1. Question 23 2017 The ADMIN question
Dr Tony Kambourakis
FACEM FRACMA
Twitter: @drtonykam

2. Your mixed Emergency Department has a high “did not wait” rate in comparison to adult presentations.
A) List FOUR potential reasons for this difference
B) State FOUR steps you would take to address this issue
C) List FOUR specific interventions you could consider to improve paediatric experience through your ED.

3. General points Question stem should have been more clear
Question refers to a disproportionately higher did not wait rate for paediatric patients in comparison to adult patients.
Pass mark = 6 / 12
Pass rate = 58%

4. General points Read the questions carefully
Write legibly – including your candidate number
One point/answer per line
Four only - others will be ignored
Use professional language & avoid judgemental/emotional terms
‘ ‘trivial presentations’
‘the clientele’ (for patients/carers)
Be careful and qualify words such as ‘inadequate’ and ‘inappropriate’

5. A) 4 reasons for difference
Need to talk about reasons that paediatric DNW is higher than adult.
Some leniency in marking due to ambiguity in question
Good answers considered:
Patient/family factors
Staff factors
Department/model/environment factors

6. A) 4 reasons for difference
Patient/carer factors
Paediatric patients may have lower acuity - longer waiting time
Symptoms may resolve while waiting
Carers may perceive frontline staff as uncaring/sympathetic
Staff factors
Triage staff may be less experienced with children – impacts on triage, communication, explanation of alternatives, escalation, initiation of treatment
Medical staff not experienced/comfortable with children may preferentially see adult patients
Staffing levels and experience may not be aligned to demand

7. A) 4 reasons for difference
ED /model/ environment factors
Waiting room environment crowded/uncomfortable/unsuitable for children
Availability of alternatives nearby – bigger ED, GP clinic
ED overcrowding
No dedicated paediatric/fast track stream or model of care
No system of communicating wait times and reviewing patients waiting beyond appropriate timeframes
No system of front-loading care (eg rapid assessment, initiation of management etc)

8. A) 4 reasons for difference
I would not accept (unless qualified)
Access block
Long waiting times
Inadequate resources
Insufficient staff
No beds
These are not thought out reasons. Imagine you had to make a case to a hospital executives for more resources. Be specific!

9. B) State FOUR steps to address issue
Model of care
Dedicated paediatric stream/model of care to ensure paediatric patients seen in appropriate timeframes
Could also include fast track and paediatric SSU model of care
Front-loaded care – rapid senior clinician assessment; initiation of management (eg analgesia, oral rehydration, topical anaesthetic
Standard initial management guidelines for common conditions:
Eg fever, asthma, gastroenteritis, limb injuries
Follow up system for ‘do not wait’ patients
GP clinic/ambulatory care referral model
Rapid review/phone review model

10. B) State FOUR steps to address issue
Staff
Allocate staff specifically for paediatrics during peak periods (depending on numbers)
Can be either medical or nursing (eg initiate management)
Train clinical staff in recognition and management of children
Training to communicate wait times, discuss alternatives to ED where appropriate
Nurse practitioner, primary contact physio, mental health clinician, ED pharmacist models

11. B) State FOUR steps to address issue
Environment
Dedicated treatment and waiting areas
Some overlap with the next question which focuses specifically on improving patient EXPERIENCE, rather than addressing Do Not Waits

12. B) State FOUR steps to address issue
I would not accept, without qualifications:
‘more staff’
‘more resources’
‘staff education’
‘ more beds’
‘improve patient flow’
‘improve communication’
“Plan, Do, Study, Act” without mentioning any specific interventions

13. C) 4 Specific interventions to improve experience
Child-friendly waiting facilities & treatment areas - separate if possible
Toilet/changing/feeding facilities
Vending machines
Entertainment – TV, toys, books, games
Art/decorations
Seating/space for carers
Child-friendly meals (including dietary/allergy specific needs)
Distraction therapies – play therapist, clown doctors, stickers, bubbles
Focus on improving pain & fever – analgesia, procedural sedation

14. C) 4 Specific interventions to improve experience
Staff
training in care of children/carers – including non-clinical staff
Paed-friendly scrubs/uniforms
Play therapists, clown doctors etc
Models of care
Distraction therapies – play therapist, clown doctors, stickers, bubbles
Focus on rapid improvement of pain, fever, dehydration – analgesia, procedural sedation, oral rehydration
Review/follow up clinic to facilitate early discharge, review

15. C) 4 Specific interventions to improve experience
I did not accept:
More staff
Improved communication
Reduce access block
Staff education

16. Best of luck with your exam preparation!
Imagine answering this question as a sales pitch to an influential either hospital executive, influential senior medical staff in hospital, or even a politician.
They are sick of hearing “more beds, more staff, more resources”
Describe specifics of what the problem areas may be
Describe specific solutions/ideas that you may be able to advocate for.
As leaders we have a system improvement, wider education and advocacy role.
Best wishes for Christmas and New Year. Hope this feedback is useful.