Safe disposition, escalation, referral and safety-netting — formative SAQs

SAQ 1 — ED discharge with caregiver concern (20 marks, ~15 minutes)

A 20-month-old attends the ED with viral wheeze. After bronchodilators and observation, oxygen saturations are acceptable in air, but the last blood pressure was not recorded. Father says, "He is still not himself." The local PEWS band is below automatic MET threshold. The family lives 40 minutes away without a car at night. [3] [4]

Questions

1. Define capability-matched disposition using four decision axes for this child. (4 marks) [4]
2. How should caregiver concern and incomplete observations change your plan? Cite the key Mills association. (4 marks) [3]
3. If you keep the child, outline escalation and handover using I-PASS elements. (6 marks) [2]
4. If you discharge, give a full safety-netting script covering consensus content and delivery form. (6 marks) [5] [1]

Model answer

1. Four axes (4)
Acuity now; trajectory after treatment; social capability (night transport, understanding, re-access); system capability (observation, staffing, ability to escalate). Destination must match all four, not diagnosis label alone. [4]

2. Concern and incomplete chart (4)
Caregiver concern is an independent risk signal — Mills aOR 1.72 for ICU admission after vital-sign adjustment, stronger than any single abnormal vital sign in that analysis. Missing BP means risk may be under-estimated; complete observations or escalate rather than discharging on a low band. [3]

3. Keep + I-PASS (6)
Illness severity (post-treatment respiratory risk, incomplete set, paternal concern); Patient summary (age, viral wheeze course, treatments); Action list (complete vitals, oxygen plan, senior review/MET criteria); Situation awareness/contingency (if oxygen need rises or interaction falls → MET/HDU); Synthesis by receiver (ask senior/MET to restate plan). [2] [14]

4. Discharge SNA only if truly safe (6)
Prefer observation given transport limits. If discharge ever appropriate: verbal + written advice; expected course; uncertainty; red flags (breathing harder, poor feeding, reduced interaction, colour change, cannot wake); where/how to get help including ambulance; teach-back. Paper/oral SNA may reduce return visits (OR 0.74) in NMA — quote certainty limits. [1] [5]

SAQ 2 — Rural retrieval and system design (20 marks, ~15 minutes)

You are the paediatric registrar in a regional hospital without PICU. A 5-year-old with evolving respiratory failure has rising oxygen need. Night PEWS is incomplete. Mother is worried. Governance later asks how discharge safety and structured handover should be improved hospital-wide. [2] [9] [14]

Questions

1. Outline immediate stabilisation, escalation and retrieval priorities. (5 marks) [14]
2. Deliver a structured ISBAR call to the retrieval consultant. (4 marks)
3. Summarise Starmer 2014 I-PASS error outcomes without overclaiming. (5 marks) [2]
4. Name three ED discharge-process interventions from Paydar-Darian and the reported serious-safety-event result. (6 marks) [9]

Model answer

1. Immediate plan (5)
Bedside ABCDE; oxygen/airway support; complete critical observations without delaying care; activate senior/MET on concern and trajectory; call retrieval early while stabilising; do not wait for perfect imaging package. [14] [3]

2. ISBAR (4)
Identify child/age/location; Situation (evolving respiratory failure, rising O2, maternal concern, incomplete night chart); Background (presentation and treatments); Assessment (capability exceeded, high risk of critical deterioration); Recommendation (retrieval now, continuous monitoring, senior airway support). [2]

3. Starmer (5)
Medical errors −23% (24.5→18.8/100 admissions); preventable adverse events −30% (4.7→3.3/100); nonpreventable AEs unchanged; handoff element completeness improved; oral handoff duration not significantly increased. Do not invent mortality claims. [2]

4. Discharge QI (6)
Checklist; provider huddle emphasising discharge vitals; scripted family review of instructions. Report: preventable discharge-related serious safety events eliminated; checklist adoption high; LOS/returns not increased. [9]