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Objectives15% of GMC [1] registered doctors are international medical graduates (IMGs). Despite this, there has been no standardised additional support provided at induction for this group. In 2022, The Welcoming and Valuing International Medical Graduate Guidance [2] set out the minimum standards for effective NHS induction and support.11 IMGs surveyed at Birmingham Children’s Hospital reported suboptimal induction that affected their clinical and personal integration. Following high level process mapping and fishbone analysis (figure 1) of the IMG induction process, an aim was established to improve the clinical integration of three newly appointed IMG colleagues in the general paediatrics department over a period of three months (May to August 2022). The measure used was improved confidence in using RCPCH ePortfolio. This is an important tool for the clinical integration of doctors in paediatrics as it provides a platform to record learning in all its forms and settings to monitor progress against the RCPCH curriculum [3] regardless of career route chosen (CCT, CESR or SAS).MethodsFour interactive focus group sessions were introduced and confidence levels in using the RCPCH ePortfolio before and after each session using Google forms were collated. The first session was virtual where an example of the RCPCH ePortfolio and its use was demonstrated. The next three sessions were face to face and guided by feedback provided after each session. Over these sessions colleagues logged into their own RCPCH ePortfolio for the first time to navigate it and were then supported in creating their first event. Subsequently, events that they independently created were reviewed. All three colleagues were encouraged to engage with the wider team for on-going RCPCH ePortfolio events.ResultsAll four sessions showed improved confidence in using RCPCH ePortfolio before and after each session. The first session showed the highest average improvement in confidence by 77%. The overall average confidence level improved by 44% after all four sessions were completed. All three colleagues recommended that these sessions should be part of all paediatric IMG doctor’s induction.Abstract 146 Figure 1Fishbone diagram of potential causes of suboptimal international medical graduate (IMG) doctor’s induction process[Image Omitted. See PDF.]ConclusionMore can be done to support IMGs in paediatrics particularly during their first induction process as outlined in The Welcoming and Valuing International Medical Graduate Guidance. Improving confidence in using RCPCH ePortfolio with regular mentorship meetings can help improve clinical integration as well as aid in future career progression. RCPCH trainees and supervisors are key to improving this support.ReferencesGMC Data Explorer https://data.gmc-uk.org/gmcdata/home/#/(2021)Welcoming and Valuing International Medical Graduates: A guide to induction for IMGs recruited to the NHS https://www.e-lfh.org.uk/programmes/nhs-induction-programme-for-international-medical-graduates/(2022)RCPCH ePortfolio guidance for doctors https://www.rcpch.ac.uk/resources/rcpch-eportfolio-guidance-doctors (2022)

ObjectivesThis project aims to establish a robust feedback loop between PICU- ED in order to encourage real time feedback and shared learning. RCEM/FICM 20211 ‘Better Together’ document highlights the need for ‘robust processes for learning from excellence and incidents’ as well as collaborative learning between teams. From experience there is often formal feedback in the event that an admission triggers a discussion at M+M or equivalent panel however regular timely feedback, especially for nursing colleagues is something that we felt could be improved.MethodsSurvey was carried out and sent to ALL ED staff to review if there was a need for this- 40 respondents medical and nursing 60% (24/40).Results50% of respondents (20/40) Rarely received feedback from patients admitted from ED- PICU with 15% (6/40) responding Never. 98% (39/40) of respondents strongly agreed or agreed that they would like to receive feedback. The time interval for which staff would like to receive feedback for the majority of people was <5 days 78% (31/40). 80% (32/40) of respondents wanted to be given the information via nhs.net email, therefore a generic email address was created (bwc.pic-edup@nhs.net). 73% (29/40) did not mind who communicated the information, the most popular choice after this was the PEM registrar 28% (11/40) who we felt created a good link between ED and PICU.ConclusionA central email address was created and PEM Registrars (3) agreed to be part of the project with a PICU Consultant overseeing and delivering feedback. Generic feedback table (see promotional poster PDF) was formulated and sent back to ED nursing staff and ED Clinicians upon requested via email. In addition to the feedback table suggested resources for further reading were signposted. A survey link was sent out to enable those receiving feedback to inform the PIC- EDUp team of how they felt afterwards in addition to any additional areas they would have found useful to get more information on.We feel that this has created a robust feedback loop which looks at diagnosis in addition to areas for learning and excellence. Some initial feedback from those who requested and then received the information (responses ongoing at the time of writing this abstract) stated ‘I think this is a GREAT project and extremely beneficial for ED staff with proving some form of closure to cases once they are taken to PICU. I am personally grateful this was set up! Thankyou’.Referencehttps://www.ficm.ac.uk/better-together-collaborative-working-between-emergency-medicine-and-critical-care-framework

ObjectivesThe rise in UK child poverty has significantly impacted on child health1 and the increase in children’s attendances to Emergency Departments (EDs) is a clear indicator of the challenges faced.2Early Help (EH) was introduced in our ED in October 2021. Figure 1 shows the wide-ranging support to children and the wider family that EH provides.3 The first 250 referrals were analysed to understand the reasons for referral and outcomes achieved.Abstract 6174 Figure 1From birmingham children and families vision- a vision for all professionals working in our city. 2021 [3]MethodsData was collected from EH and hospital records and pseudonymised data was entered on an excel spreadsheet for analysis. Only patients who were referred by an ED clinician with adequate patient information provided in the early help data sheet were included. The study was deemed a service evaluation by the trust.Results250 patients were referred to EH between 22/10/2021 and 24/05/2022. 16 patients were excluded from the analysis because of inadequate data. For the remaining 234 patients, gender split was nearly half with 49.6% female and 50.4% male. The most frequent age category was between 11 to 16 years old (29%) and the least frequent being under 1 year old (20%). Of the 13 patients who had five or more attendances in the previous year, 10 had less than 5 ED attendances the following year after an EH referral.Respiratory illness (27%) followed by mental health concerns (12.8%) were the most common reason for attendance. Over half of referrals (56%) were for patients in the lowest socio-economic decile (Index of Multiple Deprivation score 1). 168 (72%) patients were not known to social services. Figure 2 shows the main reasons for referral: family support (34%), housing (21%) and mental health (12%). Nearly half of referrals (46%) resulted in family connect forms which provide multiagency support.Abstract 6174 Figure 2Distribution of primary reason for early help referral made by ED clinicians for 234 patients between 22/10/2021 to 24/05/2022ConclusionPreliminary data shows the EH offer helps target families from deprived areas, addressing the social determinants of health. The high numbers of families provided ‘family support’ (intensive, multi-disciplinary support) demonstrates unmet needs in our population. Future evaluations should study the impact of early years interventions (in EDs as well as other departments across hospitals in the UK) in more detail, including child and family wellbeing.ReferencesWickham S, Anwar E, Barr B, et al. Poverty and child health in the UK: using evidence for action. Arch Dis Child. 2016 Aug;101(8):759–66. doi: 10.1136/archdischild-2014-306746.Rudge GM, Mohammed MA, Fillingham SC, et al. The combined influence of distance and neighbourhood deprivation on emergency department attendance in a large english population: a retrospective database study. PLoS One. 2013 Jul 16;8(7):e67943. doi:10.1371/journal.pone.0067943.Birmingham Children and Families Vision- A Vision for all professionals working in our city. 2021. https://www.localofferbirmingham.co.uk/wp-content/uploads/2021/06/Birmingham-Children-Families-Vision-FINAL.pdf.

BackgroundThere is a national strategy ATAIN aimed at reducing term admissions to the neonatal unit. Whilst this is aimed at looking at potentially preventable term admissions to the neonatal unit, it does not address the issue of re-admission following discharge from the postnatal ward or neonatal unit. Given the limited midwifery resources in the community, we believe some of the re-admissions are potentially preventable if there were adequate resources to support the mother and baby at home.AimsTo review the reasons for readmissions from home and identify potentially avoidable causes.MethodsWe retrospectively reviewed the BadgerNet neonatal electronic patient record to identify readmissions over the last financial year between 01/04/2017 and 31/03/2018. A standard excel profoma was used to collect and analyse the data. The reason for admission, interventions carried out and outcome was reviewed including the length of stay.ResultsIn the last financial year there were 142 babies resulting in 143 readmissions to the postnatal or transitional care ward. Of these 120 babies were re-admitted for jaundice as a primary cause of admission. Of these jaundiced babies, 31 also had associated weight loss noted on admission. One baby had two episodes of re-admission for jaundice. Five of these babies had an infection screen, which were negative and antibiotics were discontinued by 48hrs. The median length of stay was 4 days and the range was between 3 and 11 days. Only one had admission to the neonatal unit with bronchiolitis. The total length of stay for the 120 babies was 446 days.Another 22 babies were readmitted because of weight loss. The median length of stay was 3 days and the range was between 1–4 days. The total length of stay for the 22 babies was 70 days. Of all the re-admission, 99 were breastfeeding on re-admission, 24 were mixed feeds and 19 bottle fed.ConclusionsThe two main reasons for readmissions were jaundice and weight loss. There was an overlap of this because a proportion of jaundiced babies were noted to have weight loss or poor feeding on readmission. We believe that these are potentially avoidable readmissions if there was sufficient feeding support for the mother and babies in the community. It would alleviate the additional emotional stress imposed on the mother and family by the readmission. It would also reduce the impact on the bed occupancy on an already stretched maternity and transitional care wards.

BackgroundIncorrect penicillin allergy labels result in the use of inappropriately broad-spectrum antibiotics. De-labelling inaccurate penicillin allergy promotes antimicrobial stewardship and optimises prescribing practices. The objectives were to evaluate paediatric clinicians’ knowledge and understanding of penicillin allergy and to identify barriers in tackling incorrect penicillin allergy labels.MethodsPaediatric clinicians from across the West Midlands of the UK were surveyed using an online, anonymised questionnaire between 1 August and 30 September 2021. Domains explored were (1) approach to penicillin allergy clinical vignettes, (2) knowledge of the impact of penicillin allergy labels, (3) frequency of allergy-focused history questions and (4) barriers in tackling incorrect penicillin allergy.ResultsResponses were received from 307 paediatric clinicians across 12 hospitals. Sixty-one per cent would not prescribe a penicillin-based antibiotic if a family history of penicillin allergy was reported. There was an overall deficit in taking an allergy-focused history with only 36.5% inquiring about diagnostic confirmation. Absence, or lack of awareness of a referral pathway for antibiotic allergy evaluation (58.6%) and unfamiliarity of the indications for oral provocation testing (55%) were the most common reported barriers to penicillin allergy de-labelling. Fifty-one per cent would rather ‘play it safe’ than explore penicillin allergy confirmation as it is felt that alternative treatments were readily available.ConclusionsThe deficiency in antibiotic allergy-focused history among paediatric clinicians highlights the need for better allergy education across all clinical grades. Pragmatic algorithms and clear referral pathways could address barriers faced by non-allergists in de-labelling incorrect penicillin allergy.

BackgroundInternational medical graduates (IMG) face unique sociocultural and educational challenges during their training in the UK. Identifying and working on these challenges would help in addressing the differential attainment of IMGs in postgraduate medical education in the UK.ObjectivesWe aimed to capture the challenges faced by IMGs in paediatric speciality training and identify possible solutions to enable them to reach their full potential.MethodsA semi-structured online questionnaire consisting of multiple-choice and free text questions was designed to collect data on the demographics, challenges, self-reported performances, and potential solutions. The survey was anonymously filled by 45 IMG paediatric trainees in the West Midlands.ResultsDemographics24 (53%) IMG trainees started their training at ST1.36 (80%) completed their foundation training outside the UK/EEA.41 (91%) had prior experience in the NHS, with an average duration of 19 months.ChallengesCommonly reported challenges in paediatric training were work-life balance (69%), portfolio and assessments (62%), placements (60%), meeting speciality (GRID) training requirements (60%) and socio-cultural issues (60%).Lack of trust among seniors and nursing colleagues, loneliness and isolation, difficulty with reporting and escalating difficulties, and communication issues were among other reported challenges.7(15.6%) respondents reported having faced complaints but felt well supported by their supervisors on those occasions.11(24.4%) IMG trainees had worked less than full time (LTFT) while 5 (11%) had pursued out of programme activities (OOP). 16(35.6%) trainees felt that being an IMG hindered them from working LTFT or pursuing OOP due to visa or financial restrictions.Performance:9 (20%) of the respondents have had unfavourable ARCP outcomes requiring additional training time. Difficulty in passing membership exams was quoted as the important reason for this outcome.Poor performance with nil achievement was reported by 32 (71%) trainees in publication, 29 (64%) trainees in research and 16 (35%) trainees in leadership domains.IMGs felt to be at a disadvantage in the Grid application process due to lack of recognition of their overseas experience, poor representation in management positions, inability to boost CV through OOP projects, language and communication difficulties and lack of guidance in the application processes.SolutionsThe major sources of support were peers, consultants, and supervisors.Enhanced support with regards to examinations, portfolios, audits, publishing and research, having a platform to discuss IMG specific challenges, addressing bias about their capability, improving cultural awareness and nurturing a friendly and non-judgemental work environment would help to improve the performance and well-being of IMG trainees.ConclusionsOur survey finds that in addition to meeting the demands of a rigorous training programme, IMGs also face additional difficulties in the form of isolation, socio-cultural and communication issues. Further studies are needed to quantify the difficulties and performance of IMGs in paediatric training in comparison to trainees with UK primary medical qualification. Ensuring that IMGs benefit from the existing support system while exploring strategies to enable equal opportunities will help in addressing differential attainment of IMGs in paediatric training.

This paper is intended to persuade the academic community of the value of a standard user-friendly software framework to assist businesses to keep up with the rapid barrage of new regulatory compliance requirements. There is a clearly defined problem in today’s business world on the topic of how to manage regulatory compliance. Companies need a method to comply with regulations without amassing a mountain of new software programs, hiring additional staff, and avoiding the hefty mandated fines and overhead costs that are associated with regulations. This research paper substantiates the theory that it is possible for companies to use a framework to build a Standard Compliance Architecture (SCA) for monitoring compliance with regulations using a simple technology solution to ensure regulatory compliance. In this paper, we study several framework policy modeling and policy verification techniques, and we propose a corresponding basic taxonomy for the SCA.

ObjectivesAmerican Academy of Pediatrics (AAP) guidelines (2016)1 redefined ALTE (Acute Life Threatening Event) as BRUE (Brief Resolved Unexplained Event), with separate management pathways2 for high-risk and low-risk categories of patients. Although the term BRUE is used in the UK, there is no national BRUE guideline. The Partners in Paediatrics (PiP) handbook (2022–24 edition)3 includes a BRUE guideline aligned with AAP recommendations, which can be accessed by hospitals in West Midlands. Our aim was to audit the management of BRUE across seven hospitals in West Midlands.MethodsA prospective audit was undertaken by PRAM (Paediatric Research Across the Midlands), from May to July 2022, on the initial management of patients with suspected BRUE, attending the emergency department or paediatric assessment unit at seven West Midlands hospitals. The PiP BRUE guideline was used as audit standard: all low risk patients should be discharged without further investigations; all high risk patients should be admitted for minimum of 24 hours observations, have all first-line investigations completed, and Tier 2 or consultant review before discharge.Results63 patients were included, 20 (31%) were of age 61 days to 6 months and 35 (55% ) were male. 53 (84%) met the high-risk criteria (figure 1). None of the high-risk category patients received the complete set of recommended first-line investigations. 100% of low-risk patients underwent further investigations and were observed for more than 4 hours (Figure 2). Of the high-risk category patients, 52 (98%) were seen by a Tier 2 professional or consultant and 20 (38%) were observed for at least 24 hours prior to discharge. 33 (52%) patients had a discharge diagnosis of BRUE. 11 (17%) had acute respiratory illness and 7 (11%) had gastroesophageal reflux as discharge diagnosis.ConclusionOur audit shows variable adherence to the regional PiP BRUE guideline. One participating hospital had a local BRUE guideline, while the other six hospitals did not have a local BRUE guideline or clear signposting to PiP guidelines. We recommend that there should be increased awareness and implementation of established BRUE management guidelines in paediatric units, to ensure standardised care for patients. It also prompts the observation that there have been no studies validating the AAP BRUE guideline in the UK population. Further work should be undertaken to evaluate the performance of the AAP BRUE guideline in the UK, to determine the need for a bespoke national BRUE guideline.ReferencesTieder Joel S, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: executive summary. Pediatrics 2016;137.5.Merritt J Lawrence, et al. A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics 2019;144.2.Partners In Paediatrics Clinical Guidelines 2022–24. https://partnersinpaediatrics.org/clinical-guidelines/(2022)Abstract 147 Figure 1Prevalence of high risk indicators or suspected BRUE presentations as defined by PiP guidelines[Image Omitted. See PDF.]

The rheological properties of erythrocytes are impaired in diabetes mellitus, especially because of changes in their membrane lipid composition.The aim of this study was to determine and examine the relationship between red blood cell (RBC) membrane and serum lipid composition in type II diabetes subjects with and without nephropathy. Trinidadian subjects aged 18-65 years were recruited for the study regardless of gender and ethnicity. Fasting blood samples were collected from 60 subjects of whom 20 were healthy individuals, 20 had type II diabetes without complications, and 20 were type II diabetics with nephropathy. Weight, height, waist/hip ratio, and blood pressure were recorded. All the blood samples were analysed to determine the serum lipid concentration, membrane lipid composition and plasma glucose concentration. The body mass index and the systolic blood pressure of the diabetics (28.17 +/- 4.98 kg/m2, 153.21 +/- 22.10 mmHg) and those with nephropathy (25.87 +/- 4.68, 158.60 +/- 22.49 mmHg) were higher when compared with controls (24.67 +/- 5.18, 119.15 +/- 13.03 mmHg). The diabetic (175.89 +/- 102.73 microg/mgprotein) and diabetic nephropathy (358.80 +/- 262.66) subjects showed significantly higher levels of RBC membrane cholesterol compared with controls (132.27 +/- 66.47). The membrane phospholipids, protein and Na+/K+ATPase concentrations were altered in diabetics and diabetic nephropathy patients when compared with controls. The trends of increased serum cholesterol and decreased high-density lipoprotein in diabetics and diabetic nephropathy patients were noted as compared with controls but they are not significant as expected. The low-density lipoprotein cholesterol was significantly higher in diabetics when compared with diabetic nephropathy and control subjects. Our data suggest that there is a relationship between RBC membrane and serum lipid composition in subjects with type II diabetes with and without nephropathy. This relationship shows that diet and lifestyle plays a significant role in the alterations of the lipids both in serum and RBC membrane. The membrane and serum lipid composition may be used as possible indicators for type II diabetic patients with and without nephropathy to control their diet in the beginning stages to prevent them from further complications.

Background Paediatric convulsive status epilepticus is the most common neurological emergency presenting to emergency departments. Risks of resultant neurological morbidity and mortality increase with seizure duration. If the seizure fails to stop within defined time-windows, standard care follows an algorithm of stepwise escalation to more intensive treatments, ultimately resorting to induction of general anaesthesia and ventilation. Additionally, ventilatory support may also be required to treat respiratory depression, a common unwanted effect of treatment. There is strong pre-clinical evidence that pH (acid–base balance) is an important determinant of seizure commencement and cessation, with seizures tending to start under alkaline conditions and terminate under acidic conditions. These mechanisms may be particularly important in febrile status epilepticus: prolonged fever-related seizures which predominantly affect very young children. This trial will assess whether imposition of mild respiratory acidosis by manipulation of inhaled medical gas improves response rates to first-line medical treatment. Methods A double-blind, placebo-controlled trial of pH manipulation as an adjunct to standard medical treatment of convulsive status epilepticus in children. The control arm receives standard medical management whilst inhaling 100% oxygen; the active arm receives standard medical management whilst inhaling a commercially available mixture of 95% oxygen, 5% carbon dioxide known as ‘carbogen’. Due to the urgent need to treat the seizure, deferred consent is used. The primary outcome is success of first-line treatment in seizure cessation. Planned subgroup analyses will be undertaken for febrile and non-febrile seizures. Secondary outcomes include rates of induction of general anaesthesia, admission to intensive care, adverse events, and 30-day mortality. Discussion If safe and effective 95% oxygen, 5% carbon dioxide may be an important adjunct in the management of convulsive status epilepticus with potential for pre-hospital use by paramedics, families, and school staff. Trial registration EudraCT: 2021-005367-49. CTA: 17136/0300/001. ISRCTN: 52731862. Registered on July 2022.