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]