or during the first 2 weeks of the rotation into CED. The MCQ is attached in appendix 5 at the end of this manual. Please submit to the Director of PEM Training in the specified time frame.

RESUSCITATION COMPETENCY

All consultants, registrars and residents are required to have completed ANY 1 of the following PLS courses before or during their tenure in the CED:

APLS 3 day course (current) PLS 1 day course (current) or RMDPP equivalent Skills development centre resuscitation online module + TPCH CED Practical

Resuscitation Module (see Director PEM Training)

All staff working in the children’s ED should familiarise themselves with the following WUGs on resuscitation early on in their rotation

Children’s Medical Emergency Response Team Trauma Activation Protocol ED resus Team

They should also familiarise themselves with the following resources which are available on the resus trolleys

Resus flow charts Resus calculations sheets Appendix 3 Resus Calculator on PEMsoft

Available resus equipment should be explored especially the equipment available in the

MET pack Resus trolleys Cosy cot resuscitaire

For further information please contact the CED consultant or the Director of PEM training

RECOMMENDED ADDITIONAL PEM COURSES (NOT MANDATORY REQUIREMENTS)

APLS (3 DAY) COURSENational course acknowledged as the international standard in paediatric resuscitation training. The APLS learning environment is interactive, practical and covers all aspects of the emergency management of children, taught by leading paediatric specialists.


21

Lectures are supported by emergency scenarios, practical sessions, video and skills workshops in small group sessions. A comprehensive course manual is also provided to all candidates for pre and post-course referenceSee https://www.apls.org.au/course/advanced-paediatric-life-support for further details

THE ADVANCED PAEDIATRIC EMERGENCY MEDICINE COURSE (APEM - http://www.apemaustralia.com)The APEM Course (apemaustralia.com) is a 3-day intensive Specialist PEM course aimed at front line decision makers managing children in acute care settings. It covers the ACEM curriculum for PEM, exploring the international evidence base behind some of the common local and international guidelines for common PEM conditions, providing updates on new advances in the field of PEM. The course is a combination of interactive case based workshops, lectures and video based scenarios that immerse candidates in the field of cutting edge PEM. APEM is fully accredited with ACEM for 12 MOPPS points and is highly recommended for senior nurses or NP’s, residents, registrars or consultants to attend for purposes of further professional development or ACEM Fellowship preparation. Pre-reading resources, website access, an APEM Manual with reference list, and an APEM Exam Handbook (for ACEM Fellowship candidates) are all provided. See the website for further details.

The PAC conferenceAnnual conference update on PEM run by APLS.

PECRM – Paediatric Emergency Crisis Resource ManagementRun by the Clinical Skills and Development Service at the Skills Development Centre PECRM is a one day course designed to help doctors and nurses to improve their management of paediatric emergencies by applying Crisis resource management skills in a simulated environment

APICS – Advanced Paediatric Intensive Care SimulationRun by the Skills development centre this is a 3 day course that covers Paediatric ICU topics based on the JFICM curriculum, including specifics on managing children requiring ventilation and inotropic support, amongst many other tidbits useful to PEM.

Diploma in Child Health (Online Distance learning)Offered through Westmead Children’s Hospital in Sydney, the DCH offers Emergency Consultants, registrars or residents the opportunity to develop a broad depth of knowledge regarding Paediatric Medicine, with the options to tailor the Diploma to the candidate’s specific needs. The DCH is convertible to a full Masters in Paediatric Medicine with the University of Sydney.

RESOURCES FOR USE ON THE FLOOR

Folders: TPCH Clinical guidelines and Procedures and blue folder (updated versions), TPCH WUGs, Resuscitation flipcharts These are available in the “fish


https://www.apls.org.au/course/advanced-paediatric-life-support

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bowl” of CED and a contents list is available at the end of this document. They are your first stop for guidelines until loaded on the website

tpched.org website – contains guidelines and other useful resources

Royal Children’s Melbourne Clinical practice Guidelines –www.rch.org.au. A resource available via the web which should be used for managing conditions where TPCH CED does not have a specified endorsed guideline.

The Textbook of Pediatric Emergency Medicine – Fleischer et al –PEM reference for TPCH CED, and Rosen’s Emergency medicine. A copy is permanently available in the PEM area, the GED or CED Library. It is excellent for reviewing difficult cases, or generating differentials for less common presentations.

Paediatric Pharmacopoeia - official reference for paediatric dosing in TPCH ED. Available on QHEPS intranet, but hard copies are available from Dr Z Pandie – to be returned at concluding the term in PEM. Please do not use MIMS as a dosing reference.

PEMSOFT is a useful basic reference for PEM on the floor, but it is not specialist level knowledge and thus is less useful for ED registrars wanting to study for ACEM exam level. The ‘Elbow’ and ‘Upper limb Fractures’ Modules are very useful for easy reference.

All registrars should be familiar with the resuscitation calculator on PEMSOFT as it makes resuscitation calculations very simple. The Toxicology Handbook –for the management of toxicological emergencies in children in discussion with CED consultant or in consultation with a toxicologist where unusual ingestions are involved. Copies are usually available in the CED or the library.

REGISTRAR EDUCATION PROGRAMME CHILDREN’S SERVICE

The CED registrar education programme has been designed around the PEM syllabus for General ACEM training and the Paediatric Emergency Medicine Advanced Training curriculum for RACP. The Department has 6 month Advanced Paediatric Emergency Medicine ACEM Accreditation and is accredited for the critical care component of the RACP Basic trainine pathway.

***ESSENTIALS TO BE COMPLETED DURING A REG TERM***

Pls review this list on the website under PEM Reg Mandatory Term Requirements

11.ORIENTATION PACKAGE AND MCQ INTRO COMPETENCY (WK1-2)


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12. COMPLETE THE TPCH RESUSCITATION TROLLEY CHECKLIST INCLUDING CALCULATIONS WORKSHEET AND PEMSOFT CALCULATOR BACKUP (WK1)

13. COMPLETE ONLINE RESUCITATION MODULES – RMDPP A AND RMDPP C (OR PROVE APLS /PLS /RMDPP CERTIFIIED) (WK1)

14. READ ALL GUIDELINES AND WORK UNIT GUIDELINES (SEE APPENDICES) (WK 2-3)

15.PROCEDURAL SEDATION PACKAGE (SEE DEMT AND WEBSITE)16.CHILD SAFETY ONLINE COURSE(http://qheps.health.qld.gov.au/csu/edumodule.htm

17. CRITICAL AIRWAY MANAGEMENT PACKAGE (SEE DEMT AND WEBSITE)

18.PAEDIATRIC TRAUMA COURSE ONLINE (PACT) AND TRAUMA WORKSHOP (SEE WEBSITE FOR TIMETABLE)

19. ASTHMA COMPETENCY (SEE WEBSITE FOR DETAILS)20.BRONCHIOLITIS PACKAGE (SEE WEBSITE FOR DETAILS)

Education in the month will consist of a combination of 1. Orientation reading and MCQ testing- aimed to familiarise you with

commonly used clinical procedures in the service. Dr Pandie, Dr Wood or Dr Ibrahim will approach you early in your term to discuss this assessment. See Appendix 5 in this document for the MCQs and references required

2. Formal Rostered Children’s Service Training days - occur with the adult training on a Thursday. The sessions will be largely in Education centre room. Layout of the training day in table below and details of topics on “m” drive under M:\EmergencyDept\Medical\Education\Thursday training day. You will notice from the timetable

a. PEM specific program will take place 0830-0930hrs except when workshops taking place.

b. Morning sims occur in the early session. This will be a combination of adult and paeds topics and are allocated by Dr Fahy

c. 11-1 session is Consultant led training and often when topics are Paediatric emergency Medicine Orientation and Accreditation ManualTPCH Children’s Services revised Dr MZ Pandie Jan 2017- review date Feb2017 v3.0 (MCQ and pre-reading updated June 2017)


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relevant the General Paediatric service attends also. d. The afternoon is dedicated to self directed learning and part one and

two training. If you are not sitting an exam joining the General Paediatric training programme at 1500 is mandatory. This also provides time to spend on doing an audit which will be allocated early on in your term.

TimesCombined Programme

Tute room 3M:\EmergencyDept\Medical\Education\Thursday training day

0800-0830 Registrar meeting0830-0930 PEM Session or Combined or Workshop0930-1100

Sim1100-1300 Combined Departmental Topics – eg Resus, M and M, transfer

and retrievals, Journal club, combined meetings

1300-1330 Lunch1330-1500 Consultant Meeting1330-1500 Registrar mandatory training – including procedural sedation,

orientation packages, audits etc1500-1600 Paediatric Ward based training (any ED registrars not doing part

1 and 2 training to attend) CS meeting room1500-1700 ED Primary and Fellowship Training

As part of this training programme you will be contacted throughout the term to present PEM topics for the teaching programme. Please make this presentation relevant to local policies and procedures (available for reference on the ED intranet and in appendix 1 and 2 in this document) and evidenced based (and entertaining if at all possible). You may also be asked to provide talks for the combined sessions including Evidenced based medicine sessions, quality and safety reports and Audit meetings. If this is the case one of the ED/PEM consultants will be tasked as your reference person for this talk

3. Trainee Needs Analysis. Early in the term you should arrange to meet with Dr David Wood or Dr Alaa Ibrahim to discuss your term goals.

a. For advanced ACEM and PEM trainees we expect a combination of PEM Core knowledge, Procedural expertise and then involvement in some of the administration and educational tasks of the department including protocol design, auditing processes and educational tasks. Personal goals for the term can also be discussed at this meeting. Exam based goals are also explored.

b. For Provisional trainees and SHOs who are coming for 6/12 we expect PEM core knowledge, procedural competency and resuscitation competency and full participation in the education programme. Exam based and personal goals could also be discussed.

4. PEM Fellowship training Programme. This is an after hours training


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programme run monthly on a Wednesday evening at TPCH by Dr Alaa Ibrahim and tutored by a number of the FACEM/PEM staff at TPCH and from other Qld hospitals. This is an excellent programme for the PEM preparation component of the Fellowship exam and is open to ED/PEM trainees throughout the state.

5. Teleconferenced talks and meetings and invited speakers. We teleconference in to a number of relevant tertiary level meetings and talks at different times of the week. The RCH grand rounds programme occurs weekly at 745 on a Wednesday (Teleconference at TPCH in Education Centre) however other talks are more sporadic. For topics and room booking information see the Children’s Service Education board on the wall in the corridor near the Children’s service meeting room.

6. Radiology meeting. There is an ED Radiology meeting teleconferenced from LCCH ED every Tuesday and Friday 0900-0945hrs. Please attend providing clinical workload allows. It takes place in the paediatric handover room.

7. Self directed learning. During your afternoon training time you will be expected to utilise your time wisely and log what you do during your time. The Children’s Service library should be largely where you spend this time. Activities during this time should include

a. Orientation competencies required in the earlier portion of the package

b. Mandatory competencies including i. Child Safety training

http://qheps.health.qld.gov.au/csu/edumodule.htm registrars should go through the capability self assessment tool +/- go through the education module available through the site

ii. Procedural sedation training. If not completed components of this training can be completed in this time. See Drs Davison, Rule or Newton

iii. RMDPP core and advanced competency training an online training module supplied free to Q health employees via the SDC (also part of the orientation resus competency) http://www.sdc.qld.edu.au/courses/65?type=e . During your month you will be expected to log on, register and complete the module. We will attempt to allocate you to the practical RMDPP program during your term where possible.

c. Other self directed training eg online modules available through the SDC see link http://www.sdc.qld.edu.au/courses/index?specialtyID=21 Courses of interest include the PACT paediatric trauma course, Paediatric asthma, paediatric diabetes and SUDI safe sleeping course. These are all free to QHealth employees

d. Journal reading – there are a number of very good PEM journals available. An article of the week will also be available on the notice board.


http://www.sdc.qld.edu.au/courses/index?specialtyID=21

http://www.sdc.qld.edu.au/courses/index?specialtyID=21

http://www.sdc.qld.edu.au/courses/65?type=e


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e. Quality and safety activities including clinical audit. Please see any of the consultants for innovative ideas and these can then be presented to your colleagues at teaching and form valuable additions to your CV.

8. On the job training and Bedside teaching. This goes without saying but there is a wealth of PEM knowledge in your consultant’s white matter … tap into it.

9. Skills based training modules with task trainers – see Dr Ibrahim for details

10.Equipment inservices – watch the CS Education noticeboard for info.

11.RMO education – Please let Dr David Wood know if you are keen to deliver a resident topic as part of their education programme – this is a great way to consolidate your own knowledge.

There are also a number of other educational opportunities – courses, conferences etc. The children’s Service education board in the hall way in the offices near the tea room is a good spot to find info on what is on in Paediatric Emergency medicine. Dr David Wood co-ordinates the Paediatric Emergency Medicine training programme and can be contacted to answer any questions surrounding this on #6937 or #5469. Drs Lisa Gotley/Suzanne Royle co-ordinates the General Paediatric training.

RESIDENT EDUCATION IN THE CHILDREN’S SERVICE

Resident Education occurs on a Monday and Tues 1400-1430 and is coordinated by Dr David Wood/SR Portfolio .A formal Program is available for review on the tpcheducation.com website.

SHO Program

TPCH is currently developing an SHO program for ed trainees registered with the college. This program will be available on the tpched.org website.


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Appendix 1List of CS Work Unit Guidelines

Available in your clinical area

Admission to Childrens ward

Childrens MET Response

ED Resus Teams

Handover process

High Flow Oxygen Nursing Management in Infants and Children

Interhospital transfer- Children’s ward

Interhospital transfer- Emergency

Interhospital transfer- Retrieval

Management Burns

Management ENT Conditions

Management Eye conditions

Management Max Fac/ Dental conditions

Management Mental Health conditions

Management Orthopaedic conditions

Management Scrotal pain/swelling

Management Surgical/Urological conditions

Medical Work practice guideline

Medication administration- Nursing

Procedural sedation

Radiology

Sedation for radiological investigations

Short Stay Unit

Trauma activation


http://qheps.health.qld.gov.au/tpch/emergency/paedtraumaactpp.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugshoetstayadm.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugradiologysed.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugradiology.pdf%20

http://qheps.health.qld.gov.au/tpch/emergency/ecswugmgtpsed.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugmedwpguidel.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugsurgcond.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugscrotalpain.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugorthopcond.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugmaxfacdent.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugeyecond.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugent.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cswugburns.pdf%20

http://qheps.health.qld.gov.au/tpch/emergency/csservproctransret.pdf

http://qheps.health.qld.gov.au/tpch/emergency/hiflooxynmpaed.pdf

http://qheps.health.qld.gov.au/tpch/emergency/cshandoverwug.pdf

http://qheps.health.qld.gov.au/tpch/emergency/edwugedresusteam.pdf

http://qheps.health.qld.gov.au/tpch/policy/tpchs13007.pdf

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Appendix 2Guidelines for orientation “in the blue folder in the fish bowl” and on

tpched.org

o Abdominal Pain:QHealth CHQ Procedure “Abdominal pain acute management in children”

O Allergic Reaction: QHealth CHQ Procedure “Allergic reaction emergency management in children”

o Anaphylaxis APLS => FLOWCHART “Anaphylaxis Management”o Antibiotic Guidelines: TPCH Children’s Health Services –

AntibioCard (Version 2) o Asthma : QHealth CHQ Procedure “Asthma acute management in

children”o Bronchiolitis : QHealth CHQ Procedure “Acute bronchiolitis

management in infants”o Croup: QHealth CHQ Procedure “Croup acute management in

children”o Diabetes: QHealth CHQ Procedure “Diabetic ketoacidosis emergency

management in children”o Fever : QHealth CHQ Procedure “Fever acute management in

children”o Gastroenteritis : QHealth CHQ Procedure “Gastroenteritis acute

management in children”o Head Injury: QHealth CHQ Procedure “Head injury management in

children”o High Flow Oxygen: TPCH Children’s Health Services => FLOWCHART (DRAFT)“High Flow Oxygen Policy – TPCH Children’s Health Services”

o Meningitis :QHealth CHQ Procedure “Meningitis management in children”

o Seizures: QHealth CHQ Procedure “Seizures acute management in children”

o Otitis media: QHealth CHQ Procedure “Otitis media management in children”


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Appendix 3Resuscitation Calculations

Weight = (Age + 4) x2 Note this is not the “Best Guess” Calculation used in the PLS Core competency package but is the calculator commonly used and chosen for use at TPCH

Joules – 4J/kg ETT (Microcuff) Age/4 +3.5 Normal Saline – 20ml/kg Adrenaline IV 1:10,000 – 0.1ml/kg Adrenaline IM 1:1000 – 0.01ml/kg Glucose 10% - 2ml/kg Amiodarone – 5mg/kg Atropine – 0.02mg/kg

IV anaesthetic, Sedative and Analgesic Drug doses

Propofol 2.5-3.5mg/kg Midazolam 0.1mg/kg Ketamine 1-2mg/kg Suxamethonium 2mg/kg Fentanyl 2mcg/kg Morphine 0.1mg/kg Vecuronium 0.1mg/kg Rocuronium 0.6-1.2mg/kg


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Appendix 4

Framework for Effective Handover – ISBAR

ISBAR is an initiative developed by the Australian Commission for Safety Quality in Healthcare (ACSQH) to help reduce patient harm as a result of ineffective patient handover. It is a framework that aims to provide standardised consistent handover.

ISBAR is an acronym. It stands for:

I I am ………………. I am the ……………… I am ringing from…….

S SituationWhat is the immediate situation?

Identify Self, Unit, Patient, Room number Briefly state the problem

B BackgroundWhat led to this situation?

Admitting diagnosis, date of admission. Current medications, Allergies, IV Fluids Brief history, Current treatment

A AssessmentWhat do you think the problem is?

Explain your assessment of the patient and how you came to this assessment eg. stable / deteriorating

R RecommendationWhat do you recommend should happen next?I would like you to ….

Review/see the patient now Perform/review tests


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Appendix 5PEM COMPETENCY MCQ TEST (21 questions)

Please complete the required reading before attempting the questions in each section.Guidelines are available at http://www.tpched.org/kids-ed-guidelines.htmlPaediatric ALS guidelines available at https://resus.org.au/guidelines/

RESUSCITATION (Q1-7)

Pre-reading:APLS Introductory Chapters on Physiology, Basic Life Support, Cardiac Arrest & The Seriously Ill ChildARC Guidelines – Paediatric Advanced Life Support

Paediatric PhysiologyWhen considering airway management in children, which one of the following is incorrect:

A. The large occiput in babies results in flexion of the neck and possible airway obstruction. B. The larynx lies at the level of the 2nd & 3rd cervical vertebra. C. Intubation with a straight blade is recommended. D. The larynx is the narrowest part of the airway.

Basic Life Support2. With regard to basic life support in children, which of the following is the correct option:

A. Infants should be placed in a 'sniffing' position when performing a head tilt chin lift manoeuvre. B. Placing a large pillow behind a child's head on a flat surface is an excellent way to facilitate an open airway. C. The depth of cardiac compression is one third the anteroposterior diameter of the chest. D. The correct ventilation compression ratio is 30:2

Cardiac arrest3. With regards to cardiac arrest in children, which of the following is the best option:

A. Asystole may have p waves present on an ECG tracing or cardiac monitor.B. PEA (Pulseless Electrical Activity) usually suggests a perfusing rhythm.C. Pulmonary Embolism is a common cause of PEA in children.D. Adrenaline 10mcg/kg is best administered via the Endotracheal route for the management of PEA.


https://resus.org.au/guidelines/

http://www.tpched.org/kids-ed-guidelines.html

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4. With regards to administering chest compressions in children, which of the following is incorrect:A. CPR may be interrupted to check the rhythm of the patient.B. CPR may be interrupted to intubate the patient.C. CPR should be interrupted to charge the defibrillator.D. The compression rate for children is 100 - 120 per minute.

5. With regard to the Return of Spontaneous Circulation (ROSC) in children, which of the following is the best option:A. ROSC is only indicated by a palpable pulse.B. If the pulse is palpable but less than 100 per minute, CPR should continue.C. Eye opening, spontaneous breathing and a rise in End Tidal CO2 suggest that ROSC has occurred.D. Ventilation of the patient can be stopped if a palpable pulse is felt.

6. With regard to the use of Sodium Bicarbonate during cardiac arrest, which of the following is the best option:A. The routine use of bicarbonate has been shown to benefit patients in cardiac arrest.B. Sodium Bicarbonate has been shown to be of benefit in cardiac arrest due to tricyclic antidepressant overdose.C. Sodium Bicarbonate can be administered via the ETT.D. Sodium Bicarbonate is better than CPR at raising myocardial pH.

7. With regard to Pulseless VT or VF in children, which of the following is the best option:A. VT is more common than PEA in children.B. Amiodarone is indicated for polymorphic VT.C. Amiodarone is specifically indicated for the management of VF/VT in the setting of arrythmogenic drug overdose.D. Adrenaline may facilitate defibrillation by improving myocardial blood flow during CPR.


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FEVER IN CHILDREN (Q8-11)

Pre-reading:Child Health Queensland Guideline: Febrile Illness – Emergency Management in Children. F Thompson et al.Uptodate. Fever without a source in children 3 to 36 months of age. Coburn H Allen.

8. With regard to managing fever in children, which of the following is the best option:A. A high temperature (due to intercurrent infection) may result in neurological

damage to a previously well child.B. A child with a viral illness with a high temperature and an underlying history of

cardiac failure, will benefit from antipyretic administration.C. A high temperature in a child who has had a large ingestion of unknown

medication will benefit from antipyretics.D. Controlling the temperature of children with a history of febrile seizures is very

important in order to prevent further seizures.

9. With regards to children with a fever but no apparent source of infection, which of the following is the incorrect option:A. The incidence of occult bacteraemia has been reduced to less than 0.5% since

the introduction of streptococcal conjugate vaccination.B. Organisms such as meningococcus, salmonella, E. coli and staphylococcus are

now more prevalent as causes of true bacteraemia (without clinical focus).C. The commonest serious bacterial infection in children in the post HiB and

Streptococcal vaccine era is Urinary Tract Infection.D. A well appearing child aged > 4 months old and unvaccinated, with high fever,

requires a period of observation and screening of urine for UTI; further investigation is unnecessary.

10. With regard to petechial rash and fever in children, which of the following is the best option:A. The risk of meningococcal infection is 25%.B. A well appearing child with petechiae on the limbs and thorax does not need

further investigation.C. A toxic appearing child with petechiae in the SVC distribution does not need

investigation.D. Viral illnesses are the commonest cause of petechiae and fever.

11. A 2-month-old child presents with high fever and no evidence of any focus of infection. The child appears well and has normal vital signs. Which of the following is the correct option:A. The Yale Observation Scale is accurate is assessing toxicity in this age group.B. E. Coli, Listeria Monocytogenes and group B Streptococcus are possible

bacterial pathogens in this group.C. Lumbar puncture is not indicated in this group.D. A CXR is likely to be useful in this setting.


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SEIZURES IN CHILDREN (Q12)

Pre-reading:Child Health Queensland Guideline Proc 00711: Seizures – Emergency Management in Children12. With regard to Status Epilepticus (SE) in children, which one of the following is the best option:A. Status Epilepticus only occurs once the child has actively seized for more than

30 min.B. Midazolam has an excellent side effect profile and has longer duration of action

than diazepam in managing SE.C. PR Diazepam is the first choice agent for administration of a benzodiazepine by

parents in the home setting.D. IV Valproate and IV Keppra are effective in terminating SE seizures without

inducing respiratory depression.

RESPIRATORY DISEASE (Q13-16)

BronchiolitisPre-reading:PREDICT Australasian Bronchiolitis Bedside Clinical Guideline

13. A 7-month-old child with no previous medical illness presents with a 3-day history of coryza and cough. Vitals signs include: Respiratory rate 44, HR 120, Saturations 94% and mild subcostal recession. Examination reveals widespread inspiratory crepitations and expiratory wheeze with bilateral equal air entry. 2 other children in the family have ‘flu-like illness’. The child is breastfeeding comfortably in the mother’s arms. There is no family history of atopy or asthma.

Which of the following is the best option:A. Oxygen therapy should be instituted if the saturations are persistently below 92%B. Ventolin is likely to be of benefit and should be trialed.C. A trial of hypertonic 3% saline may be beneficial.D. A CXR is indicated to exclude pneumonia.


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Asthma Pre-reading:Child Health Queensland Guideline CHQ Proc 00700: Acute Asthma Management in ChildrenChild Health Queensland Guideline: Pre-school Wheeze – Emergency Management in ChildrenGlobal Strategy for the Prevention of Asthma in Children 5 years and younger (GINA 2009 – Global Initiative for Asthma – www.ginasthma.org)

14. With regard to asthma in children, which of the following is the best option:A. In moderate cases of asthma, a CXR is useful for excluding pneumonia.B. An arterial blood gas is useful to exclude fatigue in severe asthma.C. Children aged 2-4 yrs with wheeze responsive to ventolin may not benefit from

oral steroids, unless they are moderate -to –severely unwell and require admission to hospital.

D. Nebulised Magnesium Sulphate is not effective in the management of asthma.

CroupPre-reading:Queensland Health, Child Health Services Guidelines 2012. Version No.: 1.0; CHS Proc 00702: Acute Croup Management in Children.

15. With regards to stridor in children, which of the following is the best option:A. In a 15-month-old child with classic features of typical viral croup assessed as

‘moderate severity’, a lateral neck soft tissue x-ray is important to exclude foreign body.

B. Children with moderate viral croup require saturation monitoring and oxygen via facemask.

C. Children with moderate to severe viral croup may need adrenaline nebulization. This requires admission to the inpatient unit.

D. Oral dexamethasone lasts longer than prednisolone, but is less palatable than prednisolone.

High Flow Nasal Humidified Oxygen TherapyPre-reading:High Flow oxygen flow chart TPCH Children’s Health Queensland Guideline : High Flow Nasal Cannula Therapy

16. With regard to High Flow Nasal Humidified Oxygen therapy, which of the following is incorrect:

A. It is useful in the setting of severe bronchiolitis.B. It is indicated in the setting of severe asthma.C. It is indicated in patients with a decreased level of consciousnessD. It provides a degree of positive end expiratory pressure approximating 5 cm

of H2O.


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HEAD INJURY IN CHILDREN (Q17)

Prereading:QHealth Child Health Queensland Guideline. Head injury management in children.Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: a systematic review. Arch Dis Child. 2011 May; 96(5): 414-21.Emerg Med J doi: 10.1136/emermed-2011-200225. ReviewComparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuriesMark D Lyttle, Louise Crowe, Ed

17. With regard to head injuries in children, which of the following is the best option:A. A child with a ‘boggy’ scalp hematoma is likely to have a skull fracture and should

therefore proceed to skull x-ray.B. Examination findings suggestive of non-accidental injury require escalation to a

CT scan of the brain.C. A child with a severe headache after a head injury should always proceed to CT

Scan of the brain.D. A child that vomits on 3 occasions after a head injury should always proceed to a

CT scan of the brain.

GASTROENTERITIS (Q18-20)

Pre-reading:QHealth Child Health Queensland Guideline CHQ 00703 Acute Gastroenteritis Management in ChildrenChildren’s Health Services.

18. An 8-month-old child presents with one day of non-bilious vomiting (3 episodes) and fever to 37.8 degrees. No background medical problems are present and the child is fully immunized. Vital signs are normal, abdominal examination is normal, mucus membranes are dry and the rest of exam is normal.

Which of the following is the best option:A. This child requires lab investigations.B. This child has gastroenteritis until proven otherwise.C. A ‘Trial of fluid is required’.D. ‘Rehydration’ is required.

19. With regards to gastroenteritis in children, which of the following is the best option:A. Suspected bacterial gastroenteritis does not always require antibiotic treatment.B. Clinical hydration assessment is usually an accurate measure of body fluid

deficit.C. Hypernatremia needs to be excluded on lab investigations in all children with

dehydration.D. Stool microscopy and culture is useful in most children with gastroenteritis.


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20. With regards to management of gastroenteritis in children which of the following is the incorrect option:A. Enteral rehydration is the best treatment for dehydration secondary to

gastroenteritis.B. Enteral rapid rehydration is better than intravenous rapid rehydration.C. All children with vomiting should receive ondansetron treatment.D. Fruit juice commonly causes an osmotic diarrhoea in these patients.

ABDOMINAL PAIN IN CHILDREN (Q21)

Pre-reading:QHealth Child Health Queensland Guideline. Management of Children with Acute Abdominal PainPediatric Emergency Medicine Update. February 2012.The Evaluation And Management Of Constipation In The Pediatric Emergency Department

21.A 3 yo boy presents to ED with 1 day of abdominal pain. He is having episodes of extreme pain, with associated vomiting, but no diarrhoea. He has not passed stool for 2 days, which is unusual for him. He has had coryza and a cough for 2 days. His background includes mild cerebral palsy, mild developmental delay, previous constipation and occasional seizures. He is afebrile and his vital signs are normal. He is in no distress currently and his abdomen is soft.

Which of the following is the correct option:A. Pneumonia is a possible cause of abdominal pain in this child.B. An AXR will exclude constipation.C. Rectal examination is contraindicated in all children. D. Intussusception is unlikely as ‘red currant jelly stool’ is not present.


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E. PEM Registrar training log Date complete

Supervisor Comments

Orientation Package including MCQsWUGs readClinical procedures read

Abdo pain Allergic reaction Asthma Bronchiolitis Croup Diabetes Fever Gastroenteritis Head injury Meningitis Seizures

APLS/PLS (year)PLS online modulePLS face to faceTalk for teachingTopic _____________Talk for teachingTopic _____________Talk for teachingTopic _____________Talk for teachingTopic _____________Talk for teachingTopic _____________Talk for teachingTopic _____________Mandatory competency log


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1330-1500 Time Log Teaching Day Activities Supervisor Comments

Personal Term Goals


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PEM Training Paediatric Procedure logProcedure Tally NotesIntubationsOther airway managementCPR and arrest managementInotrope administrationCentral line insertionArterial line insertionCardioversion /defibrillationFracture reductionRelocation of large joint dislocationProcedural Sedation

Aspiration of a pneumothoraxInsertion of a intercostal catheterUse of US – diagnostic or IV accessSuprapubic catheter aspirateFemoral nerve blockLumbar punctureIn out catheter


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Orientation MCQ answers

Name_______________Date________________Please cross in the box

Question A B C D123456789

101112131415161718192021

Mark /21


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