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G43 ALCOHOL RELATED ATTENDANCES IN YOUNG CHILDREN: TAKING AN INITIATIVE

B. M. Mehta, M. Barlow, N. Evans, K. Williams.Accident and Emergency Department, Alder Hey Children’s Hospital, Liverpool, UK

Introduction: Alcohol consumption is increasing among young people; those under 16 years are drinking twice as much compared with 10 years ago. The National Alcohol Harm Reduction Strategy (NAHRS) acknowledges that educating young people to drink responsibly is fundamental to any long term strategy aimed at minimising the detrimental effects of alcohol misuse on society. Emergency departments are a key place to recognise these vulnerable drinkers. A previous audit of alcohol related attendances to our large urban paediatric emergency department in 2002/3 identified increasing attendances, weaknesses in information collection, inconsistencies in acute management, and poor follow up and support for these potentially vulnerable children and their families. A clinical care pathway was formulated by a multidisciplinary team, which consisted of hospital and community stakeholders.

Methods: Following implementation of the Alcohol Care Pathway in spring 2004 all children who present to the emergency department with alcohol related problems and their parents are given an information pack and offered follow up at a brief intervention clinic with trained nurse specialists. Subsequent alcohol related attendances were re-audited for the 3 month period of summer 2004.

Results: Sixty children presented to A&E with primarily alcohol related attendances in the summer 2004 audit period (0.4% of new attendees). Four patients were excluded from analysis because they left before assessment. Age range was 10–15 years. Female to male ratio was 1.8:1. Over 10% presented with a GCS of 8 or lower. 62% had drunk alcohol previously and 7% had previous alcohol related hospital attendances. 16% were hypothermic. None was hypoglycaemic. Seven children had taken other substances and coingestion was suspected in a further three. Comorbidity included head injury, assault, and alleged or suspected rape. Blood alcohol concentration was measured in 14 patients and ranged between 108 and 343.5 mg/dl. Eleven patients (20%) were admitted for a variety of indications from reduced GCS to psychosocial problems. Over 90% of families received an alcohol information pack. 92% of children had some form of follow up (80% at the brief intervention clinic; a further 12% were referred to social services, mental health services, child protection teams, or school nurses). This is an increase from 39% in summer 2002 and 65% in summer 2003. In addition, all children who presented with minor injuries and had drunk alcohol were given an information pack and offered a brief intervention clinic appointment.

Conclusion: The re-audit confirms an increasing trend of alcohol related attendances to our emergency department among young people, some with serious and potentially devastating outcomes. As a result of the Alcohol Care Pathway awareness has been raised of the dangers these children may encounter and they are being offered follow up for education and intervention

G44 MANAGEMENT OF YOUNG PEOPLE IN A UNIVERSITY HOSPITAL EMERGENCY DEPARTMENT PRESENTING FOLLOWING A NON-ACCIDENTAL OVERDOSE

S. Rajapaksa, B. Sands, L. Williams, S. Smith.1Queens Medical Centre, Nottingham, UK

Introduction and Aims: Suicide accounts for 20% of deaths in young people.1 The government has recognised this in recent publications. Evidence shows that an episode of self-harm is a significant risk factor for completed suicide.2 Current recommendations from the Royal College of Psychiatrists are that all children under 16 years should be admitted for assessment following an episode of self-harm, but little has been published to show that these guidelines are being followed.3 This audit examines the cases of young people who discharged from an emergency department providing independent adult and paediatric emergency services, in order to try and establish practical solutions to the problem.

Method: A retrospective analysis of patients <16 years, seen in the emergency department at Queens Medical Centre (QMC) from 1 Oct 2002 to 31 Sept 2003 after an overdose, was carried out. Data were collected on place of assessment (adult or paediatric area); what was taken; and whether admission was offered or follow up arranged. In addition, patients were assigned a level of risk for suicide based on the local adult assessment tool, as no tool currently exists in paediatric psychiatry.

Results: The emergency department at QMC is the busiest in the country, seeing approximately 120 000 new patients per year. There were 109 presentations following an overdose, of which 13 (11.9%) were incorrectly discharged home. Of those patients who were discharged, 79% were seen in the adult area, mean age being 15.1 years cf 13.5 years in the paediatric area (p<0.05). 31% were categorised as high risk, 23% as medium, 38% as low and, in 8%, no level of risk could be ascertained. Paracetamol alone was the commonest overdose (54%) followed by polypharmacy (38%). In 30% of patients going home, no follow up with child and adolescent psychiatry was organised.

Conclusions: Despite established guidelines, we have demonstrated that approximately 12% of eligible patients were sent home. The most problematic age group seems to be 14–16 years, when assessment is commonly by a junior doctor who may have limited knowledge of paediatric guidelines. The lack of an assessment tool in this area makes management more complex and this has been recognised at QMC, where such a tool is currently being developed. We propose that the important issues in managing these complex patients are highlighted to all professionals who work with these vulnerable young people.

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G45 INFANTS WITH FRACTURES: IS SUFFICIENT INFORMATION COLLECTED TO EXPLORE THE POSSIBILITY OF DELIBERATE HARM?

S. Bowring.Child Health University of Leeds, Leeds, UK

Background: The Lamming report recommends that cases of possible deliberate harm should be approached in the same rigorous and systematic manner as any other potentially fatal disease. This study investigates the assessment of children <12 months with fractures, a group in whom the possibility of deliberate harm should be considered.

Methods: A retrospective review of notes, available radiograph reports, and child protection records of children <12 months with a fracture seen in the emergency departments of two teaching hospitals between 1/1/2002 and 31/12/2003 was performed. Details extracted included age, fracture type, reported mechanism of injury, whether any child protection concerns were documented, and any further investigations or referrals arranged. Emergency department records from one hospital were audited using a Likert scale by two consultants assessing the completeness of history, examination, and management plans with reference to the assessment of possible deliberate harm.

Results: Forty seven infants with fractures were identified. Major deficiencies are apparent in the assessment of these infants. Histories taken were brief. Past medical history was documented in only 44% of cases. The injured part only was examined in 47% of children. Clear documentation whether or not the injury was accidental was absent in 42% of cases. 44% were referred from the emergency department to the paediatric team with child protection concerns. In a further 21% concerns were expressed at a later date, either during admission or at clinic follow up. After full assessment 26% (12 infants) were felt to have been deliberately harmed.

Conclusion: Deliberate harm is not routinely considered or explored in the assessment of infants with significant injuries. Insufficient information is gathered to allow an informed decision to be made regarding the aetiology of injuries. Children will remain at risk unless all injured infants are adequately assessed and examined fully. Training and supervision in emergency and paediatric departments must promote more awareness of indicators of deliberate harm in infants.

G46 REGIONAL RETRIEVAL TEAMS FOR HEAD INJURED CHILDREN: HOW WILL THIS EFFECT A&E?

C. Dieppe, T. Y. M. Lo, J. McFadzean, D. Rowney.Royal Hospital for Sick Children, Edinburgh, UK

Background and Aims: Prior to 2004 it was expected that the referring hospital should transfer head injured children to neuro intensive care units to ensure rapid transfer, preferably within 4 hours of injury. However, two recently published paediatric head injury guidelines have independently recommended that these should only be undertaken by a specialist regional paediatric retrieval team. Significant concerns remain as to whether this recommendation will result in further delay given the distances between regional paediatric retrieval teams and district hospitals. Using the experience of the Edinburgh paediatric retrieval team we aim to determine if this recommendation is realistic and how it will impact on A&E stabilisation and referral patterns of head injured children.

Method: A prospective survey of all head injured children consecutively transferred (n = 27) to the Edinburgh PICU and all Edinburgh paediatric retrieval team retrievals (n = 199) to the same unit during a 2 year period was carried out. Data were collected on physiological variables, and journey specifics allowing comparisons to be made between the transferred and retrieved children in terms of the standard of care, and time taken for journey and stabilisation.

Results: The median stabilisation time for head injured children at the referring hospital was 205 minutes, and the median time required to reach the PICU was 260 minutes. 66.7% of these transferred children had one or more physiological derangements on arrival. During the same time period the mobilisation time for the Edinburgh paediatric retrieval team was 60 minutes, with a travel time of 1.44 minutes per mile. Less than 5% of the retrieved children had physiological derangement on arrival to PICU.

Discussion: With the combination of mobilisation time and journey time it is theoretically possible for the Edinburgh paediatric retrieval team to reach any referring hospital within a 75 mile radius during the median time taken by the transferring hospital to stabilise the child. Retrieval of the head injured child by regional paediatric retrieval teams may confer less physiological derangements in transit. The consequences of implementation of these recommendations for A&E physicians may include (a) early referrals to regional paediatric retrieval team and neurosurgical services to avoid delays in mobilisation time and (b) the use of local resources to implement more definitive neuro intensive care while awaiting the arrival of the regional paediatric retrieval team.

Conclusion: The Edinburgh paediatric retrieval team may be a realistic option for referring hospitals within a 75 mile radius of Edinburgh provided A&E physicians refer these children early and use the retrieval teams mobilisation time as a potential cancellation window.

G47 A REVIEW OF THE EMERGENCY CARE OF CHILDREN IN ENGLAND SINCE THE 18TH CENTURY

W. J. Robson.Royal Liverpool Children’s NHS Trust, Liverpool University, Liverpool, UK

Aim: To review the emergency care of children in England from 1700 to 2000.

Methods: Review of historical documents and personal communications.

Results: The emergency care of children in England in the 18th century was within their families and in houses designated as children’s dispensaries for outpatient emergency care. The dispensaries were staffed by physicians. In the 19th century inpatient services were developed. Initially these were in general hospitals and were limited to children with surgical and orthopaedic conditions. The fear of cross infection excluded children with medical problems. Physicians were also concerned about the emotional effects of separating children from their mothers. In the 20th century the needs of children with acute illnesses and injuries have been more widely recognised. In general practice, community medical services, and ambulance services, and in the emergency rooms and wards of hospitals many changes have occurred which may have played a part in the reduction in mortality and morbidity in these children. These changes include the development of paediatrics in general and the development of paediatric emergency medicine as a specialty.

Conclusion: In three centuries the emergency care of children with acute illnesses and injuries has moved from being principally the responsibility of families and general physicians to being shared care between families, community based health services, and specialists in paediatric emergency care. This change has probably contributed to the reduction in mortality in childhood.

G48 ADHERENCE TO PAEDIATRIC CARDIAC ARREST PROTOCOLS: DOES PRACTICE MAKE PERFECT?

P. Davies1, C. Bernstein2, M. O’Meara3.1Royal Hospital for Children, Bristol, UK; 2St Mary’s Hospital, Paddington, UK; 3Sydney Children’s Hospital, Sydney, Australia

Aims: To assess compliance with APLS cardiac arrest protocols in a simulated scenario by doctors in a children’s emergency department, and to assess the effect of training on compliance.

Methods: All doctors working in a tertiary referral paediatric emergency department, at the Sydney Children’s Hospital, Sydney, Australia, were invited to take part in this study. Full ethical approval was granted and informed consent obtained. Subjects were asked to lead a scenario of a 6 year old following immersion with VF progressing to asystole then PEA, before return of spontaneous circulation. One to three weeks later each subject led a second scenario with a different context but identical clinical course. The subjects were not aware that the second scenario was the same as the first. Two nurses assisted but were asked to follow commands only and not to prompt or help the doctor. All interventions had to be acted as in real life, with drugs drawn up and given through a cannula. The mannequin was pre-intubated and pre-cannulated to enable easier comparisons. Timings of interventions were compared with APLS guidelines and between scenarios.

Results: Eleven doctors consented to take part. The scenario was divided into 17 time points, with APLS protocol timing to finish at 7 minutes; 1/11 doctors finished in ±1 minute on scenario 1 and 3/11 in scenario 2. All time points analysed showed greater accuracy in scenario 2, with a significant improvement in number of time points achieved in ±1 minute from the APLS standard (p = 0.004). 5/11 doctors finished the scenario on the first attempt and 8/11 on the second attempt. 7/11 reached time point 14/17 on the first attempt and 11/11 reached point 14/17 on the second attempt. Consultants and fellows (senior registrars) had the most accurate times, with RMOs (SHOs) next best. Registrars deviated most from the protocols. Doctors who had completed an APLS or PALS course in the past 3 years were just as likely to complete the scenarios, but trended to greater deviation from the protocol timings, compared with those who did not have a current resuscitation certificate.

Conclusions: Recent practice with resuscitation scenarios improves subsequent performance in a scenario. The APLS protocols have an achievable time frame, but only by the most highly qualified and experienced doctors. We note that the most junior doctors had better times than the registrars, which may suggest areas for targeted further education. Holding a current APLS certificate does not improve timing accuracy or protocol adherence. We recommend monthly scenario training to maintain performance levels in clinical staff likely to be leading resuscitation attempts.

G49 A SURVEY OF PARENTS’ EXPECTATIONS ON ATTENDING A PAEDIATRIC ACCIDENT AND EMERGENCY DEPARTMENT AND SUBSEQUENT INFORMATION RETENTION

S. Verma, L. Kehler, P. Davies, B. Wilson.Birmingham Children’s Hospital, Birmingham, UK

Aims: To determine parents’ expectations on attending a paediatric A&E department and to evaluate their subsequent information retention following discharge from the A&E department.

Methods: A prospective survey was conducted by distributing questionnaires to parents at the initial contact with A&E department reception staff. Parental consent was obtained prior to receiving a follow up telephone call within 5 days of the initial attendance, in order to evaluate their information retention.

Results: A total of 218 questionnaires were received at the end of the survey. Eighty five parents (40.7% of responders) had phoned their GP with the problem and only 30 parents (14.3%) had sought advice from NHS Direct. Eighty three parents (40.1%) had actually visited their GP and 12% had visited this A&E department in the past week. A total of 48.5% of patients responding bypassed their nearest hospital with paediatric services to attend this A&E department. A total of 41.6% of parents expected their child to be seen by a doctor within an hour. Eighty two parents (40.8%) expected their child to be discharged home but 43.6% were unsure whether the child would be admitted, discharged, or observed in the department. Parental expectation regarding investigations and treatment differed markedly from that actually received. 164 (84.5%) parents were interested in a card outlining their child’s diagnosis, treatment, and follow up prior to discharge from the department. There were 138 parents who participated in the follow up telephone survey. The diagnosis provided by the attending doctor corresponded in 76.3% when compared with the parents’ perceived diagnosis. Only 23 (17.7%) parents reported receiving written instructions compared with 41.9% who received verbal instructions. Of 51 (23.4%) parents reporting they were told to seek medical advice, 94.1% were if the child deteriorated or there was no clinical improvement and 5.9% if there were parental concerns. When asked what could be improved, 45 parents (48.4% of responders) felt that nothing could be improved and 19 parents (20.4% of responders) believed that time waiting to see a doctor could be reduced.

Conclusion: There was a reasonable agreement between actual diagnosis and perceived diagnosis but not relating to expected and actual investigations and treatment. Currently parents do not receive a letter prior to discharge from the department but a significant proportion of parents expressed interest in a card detailing the diagnosis, treatment, and subsequent follow up arrangements that they could refer to. Consequently plans are in place to introduce child specific written documentation on discharge.

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