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Introduction: Crowding is associated with poor patient outcomes in emergency departments (ED). Measures of crowding are often complex and resource-intensive to score and use in real-time. We evaluated single easily obtained variables to establish the presence of crowding compared to more complex crowding scores. Methods: Serial observations of patient flow were recorded in a tertiary Canadian ED. Single variables were evaluated including total number of patients in the ED (census), in beds, in the waiting room, in the treatment area waiting to be assessed, and total inpatient admissions. These were compared with Crowding scores (NEDOCS, EDWIN, ICMED, three regional hospital modifications of NEDOCS) as predictors of crowding. Predictive validity was compared to the reference standard of physician perception of crowding, using receiver operator curve analysis. Results: 144 of 169 potential events were recorded over 2 weeks. Crowding was present in 63.9% of the events. ED census (total number of patients in the ED) was strongly correlated with crowding (AUC = 0.82 with 95% CI = 0.76 - 0.89) and its performance was similar to that of NEDOCS (AUC = 0.80 with 95% CI = 0.76 - 0.90) and a more complex local modification of NEDOCS, the S-SAT (AUC = 0.83, 95% CI = 0.74 - 0.89). Conclusion: The single indicator, ED census was as predictive for the presence of crowding as more complex crowding scores. A two-stage approach to crowding intervention is proposed that first identifies crowding with a real-time ED census statistic followed by investigation of precipitating and modifiable factors. Real time signalling may permit more standardized and effective approaches to manage ED flow.

Aims Peer-graded practice examinations can help medical students to achieve higher results in their final exams,1 and peer-led exam revision courses have demonstrated high levels of satisfaction.2,3 Surveys show that the majority of medical students find exam practice provided by recent graduates as useful as consultant teaching.3 Our aim is to present our experience, over a 2 year period, of designing and implementing a practice Objective Structured Skills Examination (OSCE) in paediatrics, run by junior doctors from foundation year one to ST4 level, collating feedback from students and making improvements. Methods Six medical students have their paediatric placement every four weeks. During the fourth week, five members of staff run a 90-minute OSCE, consisting of 8 examined stations. Two history-taking, two clinical skills, two counselling and two data-interpretation stations were designed, reflecting real life clinical situation as well as common exam scenarios. Stations were followed by 90 seconds of immediate individual verbal feedback by examiners who also took up roles of the actors in their scenarios. The OSCE was designed as two consecutive cycles of stations and ended with a group question and answer session and feedback forms. Results We have collated written feedback from each student since September, 2012. The majority of students reported finding the OSCE useful exam preparation and something that they would recommend. We then asked the students to complete a further feedback questionnaire 1 year later, once they had completed their paediatric OSCE examination and 100% of respondents replied that the practice examination had been useful preparation for their final exams. Conclusion We can show high levels of satisfaction from participants. The detailed feedback process enabled us to improve the exam, creating a useful revision aid, and an invaluable teaching tool. This process has been easy to implement, using junior doctors available from the rota in an extremely busy Major Acute Trust, without consultant supervision. It has been maintained despite the frequent turnover of junior doctors. We hope to use this model as a template for similar hospitals. References Freeman S, Parks JW. How Accurate is Peer Grading? CBE Life Sci Educ 2010 Winter;9(4):482–8. Alcamo AM, Davids AR, Way DP, Lynn DJ, Vandre DD. The Impact of a Peer-designed and –led USMLE Step 1 Review Course: Improvement in Preparation and Scores. Acad Med 2010 Oct;85 (10 supp):S45–8. Rashid MS, Sobowale, O, Gore D. A Near-Peer teaching programme, designed, developed and delivered exclusively by recent medical graduates for final year medical students sitting the final OSCE. BMJ Med Educ 2011 Mar 17;11:11. Abstract G199(P) Figure 1 Percentage of students responding 4 when asked to rate statements 1-4 (1-Strongly Disagree, 4-Strongly Agree).

Aims Peer-graded practice examinations can help medical students to achieve higher results in their final exams (1), and peer-led exam revision courses have demonstrated high levels of satisfaction (2,3). Surveys show that the majority of medical students find exam practice provided by recent graduates as useful as consultant teaching (3). Our aim is to present our experience, over a 2 year period, of designing and implementing a practice Objective Structured Skills Examination (OSCE) in paediatrics, run by junior doctors from foundation year one to ST4 level, collating feedback from students and making improvements. Methods 6 medical students have their paediatric placement every 4 weeks. During the 4th week, 5 members of staff run a 90-minute OSCE, consisting of 8 examined stations. 2 history-taking, 2 clinical skills, 2 counselling and 2 data-interpretation stations were designed, reflecting real life clinical situations as well as common exam scenarios. Stations were followed by 90 seconds of immediate individual verbal feedback by examiners who also took up roles of the actors in their scenarios. The OSCE was designed as 2 consecutive cycles of stations and ended with a group question and answer session and feedback forms. Results We have collated written feedback from each student since September, 2012. The majority of students reported finding the OSCE useful exam preparation and something that they would recommend. We then asked the students to complete a further feedback questionnaire 1 year later, once they had completed their paediatric OSCE examination and 100% of respondents replied that the practice examination had been useful preparation for their final exams. Abstract G277(P) Figure 1 Percentage of students responding 4 when asked to rate statements 1–4 (1 – Strongly Disagree, 4 –Strongly Agree). Conclusion We can show high levels of satisfaction from participants. The detailed feedback process enabled us to improve the exam, creating a useful revision aid, and an invaluable teaching tool. This process has been easy to implement, using junior doctors available from the rota in an extremely busy Major Acute Trust, without consultant supervision. It has been maintained despite the frequent turnover of junior doctors. We hope to use this model as a template for similar hospitals. References Freeman S, Parks JW. How Accurate is Peer Grading? CBE Life Sci Educ. 2010 Winter;9(4):482–8. Alcamo AM, Davids AR, Way DP, Lynn DJ, Vandre DD. The Impact of a Peer-designed and –led USMLE Step 1 Review Course: Improvement in Preparation and Scores. Acad Med. 2010 Oct; 85 (10 supp) S45–8. Rashid MS, Sobowale, O, Gore D. A Near-Peer teaching programme, designed, developed and delivered exclusively by recent medical graduates for final year medical students sitting the final OSCE. BMJ Med Educ. 2011 Mar 17;11:11.

Introduction Improving efficiency in healthcare delivery while maintaining patient safety is central to providing high quality patient care, improved patient satisfaction and creates a culture of improved training for future paediatricians. Poor communication during patient handovers has been cited as being one of the most dangerous interventions that clinicians put patients through. The SBAR handover tool has been recognised by the WHO as well as the National Health Service Institute of Innovation and Improvement as a simple and standardised tool that encourages the clinicians to present patient information in a concise and focused fashion that has been shown to improve patient safety. SBAR is an acronym which stands for Situation, Background, Assessment and Recommendation. Aim To evaluate the impact of time spent by paediatric trainees on the morning patient handover before and after the introduction of SBAR within the department. Method The handovers involved discussing patients who were on the ward, the ED department, and ambulatory unit. An additional note was made of patients for whom there was a significant psycho-social element to their handover. Information on the time spent discussing each patient using a conventional, semi-structured handover process, was recorded for 7 days (over two consecutive weeks). This was followed by conducting the exercise again after the entire department had undergone SBAR training and a 2 month period of daily practise. Data was then gathered for a 14 day period over three consecutive weeks. Results Prior to commencing the use of SBAR, each handover was taking an average of 55.7 min (range 40 to 73) with 22 patients being discussed per handover on average. Post SBAR, it took an average of 32 min for each handover (range 19 to 49) with 21 patients being discussed per handover. Pre SBAR, it took an average of 2.57 min to handover a patient compared to 1.54 min post SBAR. This represents a 60% reduction in time using SBAR (p<0.0003). Conclusions This significant reduction in handover times using SBAR demonstrates improved efficiency. This has several benefits including enabling time to be generated for ‘micro-teach’ sessions and improved paediatric training or increasing departmental productivity.

Aims The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies: the asthma/rhinitis care pathway is the third such pathway. Asthma and rhinitis have been considered together. These conditions co-exist commonly, have remarkably similar immuno-pathology and an integrated management approach benefits symptom control. Method The asthma/rhinitis pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including the public and was approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. Results The pathway entry points are defined by symptom type and severity at presentation. Acute severe rhinitis and life-threatening asthma are presented as distinct entry routes to the pathway, recognising that initial care of these conditions requires presentation-specific treatments. However, the pathway emphasises that ideal long term care should take account of both conditions in order to achieve maximal improvements in disease control and quality of life. Conclusions The pathway recommends that acute presentations of asthma and/or rhinitis should be treated separately. Where both conditions exist, ongoing management should address the upper and lower airways. The authors recommend that this pathway is implemented locally by a multidisciplinary team (MDT) with a focus on creating networks. The MDT within these networks should work with patients to develop and agree on care plans that are age and culturally appropriate.

Objectives The Royal College of Paediatrics and Child Health (RCPCH) Science and Research Department was commissioned by the Department of Health to develop national care pathways for children with allergies. The eczema pathway focuses on defining the competences to improve the equity of care received by children with eczema. Method The eczema pathway was developed by a multidisciplinary working group and was based on a comprehensive review of evidence. The pathway was reviewed by a broad group of stakeholders including paediatricians, allergists, dermatologists, specialist nurses, dietician, patients' representatives and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. It was also reviewed by a wide range of stakeholders. Results The results are presented in three sections: the evidence review, mapping and the core knowledge document. The various entry points to the ideal pathway of care are defined from self-care through to follow-up. There is considerable emphasis on good skin care and when allergy problems should be dealt with. The pathway algorithm and associated competences can be downloaded from http://www.rcpch.ac.uk/allergy/eczema. Conclusions Effective eczema management is holistic and encompasses an assessment of severity and impact on quality of life, treatment of the inflamed epidermal skin barrier, recognition and treatment of infection and assessment and management of environmental and allergy triggers. Patient and family education which seeks to maximise understanding and concordance with treatment is also important in all children with eczema.

Aim To evaluate the benefit of in-situ simulation in detecting latent errors and improving patient safety in a district general hospital in London. Methodology Weekly in-situ simulation training was conducted within the paediatric A+E and the neonatal unit from February 2011. Structured scenarios were used with predetermined learning objectives. Training was jointly delivered by a consultant paediatrician trained in paediatric simulation, a resuscitation officer and a medical education fellow. Debrief sessions were facilitated at the end of each scenario involving the whole team. Low fidelity simulation was conducted for the first 8 months, with addition of high fidelity baby and neonatal simulators in the last 2 months. Outcomes included trainee feedback and reflective notes and identification of any clinical governance issues. Results Information on latent errors identified was available from 20 paediatric and 8 neonatal sessions out of 40 sessions. A total of 6 (6/40) latent errors were identified with no latent errors detected in the rest of the sessions (34/40). These were classified according to the NPSA guidance on risk assessment (table 1) with the help of local risk management team. All errors were recorded through the trust's incident reporting system and necessary actions were undertaken immediately. Abstract G368(P) Table 1 Error Identified Consequence Grading Likelihood Grading Overall Risk Grade Paraldehyde out of stock in A+E Major Almost certain Extreme Bag and mask not connecting to oxygen source (massive leak in connecting tubing) Major Likely Extreme Resuscitaire out of stock on the neonatal unit (NNU) Major Possible-likely High ‘Resus grab bag’ – staff unaware of its introduction Major Possible High Junior medical staff unaware of location of resuscitation equipment (UVC) on NNU Moderate Unlikely-possible Moderate Need for educating staff about CPAP identified Moderate Unlikely Moderate Conclusions We conclude that in-situ simulation is an effective way of detecting latent errors without compromising patient safety. We recommend that identified errors should be reported using local incident reporting system to rectify the situation. Providing high fidelity in-situ simulation is resource intensive for any NHS trust. We have been able to demonstrate that, using low fidelity simulation equipment available in most resuscitation departments in district general hospitals, effective in-situ simulation can be conducted to improve training and patient safety. In the future we aim to compare high fidelity to low fidelity in-situ simulation in detecting latent errors.