Simulation provides a safe, risk-free, experiential learning environment where emergency department (ED) practitioners can develop their skills with no potential for adverse consequences to real patients.
The acquisition and retention of skills requires hands-on practice complemented by feedback and robust assessments. This has been described in the learn, see, practice, prove, do, maintain framework. However, external forces and intolerance for medical errors, have significantly reduced the number of opportunities to practice procedures in the ED. Simulation can be used to provide these experiences “on-demand” and guide decisions about when a provider can be entrusted to safely perform a procedure on a patient.
Effective simulation-based training interventions have a range of difficulty customized to the individual practitioner’s skill level.
Postgraduate medical education systems are combining competency-based educational frameworks involving focused and rigorous evaluations to entrustable professional activity (EPA) frameworks that involve global assessments of performance.
The extended duration between performance of many pediatric emergency medicine (PEM) skills leads to deterioration in even the most expert providers. Just-in-time (JIT) training is a training scheme in which the required knowledge and skills are imparted for immediate application to avoid loss of retention due to a time gap.
Simulation-based education (SBE) has continued to evolve, with an increasing breadth of applications in the field of pediatric emergency medicine (PEM).1–7 Educators have recognized that simulation can provide a safe, risk-free experiential learning environment where emergency department (ED) practitioners can develop and maintain their skills with no potential for adverse consequences to real patients. PEM is an ideal field for applications of simulation, as outcomes from pediatric cardiac arrest are poor, and traditional methods of resuscitation skills training lead to poor retention of knowledge and skills.8 This chapter describes how SBE is being: (a) integrated into PEM training programs; (b) utilized for crisis resource management (CRM) training for ED healthcare teams; (c) used to teach novel PEM topics; (d) explored as a potential tool for assessment of ED skills; and (e) used to enhance procedural skills competency for ED procedures.
Simulation has become an integral part of many PEM residency and fellowship training programs.9 PEM fellowships have rapidly integrated simulation and are increasingly sharing curricula and assessment tools. SBE has been effectively integrated into pre-existing curriculum to better address PEM competencies and to provide trainees an opportunity to practice managing both common and rare conditions. Studies have shown that SBE improves the performance of emergency teams during simulated pediatric medical and trauma resuscitations.10–15 The majority of PEM training programs have integrated simulation as a key learning modality. Focused, frequent, and effortful instructional interventions are necessary to achieve substantial performance improvements.5 A longitudinal approach to the integration of simulation into the PEM curriculum was described by Cheng et al.,4 where 43 different acute care scenarios, packaged as 12 different core and specialty modules, were delivered over 2 years of PEM training. Knowledge, technical skills, and behavioral skills were discussed and reviewed after each simulation with a facilitated debriefing session. Table 153-1 provides an overview of the curriculum.4 PEM trainees who take the Pediatric Advanced Life Support (PALS) course or the Neonatal Resuscitation Program (NRP) will also be exposed to SBE, as both of these courses have recently integrated simulation as the predominant modality of learning. Future work in this area will focus on: (a) assessing the impact of SBE in training on retention of skills, knowledge, and behaviors over time; (b) defining the optimal instructional design for simulation-based education; and (c) defining how SBE fits into existing educational curricula.16
| Year 1 | Core Modules | Scenarios |
Respiratory emergencies Cardiac emergencies Shock Blunt trauma Environmental emergencies Infant/neonatal emergencies | Status asthmaticus, aspiration pneumonia, upper airway obstruction, acute chest syndrome Supraventricular tachycardia, unstable ventricular tachycardia, ventricular fibrillation, PEA/asystole Septic shock, hypovolemic shock, anaphylactic shock, cardiogenic shock Abdominal trauma, major head injury, orthopedic trauma, thoracic trauma Near drowning/hypothermia, electrical injury, smoke inhalation/carbon monoxide poisoning Nonaccidental injury, bronchiolitis, congenital diaphragmatic hernia, congenital heart disease | |
| Year 2 | Subspecialty Modules | Scenarios |
Toxicology emergencies Endocrinological emergencies Oncological emergencies Nephrological emergencies Neurological emergencies Penetrating trauma | Sympathomimetic, anticholinergic, cholinergic, and opioid toxidromes Diabetic ketoacidosis, adrenal crisis, thyroid storm Mediastinal mass, hyperleukocytosis/stroke, tumor lysis syndrome Hypertensive emergency, acute renal failure/hyperkalemia, hyponatremia Status epilepticus, coma/depressed level of consciousness, combative/encephalopathy Thoracic trauma, neck trauma, spinal cord trauma, abdominal trauma |
The management of critically ill pediatric patients requires the effective interaction of an interprofessional and specialized team of individuals who are able to provide timely and effective life-saving care. Simulation-based teamwork or CRM training focuses on teaching leadership, communication, situational awareness, and resource allocation to ED providers.2,17–20 Recently, the PALS course has emphasized team dynamics by making it an essential component of the new provider course. PALS describes the eight elements of effective team dynamics as: (a) closed loop communication; (b) clear messages; (c) clear roles and responsibilities; (d) knowing one’s limitations; (e) knowledge sharing; (f) constructive intervention; (g) re-evaluation and summarizing; and (h) mutual respect.21 With simulation, educators are able to provide on-demand scenarios tailored to teach and/or test specific aspects of CRM by manipulating the patient condition or surrounding environment to challenge healthcare teams.17 For example, the educator may intentionally introduce a phone call from an intensive care consultant during intubation of the patient, thus challenging the team leader to appropriately prioritize while under stress. Over time, these simulation experiences better prepare ED providers with the behavioral skills required to reduce errors and improve patient outcomes from critical illness.
Some PEM educators are capitalizing on the emotional engagement of learners during simulation and using SBE as a tool to teach disclosure of medical error, breaking bad news (e.g., death), and difficult discussions (e.g., withdrawal of medical care). By running learners through a simulation before engaging them in these discussions (with standardized patients or actors), the educators can provide clinical context and emotionally engage the learner, thus making the learning experience more realistic. Many institutions are using simulation as a patient safety tool by: (a) testing new clinical guidelines and protocols in the simulated environment; (b) using simulation to determine the root cause of medical errors; and (c) using simulation to test new clinical spaces.22,23 Simulation can also be utilized as a research tool, either to assess the impact of simulation-based education or to utilize simulation as investigative methodology to explore clinical issues (e.g., new technology or protocols).24 Application of simulation in these areas has tremendous potential for directly impacting the quality of patient care in the clinical environment.22,23,25
Aside from being used as an educational modality, simulation has seen growing use as an assessment modality for PEM.26,27 Several simulation-based clinical performance tools for pediatrics have recently been developed and studied.27–32 These tools are meant to assess individual or team performance by evaluating the timing, sequence, and overall quality of interventions for acutely ill patients. Similarly, performance checklists for the simulated environment have been developed to assess CRM skills of the team leader or the ED team as a functional unit.30,31 The development of these tools provides an objective measurement of clinical or behavioral performance which may be potentially used for formative or summative assessment purposes.26
An evidence-based pedagogical framework for procedural skills training has been described and includes six steps: LSPPDM. First the learner must acquire the requisite cognitive knowledge (Learn: reading/didactics; See: observe/watch video). Then they progress to the psychomotor stage of practicing the procedure with an instructor on a simulator (Practice). Next they must demonstrate their competency on a simulator prior to performing on a patient (Prove). The trainee is then allowed to perform with direct supervision until he/she can be entrusted to perform independently (Do). In PEM many procedures are performed very infrequently, and continued opportunities for simulation-based practice can supplement clinical experiences (Maintain).33
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