RCEM SLO 5 Roadmap: Achieving Paediatric Emergency Medicine Excellence for UK Trainees (2021 Curriculum)
I. Strategic Overview: Defining and Assessing Paediatric Excellence (SLO 5)
The Royal College of Emergency Medicine (RCEM) Specialty Learning Outcome 5 (SLO 5) defines the required competence for Emergency Medicine trainees in Paediatric Emergency Medicine (PEM). This outcome is comprehensive, demanding expertise in the care of children of all ages, across all stages of development, and explicitly including those with complex medical and social needs.[1] Achieving SLO 5 is not simply about clinical proficiency but requires integration across professional domains: evaluation, investigation, decision-making, safeguarding, resuscitation, and empathetic care for families and loved ones attending the Emergency Department (ED) [1].
1.1 SLO 5 Mandate: Scope and Key Capabilities (GMC and RCEM requirements)
SLO 5 encompasses a broad clinical and professional scope. Clinically, it involves mastery of Domain 2 capabilities, including history taking, diagnosis, medical management, prescribing safely, and using medical devices.[1] However, the scope extends significantly into non-clinical domains. Domain 3 requires understanding national legislation and the health service context [1], which is particularly relevant when navigating complex care pathways or legal frameworks, such as those governing mental capacity or safeguarding. Furthermore, Domain 5 capabilities in leadership and team-working are crucial for managing high-stakes paediatric cases, while Domain 7, covering safeguarding vulnerable groups, is a non-negotiable core requirement for all trainees.[1]
A crucial point of structural distinction exists between SLO 5 and SLO 3 (Adult Resuscitation). While SLO 3 provides detailed content on resuscitation and severe illness, the current Key Capabilities for SLO 5 are noted to lack this equivalent detail.[2] This structural distinction requires a deliberate approach by the trainee. Success in SLO 5 relies on the ability to transpose and apply high-level critical care skills acquired under SLO 3 onto paediatric physiology. This application must demonstrate nuanced judgement, focusing on the specific variables introduced by age—namely, correct age-appropriate equipment selection, accurate drug calculations based on weight [3], and utilizing developmental and age-specific assessment tools like the Paediatric Early Warning Score (PEWS), instead of relying on adult systems like NEWS. Therefore, the ultimate assessment emphasis in SLO 5 shifts from generic technical mastery to demonstrating applied paediatric clinical judgement and effective complexity management.
1.2 Programme of Assessment (POA) and WPBA Strategy
The RCEM 2021 Programme of Assessment (POA) mandates that trainees must continually provide evidence of activity in SLO 5 in each year of training.[4] This necessitates a proactive strategy to seek out and document workplace-based assessments (WPBAs), even during non-paediatric placements.
The curriculum specifies the use of a mixed economy of assessment tools to capture the breadth of SLO 5 capabilities.[5] High-fidelity scenarios are mandatory: trainees are expected to be observed in the resuscitation room and reflect on the feedback received regarding their assessment and management of critically unwell children.[1]
• Evaluation of Specialty Learning Event (ESLE): This tool is essential for documenting competence in leadership, especially when managing paediatric trauma or medical resuscitation.[1]
• Case-Based Discussion (CbD): CbDs are the ideal modality for demonstrating the management of complex, multi-system cases. They are particularly useful for showcasing advanced decision-making in areas such as safeguarding, ethical dilemmas (e.g., termination of resuscitation), or the longitudinal care planning for technology-dependent children.[1]
• Mini-CEX and DOPs (Direct Observation of Procedural Skills): These are best used for focused assessments of specific clinical skills, such as obtaining consent in an adolescent or performing an age-appropriate procedure.[1, 5]
• Multi-Source Feedback (MSF): MSF is critical for validating non-technical skills (NTS), such as effective communication with distressed families and robust collaboration within the multidisciplinary team (MDT), which includes acknowledging and acting upon the concerns raised by nursing staff.[6]
Furthermore, trainees are expected to develop teaching and leadership capabilities, demonstrating an ability to deliver effective feedback and set learning objectives.[4] A strategic approach to achieving this involves aligning teaching activities directly with PEM needs—for example, delivering a teaching session on paediatric triage algorithms or resuscitation human factors to junior colleagues or allied health professionals. Documenting this activity allows the trainee to efficiently gather evidence for multiple key capabilities simultaneously, covering both SLO 5 competence and broader Domain 5 (Leadership) requirements.
1.3 Quality Improvement (QI) and Portfolio Building
The GMC requires that QI capabilities are assessed annually and are demonstrably transferrable across training domains, replacing the previous single FRCEM Quality Improvement Project (QIP) essay.[4] For SLO 5, QI initiatives should be intrinsically linked to improving paediatric outcomes or safety in the ED setting.
Appropriate SLO 5 focused QI projects could include auditing department adherence to structured safeguarding checklists [7], measuring the efficacy of communication aids for non-verbal patients [8], or improving time-to-analgesia metrics for painful paediatric presentations (e.g., long bone fractures).
For strong portfolio building, documentation must extend beyond basic clinical cases. Trainees are advised to document a broad range of paediatric cases, specifically emphasizing reflection on difficult and complex situations.[9] Submitting reflections on cases involving medico-legal processes, coroner involvement, or complex family liaison is explicitly recommended.[10] This highlights that achieving expert standard in PEM involves the skilled management of significant non-clinical complexity, demonstrating professional judgment (GMC Domain 4) in the most challenging scenarios.
II. The RCEM Trainee Roadmap for PEM Competency
The formal Programme of Learning for SLO 5 defines mandatory placements, life support training, and the use of high-fidelity simulation necessary to develop the required clinical and professional competence.
2.1 Required Clinical Placements and Timeframes
The curriculum mandates a minimum of six months in PEM during intermediate training.[1] This period is essential for accumulating adequate exposure to the diverse range of paediatric presentations, from minor injury to critical illness.
Trainees must strategically utilize associated placements, such as Paediatric Intensive Care Unit (PICU) or General Paediatrics, to gather required WPBAs.[5] Given the rapid pace of rotation, advanced planning is required to ensure a comprehensive mix of assessment modalities—including CbDs, Mini-CEXs, DOPs, and ESLEs—are completed and signed off by both RCEM and RCPCH PEM consultants where possible.[5]
2.2 Essential Life Support and Professional Courses
Specific training courses are non-negotiable prerequisites for SLO 5 attainment:
• Advanced Life Support: Mandatory completion of Advanced Paediatric Life Support (APLS) or European Paediatric Advanced Life Support (EPALS) is required.[1]
• Neonatal Expertise: While optional, completion of Neonatal Life Support (NLS) is strongly recommended.[1] This training provides specialized skills for the neonate demographic, ensuring competence across the entire paediatric age range specified by SLO 5.
• Safeguarding Compliance: Mandatory completion of Safeguarding Level 1, 2, and 3 is foundational.[1]
• Spotting The Sick Child Module: Trainees must complete the "Spotting The Sick Child Online Module".[1] This popular and highly successful tool provides over five hours of clinical footage of real patients, allowing users to learn how to assess seven common, critical symptoms: difficulty in breathing, fever, rash, fits, dehydration, abdominal pain, and head injury.[11, 12]
2.3 Simulation, Team Leadership, and Human Factors
High-fidelity simulation is an integral, mandatory element of the SLO 5 Programme of Learning.[1] Trainees are required to engage in in situ simulation of PEM resuscitation scenarios and undergo simulation suite feedback specifically targeting paediatric resuscitation team leadership and human factors.[1]
Simulation training effectively addresses the inherent challenges of PEM. Paediatric critical illness is a low-frequency, high-stakes event in many EDs, meaning technical and complex procedural skills can be seldom-used.[13] High-fidelity simulation, which often uses computer-controlled mannequins to replicate life-like conditions and real-time physiological responses, directly closes this exposure gap. This training is also specifically designed to improve non-technical skills, including teamwork, communication, and critical thinking, often utilizing techniques such as video-assisted debriefings to maximize the learning transfer.[13, 14] The requirement for this structured simulation validates the importance of readiness for low-frequency emergencies and emphasizes that competence extends beyond individual technical skill to include effective multidisciplinary team coordination and leadership.[1, 15] Trainees are also expected to utilize relevant online modules, such as those provided by RCEM Learning, to supplement their knowledge base.[1]
III. Core Clinical Competency I: Paediatric Evaluation and Decision-Making
Excellence in PEM hinges on the rapid, structured evaluation of the acutely unwell child, followed by decisive action.
3.1 The Foundation: Rapid Primary Survey (ABCDE)
The foundation of assessing any deteriorating or critically ill patient, regardless of age, remains the standardized Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.[16] The core principles require continuous assessment, regular re-assessment after interventions, treating life-threatening problems before progressing, and ensuring appropriate help is called early.[16]
Central to this is the rapid, initial 30-second assessment, often referred to as "Look, Listen, and Feel." This brief overview is vital for identifying critical illness immediately.[16] The initial assessment should focus on:
• Look: Observing the child's general appearance, noting any signs of respiratory distress (e.g., recession or nasal flaring), or rash.[17] If the child can only speak in short sentences, this indicates potential breathing difficulties.[16]
• Listen: Identifying audible respiratory noises such as stridor, wheeze, or grunting.[17]
• Feel: Checking the temperature, pulse, and capillary refill time (CRT).[17] Oxygen saturations must be measured in any child showing signs of shock or respiratory distress.[17]
A common pitfall is delaying the physical assessment while attempting to console a distressed child. The expert approach necessitates beginning assessment via observation (Look/Listen) while the child is settling, often on a parent's lap, before proceeding to physical touch (Feel).[17]
3.2 Utilising Paediatric Early Warning Systems (PEWS)
PEWS is the national standardized system for identifying physiological deterioration in children.[18] The PEWS chart comprises multiple physiological parameters (Heart Rate, Respiratory Rate, CRT, etc.) that contribute to a numerical score.[18, 19] However, SLO 5 competence requires the trainee to understand and action all four mandated escalation triggers, demonstrating clinical sophistication beyond the numerical score alone.[18]
The four escalation triggers in the UK PEWS chart are:
1. PEWS Numerical Score: Activation based on physiological parameters reaching defined thresholds.
2. AVPU: A decreased level of consciousness (Alert, Voice, Pain, Unresponsive). Failure to respond to initial prompts is a clear marker of critical illness.[16, 18]
3. Clinical Intuition Trigger: This mechanism ensures that if a clinician has a concern not reflected in a low numerical score, that concern automatically triggers escalation. Staff are required to document the details of these concerns.[18] This institutionalizes the vital practice of professional judgment, particularly respecting the cumulative experience of senior nursing staff, who may voice concerns that "they just don’t look right".[6] Trainees must understand that listening to the nurses, and acting upon their worry, is integral to achieving safe practice.[6]
4. Parent Concern Trigger: This is an essential and independent route to escalation mandated by the RCPCH.[18] A concern voiced by a parent or carer must lead to escalation of care, regardless of the child's numerical score.[18]
3.3 Age and Developmental Stage Specific Assessment
Caring for children "at all stages of development" [1] requires adaptation of assessment and management techniques.
• Building Rapport: Essential soft skills include being able to connect with the child quickly. Knowledge of basic TV characters (Cocomelon, Bluey, Paw Patrollers) for younger children, and current culture (like Premier League football teams) for older children, can be highly effective distraction techniques that facilitate necessary clinical examination.[6]
• Procedural Comfort: When conducting painful or invasive procedures (DOPs), trainees must utilize age-appropriate comfort and distraction measures.[20] For infants, this includes skin-to-skin contact with the carer, swaddling, pacifiers, and pre-procedure sucrose.[20] For older children, distractions such as music, apps, toys, or engagement with a Child Life therapist are recommended.[20]
IV. Core Clinical Competency II: Leading Paediatric Resuscitation and Critical Care
The highest level of clinical competence in SLO 5 is demonstrated by the ability to lead resuscitation and manage the complex intersection of high-stakes medicine and ethical considerations.
4.1 Resuscitation Leadership and Protocols
Upon completion of higher training, the trainee must be an expert in assessing and managing all children and young adults, and specifically be able to lead a multidisciplinary paediatric resuscitation, including trauma.[1]
Effective leadership requires coordinating simultaneous interventions (e.g., assessment, monitoring, and obtaining intravenous access) and ensuring effective communication amongst the team using standardized tools such as SBAR (Situation, Background, Assessment, Recommendation) or RSVP (Reason, Story, Vital signs, Plan).[16] Crucially, the trainee must call for appropriate help early and integrate all team members into the management plan.[16]
Pharmacological management in paediatrics is uniquely challenging due to weight-based dosing. The trainee must utilize drug doses based on current Resuscitation Council UK (RCUK) Guidelines (2021) recommendations.[3] Specific attention must be paid to common critical care doses, such as Amiodarone, which is given as IV or IO bolus in arrest after the 3rd and 5th shocks, and Atropine, given at .[3] Neonatal care requires further specific knowledge, such as the recommendation for glucose at .[3]
4.2 Ethical Considerations in Termination of Resuscitation (ToR)
Paediatric resuscitation involves navigating profound ethical dilemmas, particularly regarding the termination of resuscitative efforts (ToR). Ethical principles, including beneficence and non-maleficence, are critical in balancing the potential benefits of prolonged resuscitation against the harms, such as dysthanasia (prolonging the dying process), moral distress for the clinical team, and adverse neurological outcomes.[21, 22]
Prognostic indicators guide these difficult decisions. A lack of response to intensive resuscitation for greater than 10 minutes carries an extremely poor prognosis for survival, or survival without disability.[23] While this threshold provides guidance, the clinician must consider specific mitigating factors, such as severe prearrest hypothermia (e.g., near-drowning in icy water) or drug overdose, before determining whether to extend efforts.[23] If return of spontaneous circulation (ROSC) occurs at any time, even briefly, it may necessitate extending the resuscitative attempt.[23]
The trainee must demonstrate advanced ethical communication skills (GMC Domain 4). If the decision is made to stop resuscitation, compassionate communication with families is essential.[21, 22] The trainee must inform the parents and offer them the sensitive option of holding their child as care is withdrawn.[24] The expert trainee must be prepared to navigate scenarios such as "slow codes" and, when appropriate, exercise clinical directiveness in ToR decisions while maintaining a therapeutic relationship with the family to mitigate the harm of conflict.[21, 22, 25]
V. Domain Expertise: Safeguarding and Child Protection
Safeguarding vulnerable groups constitutes a fundamental, non-negotiable core capability within SLO 5 (Domain 7).[1]
5.1 Legal Requirements and Training
All trainees must complete the mandatory Safeguarding Level 1, 2, and 3 training.[1] Beyond individual competency, the curriculum requires understanding the relevant national documents and policies that govern child protection in the ED setting.[1]
The successful trainee must demonstrate an understanding of the roles of other critical external systems required for child protection. This includes Social Services (Children Social Care, CSC), the Police Child Protection and Domestic Violence Units, and community systems such as Health Visitors and Community Paediatricians.[1] Trainees must also be proficient in using the Child Protection Information Sharing (CP-IS) system to ensure prompt communication between the ED, primary care, and other protective services.[7]
5.2 Structured Decision-Making and Escalation
Decision-making in safeguarding must utilize structured tools, such as safeguarding checklists.[7] A core requirement is the ability to escalate concerns based on clinical judgment, even in the absence of absolute certainty.[7] This mandates a department culture that encourages a proactive and non-judgmental approach, ensuring staff who raise concerns are supported without fear of reprisal.[7]
The essential action, even when in doubt, is the immediate referral to paediatrics and Children Social Care.[7] Furthermore, the trainee must be prepared to handle complex discussions, including the ability to communicate with parents, informing them sensitively that a social services referral is being made, while avoiding accusatory language and focusing on the child's safety.[1, 7]
5.3 Documentation Standards and Medico-Legal Integrity
Safeguarding documentation requires rigorous adherence to specific standards that meet high medico-legal scrutiny. The integrity of the case record is paramount, particularly in cases that may involve medico-legal review or coroner involvement.[10]
Key standards for documentation include:
• Recording injuries accurately using diagrams and photographs when appropriate.[7]
• Noting the exact words used by caregivers when providing the history or explaining the mechanism of injury (MOI).[7] This captures subtle inconsistencies or changes in the narrative.
• Documenting the decision-making process, including who was consulted (e.g., Paediatric Consultant, CSC), what was discussed, and the actions taken (e.g., arrangements for follow-up appointments).[7]
The following structured checklist represents the non-negotiable requirements for safeguarding practice:
Safeguarding Documentation and Escalation Checklist
Action Area | RCEM Standard Requirement | Rationale (Medico-Legal) |
Consultation/Referral | Document who was consulted (e.g., Consultant, Paediatrician, CSC), and the advice received. | Establishes multidisciplinary team coverage and validates shared decision-making.[7] |
Injury Recording | Record injuries with diagrams and photographs (if appropriate). | Provides objective, forensic evidence of the injury pattern.[7] |
Mechanism of Injury (MOI) | Note the exact words used by caregivers when describing the MOI. | Captures critical inconsistencies or shifts in the history provided.[7] |
Escalation Rationale | Escalate based on clinical judgment, even without certainty; document the rationale. | Meets the curriculum mandate for proactive intervention based on suspicion.[7] |
VI. Domain Expertise: Care for Children with Complex Needs
A central component of SLO 5 is the ability to assess and formulate management plans for children and young adults who present with complex medical and social needs.[1] This cohort represents a high proportion of ED users and presents unique challenges that require dedicated skills.[26]
6.1 Managing Intellectual and Developmental Disabilities (IDDs)
Children with Intellectual and Developmental Disabilities (IDDs) are among the highest users of emergency healthcare services.[26, 27] Their management is often complicated by communication, sensory, and behavioral challenges, leading to risks of negative experiences and outcomes.[26] Addressing this population directly relates to the curriculum's requirement to manage health inequalities; autistic people and individuals with learning disabilities are known to face disparities, increasing their risk of premature death from treatable causes.[28]
Achieving competence in this area requires the implementation of systemic accommodations, demonstrating a commitment to patient-centred care.[28] The ED environment must be adjusted to reduce overwhelming sensory input. This strategic adaptation ensures that vulnerable children receive equitable care, moving beyond mere clinical assessment to address the systemic barriers they face.
6.2 Practical Communication and Environmental Strategies
Effective communication is the cornerstone of managing children with complex needs. For non-verbal or autistic children, reliance on verbal language is insufficient. Trainees must be facile in utilizing Augmentative and Alternative Communication (AAC) methods.[8]
AAC encompasses all ways a person communicates besides talking, including sign language, gestures, the use of pictures, photos, objects, or dedicated electronic devices.[8] The required expert knowledge dictates the immediate implementation of "reasonable adjustments," similar to those utilized in special education, to facilitate interaction.[29] This includes employing visual supports, such as visual schedules or picture cards, as many autistic individuals process visual information more effectively than auditory input.[8]
Interaction techniques must be adapted:
• Language must be simplified, clear, and concise to reduce potential confusion.[8]
• The clinician must allow sufficient "wait time" for the child to process the request and formulate a response, resisting the natural urge to fill silences.[8]
• When situations become overwhelming, access to a quiet space or the use of sensory tools (e.g., ear defenders) should be part of the care plan.[30]
• During procedures, positive reinforcement, praise, and rewards linked to the child's specific interests can improve cooperation.[31]
6.3 The Technology-Dependent Child
The ability to manage children with technology dependence (e.g., home ventilators, tracheostomies, indwelling central lines, G/J tubes) is explicitly required by SLO 5.[1, 32] These presentations are typically high-acuity and require a rapid understanding of the child’s complex baseline physiology.
The initial assessment must prioritize troubleshooting potential equipment failure or managing intercurrent illness (e.g., fever/infection) superimposed on the baseline condition.[33] Key history points involve establishing the child’s stable ventilator settings and blood gas parameters.
Expert decision-making extends to disposition planning. Trainees must understand the stability criteria for transfer or discharge.[33] For instance, criteria for moving from intensive care to a general ward include: stable ventilator settings for at least one week, a matured tracheostomy stoma (more than one week old), no need for vasoactive drug support, and stable blood gases (e.g., on ).[33] Furthermore, protocols must address regionalization issues, determining whether transport should be to the closest ED or to a specialized paediatric center depending on the patient’s critical status and specific technological needs.[32]
VII. Professional Practice: Communication, Ethics, and Family Support
The final component of SLO 5 excellence involves mastering the non-technical skills required to manage the human context of paediatric emergencies, particularly dealing with crisis and grief.
7.1 Communicating Difficult News and Supporting Families in Crisis
A core requirement of empathetic care is acknowledging the stress of the ED experience. Trainees must validate the family’s decision to attend the ED and should never criticize or berate a family for seeking emergency care.[6] They must establish clear and timely communication, using structured models (SBAR/RSVP) for internal handovers and providing clear explanations to families.[16]
A major component of high-quality paediatric care is managing Family Presence During Resuscitation (FPDR). Policy guidance suggests that the presence of family members allows them to witness that all possible efforts are being made for their child, providing comfort and helping them gain a realistic view of the attempted resuscitation.[34] If FPDR is utilized, the trainee, acting as the team leader, must immediately allocate a dedicated staff member (often a nurse or social worker) to remain with the parents to support them through the process.[24]
7.2 Compassionate Care and Bereavement Support
When a child dies in the ED, the interaction between the healthcare team and the bereaved family has a profound, long-term impact on the grieving process.[35] Achieving SLO 5 competence requires leadership that extends to terminal and bereavement care excellence.
Key actions for compassionate care include:
• Demonstrating empathy, providing timely answers, and maintaining a clear understanding of the child’s unique medical situation.[35]
• Utilizing the child’s name consistently.[35]
• Alerting all appropriate local agencies (e.g., Acute Consultant Paediatrician on-call and Police Senior Investigating Officer, especially in cases of Sudden Unexpected Death in Infancy or Childhood, SUDIC).[24]
• Liaising with institutional Family Support Teams or dedicated resource centers to provide external resources for grief management.[35]
The expert trainee must demonstrate the capacity to maintain a therapeutic relationship with families, even when complex ethical decisions (such as ToR) lead to disagreement or conflict. This level of communication ensures that the emotional harms of conflict are mitigated for all parties involved, including the medical team.[25]
VIII. Conclusion and Recommendations
Attainment of RCEM SLO 5 represents achieving an expert level of capability in Paediatric Emergency Medicine. The curriculum demands that trainees integrate advanced critical care skills (from SLO 3) with domains unique to paediatric practice: developmental assessment, safeguarding, and profound communication skills.
The strategic requirements dictate a continuous, proactive approach to portfolio development, where trainees must gather evidence of Clinical Activity (CLA) and Quality Improvement (QI) in a broad range of paediatric cases across every year of training.[4, 9] Observation in the resuscitation room and specific feedback on leadership (ESLE/simulation) are mandatory checkpoints.[1]
Key Recommendations for Trainees:
1. Prioritize Non-Numerical Assessment: Trainees must actively document scenarios demonstrating professional judgment, specifically acting on the Clinical Intuition Trigger and the Parent Concern Trigger of the PEWS chart.[18] This validates the professional competence required beyond basic physiological scoring.
2. Rigorous Safeguarding Documentation: Treat all potential safeguarding cases as high-stakes medico-legal events. Non-negotiable practice includes utilizing structured checklists, escalating based on clinical suspicion rather than certainty, and meticulous documentation of the exact words used by caregivers and detailed photographic/diagrammatic evidence of injuries.[7]
3. Implement Systemic Accommodation: When managing children with complex needs or IDDs, the trainee must demonstrate the implementation of "reasonable adjustments." This involves utilizing visual supports and Augmentative and Alternative Communication (AAC) methods to overcome health inequalities and ensure patient-centred care.[8, 28]
4. Master Ethical Leadership: Critical care leadership must encompass the human factors of end-of-life care. Trainees must demonstrate expertise in compassionate communication, managing Family Presence During Resuscitation (FPDR), and navigating the complex ethical frameworks governing the termination of resuscitation.[21, 24, 34]
5. Utilize Simulation for Human Factors: Leverage high-fidelity simulation specifically to practice seldom-used skills and receive structured feedback on team leadership and communication during paediatric emergencies.[1, 13]
Achieving SLO 5 is ultimately defined by the trainee's capacity to manage not only the pathophysiology of illness but also the significant social, developmental, and ethical complexities inherent in caring for vulnerable children and their families.
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6. The Whole* of PEM, in One Blog - RCEMLearning, https://www.rcemlearning.co.uk/foamed/the-whole-of-pem-in-one-blog/
7. Detection and Management of Non-Accidental Injury (NAI) in Infants ..., https://somersetsafeguardingchildren.org.uk/detection-and-management-of-non-accidental-injury-nai-in-infants-rcem-guidance/
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13. Pediatric Resuscitation Training through Simulation Programs - Children's Mercy, https://www.childrensmercy.org/health-care-providers/refer-or-manage-a-patient/educational-offerings/simulation-training/
14. Enhancing Pediatric Emergency Care in Low-Resource Settings Through Simulation-Based Training: A Narrative Review - PubMed Central, https://pmc.ncbi.nlm.nih.gov/articles/PMC12220881/
15. Paediatric Emergency Medicine (PEM) Simulation Day - HEE East of England website, https://heeoe.hee.nhs.uk/emergency_medicine/simulation/paediatric-emergency-medicine-simulation-day
18. UK Paediatric Early Warning Systems (PEWS) | RCPCH, https://www.rcpch.ac.uk/resources/UK-paediatric-early-warning-systems
19. Pediatric Early Warning Score (PEWS) - MDCalc, https://www.mdcalc.com/calc/3901/pediatric-early-warning-score-pews
20. Clinical Practice Guidelines : Communicating procedures to children, https://www.rch.org.au/clinicalguide/guideline_index/Communicating_procedures_to_families/
21. Ethics in the Emergency Department: Withholding or Terminating Resuscitation - PubMed, https://pubmed.ncbi.nlm.nih.gov/40742225/?utm_source=SimplePie&utm_medium=rss&utm_campaign=pubmed-2&utm_content=1zOrwYPa_1RS6jdZ9VLHcTFM_z0nKGv5xC17ijJBVjdDspZQ-I&fc=20220524062322&ff=20250731173358&v=2.18.0.post9+e462414
22. Ethics in the Emergency Department: Withholding or Terminating Resuscitation - Health Sciences Research Commons - The George Washington University, https://hsrc.himmelfarb.gwu.edu/gwhpubs/7520/
23. Part 2: Ethical Aspects of CPR and ECC | Circulation - American Heart Association Journals, https://www.ahajournals.org/doi/10.1161/circ.102.suppl_1.i-12
24. Timeline: The Emergency Department - The Resuscitation - RCEMLearning, https://www.rcemlearning.co.uk/modules/the-sudic-protocol/lessons/clinical-assessment-42/topic/timeline-the-emergency-department-the-resuscitation/
25. Part 3: Ethics: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care | Circulation, https://www.ahajournals.org/doi/10.1161/CIR.0000000000001371
26. Seeking Care for Children with Intellectual and/or Developmental Disabilities in the Emergency Department: A Mixed Methods Systematic Review of Parents' Experiences and Information Needs - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC11194008/
27. Care for children with disabilities in emergency departments | OAEM - Dove Medical Press, https://www.dovepress.com/seeking-care-for-children-with-intellectual-andor-developmental-disabi-peer-reviewed-fulltext-article-OAEM
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29. Supports, Modifications, and Accommodations for Students - Center for Parent Information and Resources, https://www.parentcenterhub.org/accommodations/
30. Autism and communication - National Autistic Society, https://www.autism.org.uk/advice-and-guidance/topics/about-autism/autism-and-communication
31. Educator Strategies for Developmental delay | AllPlay Learn, https://www.allplaylearn.org.au/early/educator/developmental-delay/
32. Guidelines for Prehospital Pediatric Protocol Development, https://emscimprovement.center/documents/1378/5-Guidelines_for_Prehospital_Pediatric_Protocol_Development.pdf
33. Technology-dependent children - PMC - PubMed Central - NIH, https://pmc.ncbi.nlm.nih.gov/articles/PMC7335821/
34. Publication: Presence of family members at the clinical emergency of children and babies, https://www.resus.org.uk/library/publications/publication-presence-family-members-clinical-emergency
35. Communication with families, https://emscimprovement.center/documents/1009/Communication_with_families_chapter.pdf
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2.5 RCEM SLO 5 Roadmap: Achieving Paediatric Emergency Medicine Excellence for UK Trainees (2021 Curriculum)
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