Infants and children who are acutely ill and injured receive care across a continuum of emergency care settings.1,2 Emergency care begins in the communities in which the children live and go to school. When an emergency occurs, many families will first contact their pediatric primary care provider.3 In some circumstances, prehospital care may be provided by emergency medical services (EMS), which most often transport children to a nearby community emergency department (ED) for initial stabilization and treatment. In fact, 90% of the more than 30 million children evaluated in United States EDs each year receive care in community EDs as opposed to dedicated pediatric EDs.4 Selected patients will require admission to a hospital inpatient ward and/or a transfer to a children's hospital for specialized pediatric care.
Studies demonstrate that EMS agencies and pediatric primary offices are not well prepared for pediatric emergencies.5–7 Many of these community settings have inadequate pediatric resources, equipment, guidelines, and/or expertise.7 Many community-based providers report having insufficient pediatric experience during their training and/or infrequent opportunities to apply their pediatric emergency knowledge and skills. Despite being the setting where most pediatric emergency care is delivered, most community EDs in the US are not prepared for pediatric emergencies. Disparities exist in pediatric emergency preparedness between these community EDs and academic health care settings.8,9 Recently, these disparities have been linked to higher mortality rates among children presenting to community EDs compared to children's hospitals.10,11 In response to these disparities, many innovations and initiatives have been developed and implemented that aim to optimize day-to-day pediatric emergency preparedness across the emergency continuum.5,7,12 Examples include (1) the National Pediatric Readiness Project, a multi-stakeholder initiative to ensure that all EDs are prepared to care for ill children; (2) a parallel national prehospital pediatric readiness project and prehospital emergency care coordinator programs, and (3) state-level pediatric facility recognition programs to ensure the availability of certain medications, supplies, and guidelines.13 Simulation has been an important component of many of these initiatives.
Simulation in health care is “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain an understanding of systems or human actions.”14 Simulation has been shown to be an effective method of training to enhance pediatric knowledge and skills across emergency care settings that has been associated with improvements in the cognitive, technical, and behavioral skills of interprofessional providers.15 In addition, simulation can be used to evaluate processes of care, measure system preparedness, and identify targeted areas for improvement to ensure that all children receive optimal emergency care whenever and wherever it is needed across the continuum (Figure 1).5,9,16
Pediatric emergency care across the continuum. CPR, cardiopulmonary resuscitation; ED, emergency department, EMS, emergency medical services, Epi, epinephrine.
In this article, we discuss the use of simulation as an improvement methodology involving its use as a measurement tool of providers and system preparedness as well as a training/education tool to enhance emergency preparedness across the continuum. We also discuss exemplars of programs leveraging simulation to improve pediatric emergency preparedness in community settings.
Essentials of Simulation Use in Community Health Care Settings
Simulation is a valuable teaching tool that may be used to improve experiential learning in health care professionals, particularly as clinical learning opportunities decrease. Thus, it can be used in health care education to teach cognitive, psychomotor, and affective skills to people and teams.17 Studies evaluating simulated clinical performance have consistently demonstrated high levels of learner satisfaction and improvements in providers' knowledge, skills, and attitudes after simulation training.18,19
Simulation is used across the spectrum of medical education, not only with complex medical presentations but also for laypersons learning basic life support or participating in community-based training courses that use a low-technology, static model. Simulation involves the use of diverse tools and techniques that can be applied across the emergency continuum to achieve objectives that meet the needs of each group of learners (Figure 1). These tools and techniques include manikins, screens, virtual reality, tabletop games, and actors, among others.20 Modality choice depends on resources and the intended learning objectives. Adapting simulation to diverse settings, such as a community ED or to a layperson can be challenging, but it is important to keep learning objectives and the learners in mind. Adapting the scenario to the setting is key. For instance, writing a learning objective for placing an intra-osseous line may not be applicable in a setting where there are not intra-osseous placement devices. Additionally, when working in a setting that is not used to regularly simulated events, it is helpful to emphasize psychological safety to ensure a safe learning environment. This is particularly useful in settings in which facilitators do not normally work clinically. Participants may feel more at ease if they make an error when facilitators share some of their own clinical fallacies. Maintaining psychological safety in simulations is paramount to ensure learning.21 Psychological safety is the belief that the situation is safe for risk taking. Lack of psychological safety not only compromises learning but can also lead to clinical errors.21
Simulation as a Tool for Training Across the Emergency Continuum
Although simulation is traditionally thought of as being used in acute care settings such as the ED or the intensive care unit, pediatricians can use simulation across the continuum, including in the community/home setting, the prehospital setting, and within outpatient clinics to improve pediatric care and outcomes. For example, encouraging patients and families to partake in simulation-based training such as “Stop the Bleed” training, which is a national initiative to better prepare the public to save lives by raising awareness or teaching people how to quickly control serious bleeding, or engaging in first aid or basic life support, can improve pediatric outcomes.22
Using simulation to improve quality of care in EDs can help to drive changes at the provider or team level.23,24 A review by Cheng et al.25 suggests that simulation as an educational intervention can improve the knowledge, skills, and behaviors of health care providers compared to no intervention.25 In EDs, the use of rapid cycle deliberate practice simulations can be a particularly effective tool to improve team knowledge and skills.26 Simulations in situ and in the simulation center have also been documented in empirical studies to improve provider comfort and skills as well as team dynamics and performance.27 Furthermore, simulation enhances patient safety by contributing to improvements in teamwork and communication. The effective use of simulation-based team training has been reported in many clinical disciplines including pediatrics, emergency medicine, obstetrics, anesthesia, surgery, and trauma care.28,29
Simulation as a Measurement Tool Across the Emergency Continuum
Simulation can be a useful tool to measure emergency preparedness, particularly when measurement may otherwise be unfeasible, unsafe, or unethical amid actual clinical care.30 In particular, in situ simulation—where simulations are physically integrated into the clinical environment—are preferable to center-based simulations as a measurement tool and/or for the identification of safety threats.6 In-situ simulation provides higher realism as it allows providers to deliver care in their actual clinical environment involving real-world interprofessional provider teams, equipment, and resources. These simulations provide the opportunity to measure systems' aspects of care in community settings, such as EMS and ED systems. Simulation can be used as a diagnostic tool to measure various levels of care provided in community settings, whether at the provider, team, or systems level.31 At the provider and team level, simulation can be used to observe clinical care delivered by individual providers or teams to focus on decision-making, medication errors, teamwork, communication, and clinical performance.32–34 Simulation can also be useful at assessing systems-level care such as equipment, decision-making, and the availability and implementation of policies and procedures.35 Several studies have demonstrated the use of simulation to detect latent safety threats and evaluate systems safety issues.36 Examples of these threats include threats to patient safety, malfunctioning or missing pediatric equipment, or an error in a medication dosing resources in the clinical setting.6,37
In certain cases, simulation can serve as an improvement tool because it functions as a combined tool for both measurement/analysis of the system and training purposes. The results of a simulation-based measurement can be used to drive system-level improvement with simulation-based training as well as assessments to evaluate for improvements in clinical care. Several studies have used simulation as both a measurement and training tool to improve the quality of care in pediatric emergency departments.5,12,32,38 These studies have used simulation-based data to guide subsequent simulation-based training and improvements in ED policies and procedures as measured by the National Pediatric Readiness Project through the Pediatric Readiness Survey. These programs were first conducted in community EDs throughout Connecticut and Indiana and have now been disseminated nationally. The programs have consistently resulted in significant improvements in ED-level pediatric readiness and improvements in clinical care processes on repeated measurement by simulation.5,12,32,38 The next section of this article provides more details of these ED-based programs. The framework for the described simulation-based programs can be applied in any of the other settings across the emergency continuum, including patients' homes, pediatric offices, EMS, and in-patient environments.
Exemplars of Simulation-Based Preparedness Programs in Community Settings
Pediatric Community Outreach Mobile Education
The Pediatric Community Outreach Mobile Education (PCOME) is a statewide program in Indiana that was developed as a collaborative involving a tertiary pediatric academic medical center working with regional community EDs to improve care for acutely ill and injured children across the continuum. The program was led by a multi-professional team of educators and experts in pediatric critical care transport, pediatric critical care medicine, and pediatric emergency medicine from Riley Hospital for Children and Indiana University Health LifeLine ( www.rileychildrens.org/medical-education/pcome). The PCOME model included (1) a baseline assessment of pediatric readiness score and quality of simulated care; (2) an intervention phase that included a customized performance report, resource toolkit, and ongoing interactions; and (3) follow-up assessment. Starting in 2016, the program pathway used simulation as both an investigative and improvement tool. Simulation was used to assess the system of care by measuring pediatric readiness scores and the quality of pediatric emergency care. These simulation-driven data formed a foundation for the development of customized action plans and provided a context for their improvement. Through using simulation as a “burning platform” to engage community EDs and designating a pediatric “champion” at each participating site, the PCOME program targeted up to 30 community EDs in the state (including more than 600 health care providers) and performed more than 100 simulation sessions. Across three scenarios (diabetic ketoacidosis, acute respiratory failure, supraventricular tachycardia), participation in PCOME has been associated with a 15% improvement in pediatric readiness scores as well as significant improvements in adherence to evidence-based guidelines during the care of simulated acutely ill and injured children at 6 months post-intervention.7,32,34,38
Improving Pediatric Acute Care Through Simulation
Improving Pediatric Acute Care Through Simulation (ImPACTS) is an international collaborative network that was established to ensure that acutely ill and injured children receive the highest quality of care whenever and wherever it is needed. ImPACTS has evolved through many iterations, from assessing, measuring, and comparing pediatric emergency readiness and quality of acute care in a simulated setting to improving pediatric emergency readiness at a diverse set of community EDs in North America. The ImPACTS network involves a hub-and-spoke model of collaboration including in situ simulation, education, and quality improvement initiatives between academic medical centers (the ImPACTS regional “hub”) and community EDs (the “spokes”). These hubs are children's hospitals that are supported by the core group at Yale-New Haven Health and work collaboratively with their regional community EDs spokes ( www.impactscollaborative.com). To date, more than 240 spokes and 36 hubs have participated in the ImPACTS collaborative and simulation-based research projects comparing variations in the quality of care delivered to critically ill infants and children in EDs.6,9,39 Most recently, an ImPACTS collaborative program between a pediatric academic medical center and a set of 12 pediatric offices in Washington, DC measured pediatric primary office preparedness and the quality of simulated care.40 ImPACTS programs are also being implemented in EMS and hospital-based environments to improve pediatric emergency care.
Barriers and Limitations to Pediatric Emergency Simulation Across the Continuum
Barriers and limitations to simulation in the community setting include cost, time, resources, engagement, skills, and expertise. The cost can be a significant barrier to overcome with simulation in the community setting. These costs include travel to sites, simulation equipment, and, most significantly, the time of the facilitators. This can be mitigated by grant funding, an academic medical center providing financial support for the program, and/or a community center paying for participation in the program. Time can also be a barrier; not only the time required from facilitators to plan and execute the simulation, but also the time required from the learners. Learners are most often participating in these simulations on their time off, and some facilities are unable to compensate learners for their time. Engaging community sites can be another significant barrier. The process of engagement should start by connecting with the appropriate leadership and/or sponsors from the community setting. To have a successful inter-professional simulation program, engagement from both the participants (EMS, nursing, physician staff) and the leadership (managers, directors) is paramount. Insufficient skills and expertise in running simulations can also be a barrier to community sites independently conducting simulations. There can also be fear of judgment in community sites/hospitals when a team from the children's hospital comes in to collaborate on a simulation. Additionally, ongoing engagement and sustained programs are challenged when turnover occurs in staff or leadership in the community sites; this can set back already-established work and relationships. Finally, troubleshooting equipment in a new setting can be a challenge for even experienced simulation educators when traveling to the community.
All pediatric providers can use simulation to be involved in efforts to improve pediatric emergency preparedness across the continuum. This may include activities in their own work environment and/or activities where they are “reaching out” to other environments such as schools, EMS agencies, and/or community EDs. Despite the efficacy of simulation in optimizing the pediatric preparedness across the emergency continuum, it is important to acknowledge the current lack of empirical research on the impact of simulation on patient-level outcomes. Several recent studies indicated improved outcomes in levels of the structure of care and process of care provided in the simulated setting, as well as provider level outcomes. Therefore, future work is needed to examine the translation of simulation from the educational setting (translation [T] 1) to improved downstream clinical care practices (T2), and ultimately improved patient health outcomes (T3). The ImPACTS network and others are currently investigating the effect of the simulation-based improvement on patient clinical outcomes.
There is a strong body of evidence demonstrating the efficacy of simulation as both a measurement and improvement tool to optimize pediatric community preparedness across the emergency continuum. Despite the less frequent use of simulation in community settings compared to academic settings, simulation has evolved in the last decade to serve as a platform for collaboration between community and academic health care institutions. This collaboration can help address the disparity in emergency preparedness and ensure that all children who are acutely ill and injured receive the highest quality of care whenever and wherever it is needed across the emergency continuum. This collaboration requires the active engagement of pediatricians and other pediatric providers. More work is needed to explore the impact of simulation on the quality of clinical care and health care outcomes, and on strategies to sustain simulation-based initiatives in the community setting.
- Berger E. Growing pains: report notes pediatric emergencies need greater emphasis. Ann Emerg Med.2006;48(2):143–144. doi:10.1016/j.annemergmed.2006.06.024 [CrossRef] PMID:16953527
- Chamberlain JM, Krug S, Shaw KN. Emergency care for children in the United States. Health Aff (Millwood). 2013;32(12):2109–2115. doi:10.1377/hlthaff.2013.0871 [CrossRef] PMID:24301393
- Frush KAmerican Academy of Pediatrics Committee on Pediatric Emergency Medicine. Preparation for emergencies in the offices of pediatricians and pediatric primary care providers. Pediatrics. 2007;120(1):200–212. doi:10.1542/peds.2007-1109 [CrossRef] PMID:17606580
- Whitfill T, Auerbach M, Scherzer DJ, Shi J, Xiang H, Stanley RM. Emergency care for children in the United States: epidemiology and trends over time. J Emerg Med. 2018;55(3):423–434. doi:10.1016/j.jemermed.2018.04.019 [CrossRef] PMID:29793812
- Abulebda K, Lutfi R, Whitfill T, et al. A collaborative in situ simulation-based pediatric readiness improvement program for community emergency departments. Acad Emerg Med.2018;25(2):177–185. doi:10.1111/acem.13329 [CrossRef] PMID:28977717
- Kessler DO, Walsh B, Whitfill T, et al. Disparities in adherence to pediatric sepsis guidelines across a spectrum of emergency departments: a multicenter, cross-sectional observational in situ simulation study. J Emerg Med.2016;50(3):P403–415.E3. doi:10.1016/j.jemermed.2015.08.004 [CrossRef]
- Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr.2015;169(6):527–534. doi:10.1001/jamapediatrics.2015.138 [CrossRef] PMID:25867088
- Hansen M, Fleischman R, Meckler G, Newgard CD. The association between hospital type and mortality among critically ill children in US EDs. Resuscitation. 2013;84(4):488–491. doi:10.1016/j.resuscitation.2012.07.032 [CrossRef] PMID:22902464
- Auerbach M, Whitfill T, Gawel M, et al. Differences in the quality of pediatric resuscitative care across a spectrum of emergency departments. JAMA Pediatr. 2016;170(10):987–994. doi:10.1001/jamapediatrics.2016.1550 [CrossRef] PMID:27570926
- Ames SG, Davis BS, Marin JR, et al. Emergency department pediatric readiness and mortality in critically ill children. Pediatrics. 2019;144(3):e20190568 doi:10.1542/peds.2019-0568 [CrossRef] PMID:31444254
- Balmaks R, Whitfill TM, Ziemele B, et al. Pediatric readiness in the emergency department and its association with patient outcomes in critical care: a prospective cohort study. Pediatr Crit Care Med. 2020;21(5):e213–e220. doi:10.1097/PCC.0000000000002255 [CrossRef] PMID:32132503
- Whitfill T, Gawel M, Auerbach M. ASimulation-based quality improvement initiative improves pediatric readiness in community hospitals. Pediatr Emerg Care.2018;34(6):431–435. doi:10.1097/PEC.0000000000001233 [CrossRef] PMID:28719479
- Remick K, Fendya D, Bartley K. A White Paper on Developing a Statewide Pediatric Facility Recognition Program: A National Quality Improvement Collaborative of the EMS for Children Program. Emergency Mecial Services for Children; 2017.
- Lioce L, ed. Healthcare Simulation Dictionary. Agency for Healthcare Research and Quality; 2020. https://www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/resources/simulation/sim-dictionary-2nd.pdf
- Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA. 1999;282(9):861–866. doi:10.1001/jama.282.9.861 [CrossRef] PMID:10478693
- Weinberg ER, Auerbach MA, Shah NB. The use of simulation for pediatric training and assessment. Curr Opin Pediatr.2009;21(3):282–287. doi:10.1097/MOP.0b013e32832b32dc [CrossRef] PMID:19381090
- Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: a best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35(10):e1511–e1530. doi:10.3109/0142159X.2013.818632 [CrossRef] PMID:23941678
- Yee B, Naik VN, Joo HS, et al. Nontechnical skills in anesthesia crisis management with repeated exposure to simulation-based education. Anesthesiology. 2005;103(2):241–248. doi:10.1097/00000542-200508000-00006 [CrossRef] PMID:16052105
- Rao R, Dumon KR, Neylan CJ, et al. Can simulated team tasks be used to improve nontechnical skills in the operating room?J Surg Educ. 2016;73(6):e42–e47. doi:10.1016/j.jsurg.2016.06.004 [CrossRef]
- Grant VJ, Cheng A (eds.) Comprehensive Healthcare Simulation: Pediatrics. Springer; 2016. doi:10.1007/978-3-319-24187-6 [CrossRef]
- Henricksen JW, Altenburg C, Reeder RW. Operationalizing healthcare simulation psychological safety: a descriptive analysis of an intervention. Simul Healthc.2017;12(5):289–297. doi:10.1097/SIH.0000000000000253 [CrossRef] PMID:28976451
- AlSabah S, Al Haddad E, AlSaleh F. Stop the bleed campaign: a qualitative study from our experience from the Middle East. Ann Med Surg (Lond). 2018;36:67–70. doi:10.1016/j.amsu.2018.10.013 [CrossRef] PMID:30402222
- Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach.2005;27(1):10–28. doi:10.1080/01421590500046924 [CrossRef] PMID:16147767
- McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. A critical review of simulation-based medical education research: 2003–2009. Med Educ.2010;44(1):50–63. doi:10.1111/j.1365-2923.2009.03547.x [CrossRef] PMID:20078756
- Cheng A, Lang TR, Starr SR, Pusic M, Cook DA. Technology-enhanced simulation and pediatric education: a meta-analysis. Pediatrics. 2014;133(5):e1313–e1323. doi:10.1542/peds.2013-2139 [CrossRef] PMID:24733867
- Lemke DS, Fielder EK, Hsu DC, Doughty CB. Improved team performance during pediatric resuscitations after rapid cycle deliberate practice compared with traditional debriefing: a pilot study. Pediatr Emerg Care. 2019;35(7):480–486. doi:10.1097/PEC.0000000000000940 [CrossRef] PMID:27741071
- Miller D, Crandall C, Washington C III, McLaughlin S. Improving teamwork and communication in trauma care through in situ simulations. Acad Emerg Med.2012;19(5):608–612. doi:10.1111/j.1553-2712.2012.01354.x [CrossRef] PMID:22594369
- Gardner R, Walzer TB, Simon R, Raemer DB. Obstetric simulation as a risk control strategy: course design and evaluation. Simul Healthc.2008;3(2):119–127. doi:10.1097/SIH.0b013e3181671bbe [CrossRef] PMID:19088652
- McLaughlin C, Barry W, Barin E, et al. Multidisciplinary simulation-based team training for trauma resuscitation: a scoping review. J Surg Educ. 2019;76(6):1669–1680. doi:10.1016/j.jsurg.2019.05.002 [CrossRef]
- Cheng A, Kessler D, Mackinnon R, et al. International Network for Simulation-based Pediatric Innovation, Research, and Education (INSPIRE) Reporting Guidelines Investigators. Reporting guidelines for health care simulation research: extensions to the CONSORT and STROBE statements. Adv Simul (Lond). 2016;1(1):25. doi:10.1186/s41077-016-0025-y [CrossRef] PMID:29449994
- Walsh BM, Auerbach MA, Gawel MN, Brown LL, Byrne BJ, Calhoun AINSPIRE ImPACTS Investigators. Community-based in situ simulation: bringing simulation to the masses. Adv Simul (Lond). 2019;4(1):30. doi:10.1186/s41077-019-0112-y [CrossRef] PMID:31890313
- Abulebda K, Whitfill T, Montgomery EE, et al. Improving pediatric diabetic ketoacidosis management in community emergency departments using a simulation-based collaborative improvement program. Pediatr Emerg Care. 2019;03. doi:10.1097/PEC.0000000000001751 [CrossRef] PMID:30870337
- Brandstorp H, Halvorsen PA, Sterud B, Haugland B, Kirkengen AL. Primary care emergency team training in situ means learning in real context. Scand J Prim Health Care.2016;34(3):295–303. doi:10.1080/02813432.2016.1207150 [CrossRef] PMID:27442268
- Abu-Sultaneh S, Whitfill T, Rowan CM, et al. Improving simulated pediatric airway management in community emergency departments using a collaborative program with a pediatric academic medical center. Respir Care. 2019;64(9):1073–1081. doi:10.4187/respcare.06750 [CrossRef] PMID:31015388
- Kerner RL Jr, Gallo K, Cassara M, D'Angelo J, Egan A, Simmons JG. Simulation for operational readiness in a new freestanding emergency department: strategy and tactics. Simul Healthc. 2016;11(5):345–356. doi:10.1097/SIH.0000000000000180 [CrossRef] PMID:27607095
- Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In situ simulation: detection of safety threats and teamwork training in a high-risk emergency department. BMJ Qual Saf.2013;22(6):468–477. doi:10.1136/bmjqs-2012-000942 [CrossRef] PMID:23258390
- Walsh BM, Wong AH, Ray JM, et al. Practice makes perfect: simulation in emergency medicine risk management. Emerg Med Clin North Am. 2020;38(2):363–382. doi:10.1016/j.emc.2020.02.003 [CrossRef] PMID:32336331
- Lutfi R, Montgomery EE, Berrens ZJ, et al. Improving adherence to a pediatric advanced life support supraventricular tachycardia algorithm in community emergency departments following in situ simulation. J Contin Educ Nurs. 2019;50(9):404–410. doi:10.3928/00220124-20190814-06 [CrossRef] PMID:31437296
- Auerbach M, Brown L, Whitfill T, et al. Adherence to pediatric cardiac arrest guidelines across a spectrum of fifty emergency departments: a prospective, in situ, simulation-based study. Acad Emerg Med. 2018;25(12):1396–1408. doi:10.1111/acem.13564 [CrossRef] PMID:30194902
- Garrow AL, Zaveri P, Yuknis M, Abulebda K, Auerbach M, Thomas EM. Using simulation to measure and improve pediatric primary care offices emergency readiness. Simul Healthc. 2020;15(3):172–192. doi:10.1097/SIH.0000000000000472 [CrossRef] PMID:32487839