Contested discharge and retrieval — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in a regional hospital without on-site PICU. Leo, aged 22 months, presented with viral wheeze. After treatment, saturations are acceptable in air but the last blood pressure was not recorded. Father says, "He is getting worse." Bed management asks for discharge. You have 12 minutes at the bedside (simulated) and 5 minutes for discussion. [3]

Information available on request

• Weight 12 kg; previously well; immunisations up to date. [1]
• Trend: improved work of breathing after salbutamol, then quieter with reduced interactiveness; mild residual tachypnoea; discharge BP blank; SpO2 96% in air when crying stops. [3]
• Family lives 35–40 minutes away; one car; limited after-hours transport. [4]
• Local PEWS band below automatic MET colour. [3]

Tasks

1. State a disposition problem representation using acuity, trajectory, social and system capability. [4]
2. Interpret caregiver concern and incomplete discharge vitals. [3] [9]
3. Choose and defend disposition; escalate or retrieve if indicated. [14]
4. Deliver structured handover (I-PASS or ISBAR). [2]
5. If discharge were ever appropriate, give consensus safety-netting with teach-back; otherwise explain why home is unsafe. [5]

Expected performance

Must achieve

• Does not discharge on a low score alone. [3]
• Completes or escalates for missing discharge vitals. [9]
• Treats caregiver concern as an independent trigger (Mills). [3]
• Chooses capability-matched destination (observe/admit/retrieve as indicated). [14]
• Structured handover including contingency and receiver synthesis. [2]

Should achieve

• Names SNA content pillars if discussing discharge. [5]
• Mentions social/transport barriers as disposition data. [4]
• Quotes Starmer error reductions carefully. [2]

Excellent extras

• Links Paydar-Darian discharge checklist/huddle/scripted review as system fix. [9]
• Quotes Burvenich NMA process outcomes with certainty limits. [1]
• States family-activated escalation path. [3]

Examiner prompts if stuck

• "The band is not red — why keep him?" [3]
• "What exactly will you say to father if he goes home?" [5]
• "How will you speak to retrieval?" [14]
• "What hospital process would have prevented this near-miss?" [9]

Marking domains

| Domain | Weight | Anchors | [2] [3] [5] [9] | --- | --- | --- | | Assessment synthesis | High | Trajectory, concern, incomplete vitals | | Disposition decision | High | Capability match; no score veto | | Communication/handover | High | I-PASS/ISBAR + teach-back | | Systems thinking | Medium | Discharge QI, retrieval, escalation culture |