Background Over the past 25 years Sierra Leone has made progress in reducing maternal and child mortality, but the burden of preventable paediatric deaths re-mains high. Further progress towards achieving the Sustainable Development Goals will require greater strengthening of the health care system, including hospital care for perinatal and paediatric conditions. Emergency Triage Assessment and Treat-ment Plus (ETAT+) may offer a useful tool. Methods The five-day ETAT+ course was adapted as a six-month programme of in-situ training and mentoring integrated with patient flow and service delivery im-provements in 14 regional and district government hospitals across the country. Nurses were trained to carry out the initial resuscitation and assessment of the sick paediatric patient, and to administer the first dose of medication per protocol. The course was for all clinical staff; most participants were nurses. Results The intervention was associated with an improvement in the quality of pae-diatric care and a reduction in mortality. In 2017 mortality decreased by 33.1%, from 14.5% at baseline to 9.7% after six months of the intervention. Mortality at the start of the 2018 intervention was 8.5% and reduced over six months to 6.5%. Care quality indicators showed improvement across the two intervention periods, with some evidence of sustained effect. Conclusions These results suggest that adapted ETAT+ training with in-situ men-toring alongside improved patient flow and service delivery supports improvements in the quality of paediatric care in Sierra Leonean hospitals. ETAT+ may provide an affordable framework for improving the quality of secondary paediatric care in Sierra Leone and a model of nurse-led resuscitation may allow for prompt and timely emergency paediatric care in Sierra Leonean hospitals where there are fewer physicians and other resources for care.

Background: In the wake of the Ebola virus disease (EVD) epidemic in Sierra Leone, secondary care facilities faced an increase in admissions with few members of medical staff available to assess and treat patients. This led to long waiting times in hospital outpatient departments. The study was undertaken in the outpatient department of Ola During Children's Hospital (the tertiary paediatric hospital for Sierra Leone) in the period immediately following the EVD epidemic of 2014-2015. Aims: This retrospective analysis of operational programme data aimed to assess whether a quality-improvement approach and task-sharing between medical and nursing staff improved the quality of triage and the timeliness of care. Methods: All staff working in the outpatient department were offered a 4-week training course, followed by on-the-job supervision and support for 6 months. Nurses who successfully completed the course were given responsibility for the initial assessment of sick patients and for prescribing and giving initial treatment. Data were collected at three points: before intervention and at 3 and 6 months after initiation of the intervention. All children presenting to the hospital for medical attention between 0800 and 1400 Monday to Friday were included. Triage assessment by the outpatient nurse was compared to that made by a clinically experienced observer, and the time taken for each child to be triaged, assessed and given initial treatment was recorded. Results: Between months 0 and 6 of the intervention, detection of emergency signs by the triage nurse improved from 30% to 100%, and detection of priority signs improved from 34% to 100%. For children presenting with emergency signs, the median time between triage and full assessment improved from 57 minutes before intervention to 17 minutes at 3 months and 5 minutes at 6 months (p < 0.0005). For the same group, median time between triage and first antibiotic or antimalarial treatment improved from 220 minutes before intervention to 40 minutes at 3 months and 18 minutes at 6 months (p = 0.006). Conclusion: The results indicate that, with appropriate training and support, extending the emergency assessment and treatment of sick children to nursing staff in West African hospitals may improve the accuracy of triage and the time to assessment and treatment of children presenting with signs of serious illness.

Across the globe, persecution, conflict, and famine drive people from their homes. In 2014 59.5 million people were forcibly displaced, of whom more than half were children. Of those people, 38.2 million had been displaced within their country of nationality, whilst 21.3 million had crossed borders to seek refuge. In the summer of 2015, forced migration gained particular prominence in the world's media, as large numbers of migrants made the journey to Europe, and the member states of the European Union dramatized the complexities of the laws and treaties relating to migration into and within the EU.

In 2014 and 2015, Sierra Leone, along with its neighbours, Guinea and Liberia, experienced by far the biggest epidemic of ebola virus disease ever recorded. As the rapid spread of the virus became clear, a huge relief effort was undertaken and supported by governments around the globe. That the ebola virus was transmitted so freely and quickly in West Africa was due, in part, to the weakness of the healthcare systems in the countries which suffered the epidemic. The damage caused by ebola further undermined those systems. In the months following the end of the outbreak, the difficult work of building adequate healthcare systems for the people of Sierra Leone, Guinea, and Liberia, has begun. This article gives a personal account of the longer-term effects of the ebola epidemic on the healthcare systems in Sierra Leone.

AIM:To assess the training for, practice of, and effects of venepuncture in children on a general children's ward. To identify approaches that might reduce the adverse physical and psychological effects related to venepuncture.METHODS:Questionnaire survey of 51 parents, 39 children and 72 junior doctors following venepuncture in the children. Telephone survey of 25 paediatric senior house officers on venous access training.RESULTS:Parents and children assessed venepuncture as extremely distressing. Parents' assessments of the mean number of venepuncture attempts were markedly higher than those of the doctors surveyed. When carrying out venepuncture, doctors used therapeutic measures much less frequently than expected. Only seven of the 25 departments surveyed offered any training in venepuncture.CONCLUSION:Venepuncture is consistently one of the most distressing aspects of hospital admission for children. Much could be done to alleviate this, but trainir patchy and interventions shown to reduce distress are not uniformly used.

Two recent studies investigating the use of chaperones and chaperone policies in UK emergency departments suggest that the vast majority of departments do not have a formal chaperone policy.1 2 Furthermore, one of the studies suggests that doctors regularly conduct intimate examinations on patients without a chaperone being present.2 We report the results of an audit of junior doctors' use of chaperones for …

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