Background Simulation based medical education can be a powerful tool in practising communication and teamwork as well as strengthening technical and clinical skills[1]. There is growing evidence that simulation training spaced at regular intervals can improve clinical knowledge, including in paediatric acute illness management[2]. In situ, high-fidelity simulation also allows identification of errors inherent to the work environment [3,4]. Aim To determine whether repeated simulation based training improves time to key outcomes in common paediatric emergency and decreases the number of latent errors in paediatric departments. Methods Five paediatric emergency scenarios were used in simulation training of clinical staff in Myanmar and the UK. A structured interactive debriefing tool was used before repeating the scenario with the same clinical lead. The latent errors and times to key treatment points were recorded. Results The overall average reduction in time to key treatment steps was 88 s (p=0.04; 95% CI 7–190) in the UK hospital and 74 s (p=0.045; 95% CI 3–144) in the Myanmar hospital. There was an 83% and 59% decrease in the number of latent errors in the UK and Myanmar hospitals respectively. Conclusion Repeated simulation based training in both settings showed a shortened time to key treatment steps in paediatric emergency scenarios and a decrease in the overall number of latent errors identified which would enhance patient safety through improved management of critically unwell children.

Aims An Emergency Paediatric Care Programme in Myanmar provides training in the stabilisation and safe transfer of sick children. The transfer of seriously sick children may be necessary to ensure the appropriate level of care, but is fraught with difficulties. A review of current practice and local challenges was undertaken. Methods In September 2015 a retrospective audit of children admitted with dengue to a Regional Centre was performed to identify reasons for referral. Local healthcare professionals were invited to complete a survey exploring barriers to referral pathways. Results 34% of patients with dengue (n=269) were referred. Only 44% of referrals had a referral letter and 35% did not require tertiary care. Challenges identified included: Late presentation due to families’ preference for traditional medicine, concerns about the quality of public healthcare, medical and transport costs Lack of referral guidelines, human resources and training Transfer of patients who had not first been stabilised Reluctance to acknowledge the potential benefits of transfers Deficiency in ambulances such that patients were transferred by public transport Solutions identified and implemented included: Development of referral guidelines and pathways Training in stabilisation and transfer Development of transfer checklists for emergency equipment and medications Identification of voluntary sector transport vehicles Identification of outpatient tertiary clinic appointments to reduce unnecessary acute referrals Conclusions There is a deficiency in referral pathways between primary, secondary and tertiary healthcare facilities in Myanmar. Development of referral networks and the training of healthcare workers in the stabilisation and transfer of sick children is important to reduce morbidity and mortality.

Aims Clinical job aides directly benefit clinical care and assist project evaluation. We describe early experience of their introduction as part of an Emergency Paediatric Care Programme (EPCP). Methods An EPCP working group developed pilot job aides. These included admission, observation and drug charts that were piloted in 11 hospitals. Between May and October 2016 the job aides were reviewed and a survey of local healthcare workers undertaken. Results In the majority of hospitals job aides were limited or inadequately completed. Vital sign charts typically only recorded the temperature. The prescription and administration of drugs were recorded in separate places, and admission information recorded on a brief proforma. Although the job aides received positive endorsement during the EPCP courses there has been some resistance to their use in the wards. A survey of patient notes at one site demonstrated that no staff were using the admission forms or the drug charts adequately. Vital signs charts were more acceptable and 100% were satisfactory. Healthcare workers considered the job aides useful, but cited poor staffing and lack of time as the reason for limited acceptance. Suggestions included: Senior endorsement Training for all staff on how to use the job aides Explanation to nurses how vital signs charts can be used to monitor patient progress and signal when to get help Conclusion Job aides can focus the attention of healthcare workers on key signs and symptoms as taught in EPCP. Ongoing training, familiarisation, mentorship and support from senior colleagues will be key for their successful introduction.

Aims An Emergency Paediatric Care Programme (EPCP) runs training courses in district hospitals. We describe a strategy to support local leadership and develop teams responsible for devising and fulfilling individual implementation plans. Methods During EPCP courses, participants review the hospital facilities and make recommendations for improvement. A local EPCP Champion (senior clinician) supported by an EPCP Team is responsible for identifying local priorities and developing an Implementation Plan to achieve these. They are asked to consider: layout, infrastructure, staffing, patient safety and infection control, drugs and equipment, staff numbers and training, patient records, clinical guidelines, and morbidity and mortality meetings. Additional support is provided through Global Link Volunteer (GLV) placements in the hospitals. A bi-annual EPCP Champion and Team Conference provides an opportunity to share ideas and experiences, problem solve and discuss quality improvement projects. Results GLVs, EPCP Champions and Teams representing 7 district hospitals reported on their Implementation Plans at the first EPCP Champion and Team Conference in July 2016. A wide range of topics were described including weekly simulation training, new guideline wall charts, well-equipped resuscitation areas, new admission and observation charts, improved infection control through the repair of broken sinks and provision of hand-gel and multi-disciplinary mortality meetings. Feedback was extremely positive with the teams feeling motivated, empowered and rewarded for their efforts. Conclusions Successful training depends on its impact in practice; the EPCP Champions and Team Conference demonstrated that the combined efforts of local EPCP Champions and Teams and GLVs in developing the Implementation Plans had led to valuable quality improvements.

Aims Healthcare in Myanmar is evolving. This includes the use of evidence based quality improvement, a novel concept for many senior clinicians. Royal College of Paediatrics and Child Health (RCPCH) Global Links Volunteers (GLVs) aimed to deliver audit-based quality improvement teaching to 26 senior local paediatricians (consultants and senior registrars) at 3 sites in central Myanmar. We aimed to assess pre-existing knowledge and post-session motivation to affect change. Methods We devised a half-day simulated quality improvement project (QIP), including an interactive lecture along with simulated data collection and analysis. Each participant thus completed a full QIP cycle. Clinicians then discussed QIP ideas to apply to their own hospitals. One month later they completed a questionnaire to assess the impact of the session. Results Of fifteen respondents, 80% had never experienced quality improvement teaching and over half were unaware of QIP activity ever having occurred in their hospitals. Post-session, 66% of respondents reported they had discussed starting a QIP in their hospital, all whom cited specific examples. 87% reported an intention to start a QIP in the near future and 100% reported feeling more confident regarding the process. The participants seemed motivated, with 100% reporting they felt performing QIPs would make tangible improvements to their hospital, and 100% citing the purpose of a QIP as ‘improvement of patient care’. Despite this none of the respondents had actually started a QIP. Post-session, 33% of respondents reported delivering QIP teaching to local colleagues and thereby encouraging wider participation in quality improvement. They appeared to have retained the information delivered, with 100% correctly explaining the steps of the QIP cycle. Conclusions Interactive practical QIP teaching represents a simple and reproducible model to educate and enthuse senior clinicians with limited previous QIP experience. This enthusiasm appeared to remain 4–6 weeks post teaching. Newly-acquired knowledge had also been disseminated to others. While many respondents reported interest in specific QIPs of their own, none had been realised. This signals both the need and opportunity for on-going partnership to put theory into practice, and continue the evolution of a supportive culture of quality improvement across Myanmar, while further work might assess the barriers to achieving this.

Aims Dengue fever is a relatively common infection in children in the tropics and subtropics. In 2015 there was a significant outbreak of dengue in Myanmar. The aim of this case series is to identify common clinical features in children presenting with dengue shock syndrome (DSS) in Myanmar. Methods The medical notes of 26 children presenting with DSS to Mandalay Children’s Hospital in Myanmar during the rainy season (September 2015) were reviewed by a single investigator. Demographic and clinical details were recorded in a secure anonymous database. Results The mean age of the 26 children was 6 years (range 9 months - 12 years). The majority of children presented to hospital after 4–5 days of fever and developed DSS after 5 days of fever. Haemorrhagic symptoms included: haematemesis (42%), malaena (35%), petechiae (12%), gum bleeding (8%), epistaxis (4%), haematuria (4%) and bruising (4%). Other symptoms included: cold clammy extremities (42%), abdominal pain (39%), abdominal distension (27%), respiratory distress (31%), vomiting (19%), loss of appetite (19%), convulsions (19%), irritability (15%), facial puffiness (12%) and restlessness (12%). Typical laboratory investigation findings included lymphocytosis, thrombocytopenia and a microcytic anaemia. Medical treatment included the use of paracetamol, ranitidine, phytonadione, oral rehydration solution, normal-saline, dextrose-saline, gelofusine, fresh whole blood, platelets and furosemide. 4 (15%) of the children died from fluid overload, disseminated intravascular coagulation, gastrointestinal haemorrhage and encephalopathy. The mean duration of shock for the surviving 22 children was 6 h with several having 2–3 recurring episodes of shock before making a full recovery. Conclusion DSS remains a significant cause of morbidity and mortality in children. Common symptoms included cold clammy extremities, haemorrhage, gastrointestinal symptoms, dyspnoea, and convulsions. Early recognition of dengue warning signs and symptoms with intensive care monitoring and fluid management is key to improving outcome in DSS.

Aims The evidence-base for the optimal duration of parenteral antibiotics in paediatric uncomplicated acute haematogenous osteomyelitis (PUAHO) before switching to oral antibiotics is limited. Here we review current practice at a district general hospital (UK); patient/carer experience; and recommendations by regional experts. Methods Patient medical notes, laboratory and radiological results were reviewed for all children st July 2013 and 1 st August 2014. Demographic and clinical details were recorded in a secure anonymous database. A literature review and email survey of regional paediatric microbiology, infectious disease and orthopaedic experts was undertaken. Semi-structured telephone interviews with carers was conducted and transcripts analysed using a qualitative framework. Results 5 patients were diagnosed with osteomyelitis. 1 was secondary to a supracondylar fracture and 1 had septic arthritis and so were excluded from clinical analysis but included in the telephone survey. The duration of parenteral antibiotics varied from 3–6 weeks and continued for u003e14 days after normalisation of inflammatory markers and resolution of clinical signs. Regional experts confirmed “there is considerable variability in practice and limited evidence when to switch antibiotics” (range of minimum duration of parenteral antibiotics 2–6 weeks). They highlighted concerns regarding oral antibiotic compliance and that some carers are not comfortable switching early especially if they believe their child has a serious infection. From the telephone survey carers reported they found “multiple opinions for the duration of treatment confusing.” Multiple cannulas (u003e10) and trips to the hospital caused significant anxiety and disruption for family and school life. Carers would find oral antibiotics preferable “so long as they work,” although one carer found the administration of them more challenging. Conclusions There is currently no consensus and considerable variation in regional practice for the management of PUAHO. Unnecessary prolonged courses of parenteral antibiotics can have adverse financial and patient/carer experience implications. This study highlights the pressing need for robust evidence regarding the optimal duration of parenteral antibiotic therapy in PUAHO. The UK multicentre DINOSAUR study on the management of paediatric osteomyelitis is likely to provide further evidence.

Aims We describe the development of an EPCP in Myanmar that supports the Ministry of Health priorities. Methods A partnership between 3 paediatric associations – RCPCH, KPA and Myanmar Paediatric Society (MPS) reviewed ways to reduce child mortality in Myanmar. Kenyan ETAT+ teaching materials were adapted in accordance with Myanmar’s Facility-based Integrated Management of Newborn and Childhood Illness manual and national guidelines. Experienced KPA and RCPCH instructors support the development of a faculty of Myanmar EPCP instructors. The development of ETAT+ Teams and implementation plans for each hospital is crucial in minimising barriers to change. Results A key difference between the EPCP and Kenyan ETAT+ course was the inclusion of dengue, snakebite and beriberi. In 2015, 56 doctors and 47 nurses successfully attended 4 EPCP courses in Myanmar; 2 Voluntary Service Overseas international nurses joined to ensure consistent teaching. The majority had limited experience of simulation and skills training and found these sessions training doctors and nurses together particularly useful. Feedback has been very positive – “excellent training, essential for doctors and nurses” – with 1 participant reporting that they subsequently saved the lives of several children using an intraosseous needle. 14 exceptional participants were invited to attend a Generic Instructor Course which enabled them to “grow in confidence” and develop their teaching styles to “facilitate other people to learn.” They were mentored as instructor candidates on 3 subsequent EPCP courses. EPCP participants review the hospital facilities, making recommendations that guide local implementation plans; examples include regular simulation training and patient admission forms. 5 Global Links Volunteers (UK paediatricians) have been recruited to support the local ETAT+ Teams with clinical duties, training, quality improvement, monitoring and evaluation. Conclusions EPCP is designed to lead to sustainable changes in clinical practice by incorporating South-South training with highly interactive practical teaching; facility improvements to allow learning to be put into practice; leadership and teamwork to create a culture of willingness to change. The formation of a highly-skilled faculty of local instructors maintains the quality of training and reduces the need for international instructors. Support from UNICEF to expand the programme to other regions is further evidence of EPCP success.

Context The quality improvement project was undertaken at a District General Hospital and included staff who care for seriously sick or injured children including doctors and nurses working in general paediatrics, accident and emergency and anaesthetics. The appropriate initial assessment and resuscitation of serious ill and injured children together with on-going reassessment and emergency management are essential for reducing morbidity and mortality. Problem There was no integrated multi-disciplinary team (MDT) paediatric resuscitation training and several paediatric serious incidents had involved more than one department. Simulation training increases the acquisition of skills and provides a platform to review performance and make errors without compromising patient safety. Both the Department of Health and RCPCH recognise the importance of simulation training in improving patient safety through reducing human and system errors. High fidelity manikins can be monitored which significantly adds to their realism. Assessment of problem and analysis of its causes A retrospective review was undertaken by a paediatric trainee of all the paediatric serious incidents during a ten year period to identify common themes and key recommendations. The development of MDT resuscitation training was one of the principle recommendations to improve the emergency assessment and care provided to children. Intervention MDT paediatric resuscitation training sessions involving healthcare assistants, nurses, doctors and other allied healthcare professionals from general paediatrics, accident and emergency and anaesthetics were planned several months in advance through a consultation process. Dates and times were chosen to maximise trainee availability and minimise disruption to routine services. For MDT training in accident and emergency, strategies were implemented to ensure patient safety at all times. Resuscitation officers provided support and resuscitation equipment. The hospital switch board was notified so a simulated paediatric crash call could be initiated through the hospital paging system. Scenarios were developed based upon previous paediatric serious incidents to review whether key recommendations had been successfully implemented and sustained. The focus was on familiarisation with paediatric resuscitation equipment, drugs and guidelines in real time as well as teamwork, communication and leadership skills and dynamics between and within the different specialties. A pilot paediatric simulation MDT training session was also undertaken in the Education Centre. Strategy for change MDT paediatric resuscitation training was coordinated through the paediatric and emergency departments as well as the hospital resuscitation committee. Anonymous feedback through questionnaires was collected from participants. Measurement of improvement The MDT paediatric resuscitation and simulation training received very positive feedback: "Excellent scenario, felt more real than other simulated scenarios I have attended." Participants found the MDT simulation training much more realistic than weekly departmental resuscitation training with 79% strongly recommending the simulation training compared with just 33% for the weekly departmental training. Effects of changes MDT paediatric resuscitation training was successfully implemented. A business case was developed for the purchase of a paediatric simulation manikin to improve the reality of the training. Lessons learnt MDT paediatric resuscitation training is a very valuable tool for improving teamwork and paediatric resuscitation skills. Paediatric high fidelity simulation training can enhance this further through providing a more realistic experience. Message for others MDT resuscitation training should be routine practice in district general hospitals. Basing scenarios on previous serious incidents is a useful way to review previous key recommendations. A business case can be developed by demonstrating improved experience through a pilot high fidelity simulation trainer.

Aims Reliable healthcare statistics are limited in Myanmar. This study aims to describe the typical patient journey through a Paediatric Intensive Care Unit (PICU) and provide vital information to guide future development. Methods A retrospective review of the PICU admission records and patient medical notes was undertaken for all patients admitted to the PICU from 1st November 2011 until 31st October 2012. Patient information was anonymised and key data was extracted including basic demographics, history of presenting complaint, investigations, management and outcome on the PICU. Results The PICU had 10 beds, 7 ventilators and 1 haemodialysis machine. There was a shortage of staff with only 1 doctor and 2 nurses at night. Routine investigations were available although microbiology culture was rarely performed. 407 patients were admitted with the majority being infants (range 0–16 years). The furthest distance travelled was 907 Km for a child with lead poisoning. Most patients were admitted for less than 5 days. The peak admission period was during the rainy season which corresponds to the peak incidence of dengue. 64 patients (17.5%) presented with dengue shock syndrome or dengue haemorrhagic fever. The principle reasons for admission included status epilepticus (26.5%); pneumonia (20%); dengue (17.5%); multi-organ failure (14.2%); septicaemic shock (11.7%); and encephalitis (9.5%). Other important reasons for admission were meningitis; gastroenteritis; post-measles complications; diphtheria; snake bite; Beriberi (including Wernicke´s encephalopathy); tetanus; rabies; malaria; late haemorrhagic disease of the newborn; malnutrition; tuberculosis; HIV; and poisoning (organophosphates; traditional medicine). All patients with a viper bite died of complications including shock, acute renal failure and pulmonary haemorrhage. The majority of patients with diphtheria were managed with a tracheostomy. Overall mortality on the PICU was 34%. Conclusions This study provides a unique insight into the local disease burden, resources available and challenges faced in providing paediatric intensive care. The relatively high incidence of vaccine preventable diseases is of particular concern. Key priorities include support for the development of nurse and doctor training; staff retention; evidence-based guidelines; data management including follow-up; referral pathways; access to routine investigations; and a reliable supply of essential medications and equipment.

During the last half century there has been an exponential increase in international travel including to more exotic and long-haul destinations. The assessment of febrile returning child travellers presents diagnostic challenges and is often performed poorly. A detailed travel and medical history, clinical examination and appropriate first-line investigations are essential. While the majority of children will have a common self-limiting or easily treatable infection, it is important to consider other causes, including imported infections, which may be life-threatening or highly contagious. In this article, we provide guidance on the initial assessment and management of such children with a focus on some of the more important imported infections, including malaria, dengue, typhoid fever, travellers' diarrhoea, respiratory infections, tuberculosis, schistosomiasis and rickettsial diseases.