Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine), 4th Ed.

CHAPTER 152. Procedural Competency and Simulation

Adam Cheng

Marc Auerbach


• Simulation provides a safe, risk-free, experiential learning environment where emergency department (ED) practitioners can hone 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. However, external forces have significantly reduced the number of opportunities to practice procedures in the ED and tolerance for medical errors. Simulation can be used to provide these experiences “on-demand.”

• Effective simulation-based training interventions have a range of difficulty customized to the individual practitioner’s skill level.

• Postgraduate medical education systems in the United States, Canada, and United Kingdom have called for competency-based education with focused and rigorous evaluations. Mastery learning is a form of competency-based education in which training continues until the participant achieves a uniform level of skill mastery as measured by rigorous standards.

• 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 seen rapid evolution with an increasing breadth of applications to pediatric emergency medicine (PEM).14 Educators have recognized that simulation can provide a safe, risk-free, experiential learning environment where emergency department (ED) practitioners can hone 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.5 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. 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 trauma resuscitations.2,6 The PEM training programs that have integrated simulation as a key learning modality have found that focused, frequent and effortful instructional interventions are necessary to achieve substantial performance improvements.3 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 152-1 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.7,8 Future work in this area will focus on assessing the impact of SBE in training on retention of skills, knowledge and behaviors over time.

TABLE 152-1

PEM Curriculum Outline and Content



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.9 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.7 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.10 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. Application of simulation in these areas has tremendous potential of directly impacting the quality of patient care in the clinical environment.


Aside from being used as an educational modality, simulation has seen growing use as an assessment modality for PEM. Several simulation-based clinical performance tools for pediatrics have recently been developed and studied.11,12 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.13,14 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.


Optimal patient care requires that ED practitioners possess the abilities to perform a variety of procedures efficiently and safely. These procedures range from high-stakes, low-frequency (endotracheal intubation) to high-frequency, low-stakes skills (otoscopic examinations). The acquisition and retention of procedural skills requires hands-on deliberate practice complemented by feedback and robust assessments. There are physical components to performing procedures (strength, endurance, and coordination) as well as cognitive components that require perceptual inputs, problem solving, and decision making.

Effective procedural training interventions involve a range of difficulty customized to the skills development of the individual practitioner. For example, an intern needs to understand bag-valve-mask techniques, a first-year fellow should focus on intubation skills, and the experienced attending may need to practice difficult airway scenarios. The stages of procedural skills acquisition are well described in the literature (Fig. 152-1).15,16 A novice identifies and develops the component parts of the skills by forming a mental picture through reading or watching others perform. Novices may be unconsciously incompetent and can make grave errors when performing procedures. An advance beginner links the component parts of the procedure into a smooth action. They are consciously incompetent and begin to participate in hands on practice of the steps in the procedure. The proficient provider perceives the whole procedure instead of thinking out each part and can start to troubleshoot and reflect on their performance (conscious competence). The expert provider performs automatically with little or no conscious thought while performing the skill. The work of Anders Ericsson demonstrates that across multiple skills the progression from novice to expert requires 10,000 hours or 10 years of deliberate practice.16


FIGURE 152-1. Stages of procedural skills acquisition.

PED skills historically have been taught and evaluated on real patients (“see one, do one, teach one”; simulation can be used to increase the number of hours of practice). However, external forces have significantly reduced the number of opportunities to practice procedures in the ED (restricted work hours, reduced tolerance for medical errors increasing numbers of trainees, specialists, physicians assistants, nurse practitioners) (Fig. 152-2).16,17


FIGURE 152-2. The changing landscape of procedural skills development.

Research demonstrates that simulation leads to the safe acquisition and retention of a variety of procedural skills (e.g., airway management, puncture, thoracentesis, vascular access).18 Simulation allows for sustained, deliberate practice within a safe environment through access to expert coaches, ensuring that such support fades when no longer needed. The priority in the simulated environment is the learner while the -priority in the clinical environment is the patient.


Mastery learning is a form of competency-based education in which training continues until participants achieve skill mastery as measured by rigorous standards.19 Mastery is a clearly described minimum passing score based on a valid and reliable assessment instrument that is -communicated to the participant at the start of training. The time needed and process for each participant to achieve mastery is customized to each individual. At the start of training, learners undergo baseline diagnostic testing and are provided with clear learning objectives that they are expected to achieve. Learners engage in a process of active learning through coached, repetitive, deliberate practice until they reach the minimum passing score that defines mastery. Practice sessions involve repetitive cycles of formative testing, assessment by the facilitator, explicit feedback to the learner to address deficiencies followed by continued practice.20 Training is completed by a summative assessment of performance with the learner achieving mastery standards.

Wayne et al., have demonstrated the efficacy of this training paradigm for central line insertion and advanced cardiac life support.6,21 Wayne found that the time needed to achieve mastery varied by less than 20% between the fastest and slowest learners. Motivated learners try, fail, and adapt while practicing on a simulator toward a clearly defined goal. Learners evaluate their own performance and receive formative feedback from a more experienced coach who is present throughout training. Training is modified to the learners’ needs in this iterative process of practice, feedback, and correction.


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. Niles defined JIT as sessions conducted directly prior to a potential performance (e.g., lumbar puncture) and at the clinical site of the potential performance (e.g., in the ED), so that the skill is practiced in the same contextual environment where it will be performed clinically.22 This method of brief coached retraining is focused entirely on the psychomotor aspects of the skill and the specific needs of the provider in the context where the skill will be used. JIT training allows for intense repetitive performance of a skill, with rigorous assessment, with the singular goal of achieving high levels of skills during clinical performance. Distributed practice through JIT training has the potential to result in improved transfer of skills by providing refreshers in close proximity to actual skills -performance.


The extended duration between performance of many PEM skills leads to deterioration in even the most expert providers. The intensity, frequency and type of training depend on the individual, the specific skill, and the environment or context of performance.23 Training must be built into the practitioners’ schedule as part of workplace-based assessments to evaluate the maintenance of skills in the clinical environment. The responsibility for training lies with the individual and the institution to optimize patient outcomes. The degree of “overlearning” is the single most important determinant of skill retention. Overlearning provides training beyond that required for initial proficiency. This increases automaticity and reduces the amount of concentrated effort to perform the procedure and thereby increases skills, confidence and reduces stress, anxiety, and error.


While PEM practitioners’ knowledge is assessed through board examination and certification, there are no universally accepted methods to summatively assess procedural skills in PEM. Postgraduate medical education systems in the United States, Canada, and United Kingdom have called for “competency-based education” with focused and rigorous evaluations. In PEM, competency has been measured by the certifying opinion of a program director after a specified number of years of training. -Procedure-based assessments and Objective Structured Assessments of Technical Skills developed by the Royal College in the United Kingdom for surgical training programs focus on outcomes, are learner-centered, emphasize abilities, and de-emphasize time-based training. Similar programs should be explored for PEM competency to ensure optimal execution of procedures in the clinical context.


Simulation is increasingly being used for quality improvement initiatives and performance analysis. In situ simulations take place in the work place and can be used to identify deficiencies in the complex pediatric ED system. In addition, simulation can allow for the testing of new facilities and equipment. Simulation-based interventions must be measured to accurately measure the translation of performance in the simulated environment to the clinical arena. The cost and time spent in the simulated environment is a growing area of expense that must demonstrate its value. In the future PEM providers may be required to participate in regular simulation-based assessments in parallel to written board examinations to maximize their potential to deliver high quality and safe health care.AQ1: Please provide author names for Ref. 7.


1. Cheng A, Duff J, Grant E, Kissoon N, Grant VJ. Simulation in pediatrics: An educational revolution. Paediatr Child Health. 2007; 12:465–468.

2. Hunt E, Heine M, Hohenhaus S, Luo X, Frush KS. Simulation pediatric trauma team management – Assessment of an educational intervention. Pediatr Emerg Care. 2007;23:796–804.

3. Adler M, Vozenilek J, Trainor J, et al. Development and evaluation of a simulation-based pediatric emergency medicine curriculum. Academic Medicine. 2009;84:935–941.

4. Cheng A, Goldman R, Aish MA, Kissoon N. Integration and evaluation of a simulation-based acute care curriculum into a pediatric emergency medicine fellowship training program. Pediatr Emerg Care. 2010; 26:475–480.

5. Bhanji F, Mancini M, Sinz E, et al. 2010 American heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Part 16: Education, implementation and teams. Circulation. 2010;122:S920–S933.

6. Wayne DB, Didwania A, Feinglass J, Fudala MJ, Barsuk JH, McGaghie WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133:56–61.

7. Chameides L, Samson RA, Schexnayder SM, Hazinski MF Pediatric Advanced Life Support Provider Manual. Dallas, TX: American Heart Association; 2011.

8. Kattwinkel J, ed. Neonatal Resuscitation Textbook. 6th ed. USA: American Academy of Pediatrics and American Heart Association; 2011.

9. Eppich W, Brannen M, Hunt EA. Team training: implications for emergency and critical care pediatrics. Curr Opin Pediatr. 2008;20:255–260.

10. Cheng A, Donoghue A, Gilfoyle E, Eppich W. Simulation-based crisis resource management training for pediatric critical care medicine: A review for instructors. Pediatr Crit Care Med. 2012;13:197–203.

11. Donoghue A, Ventre K, Boulet J, Brett-Fleegler M, Nishisaki A, Overly F, Cheng A. Design, implementation and psychometric analysis of a scoring instrument for simulated pediatric resuscitation: A report from the EXPRESS pediatric investigators. Simul Healthc. 2011;6:71–77.

12. Brett-Fleegler MB, Vinci RJ, Weiner DL, Harris SK, Shih MC, Kleinman ME. A simulator-based tool that assesses pediatric resident resuscitation competency. Pediatrics. 2008;121:e597–e603.

13. Reid J, Stone K, Brown J, et al. The simulation team assessment tool (STAT): Development, reliability and validation. Resuscitation. 2012;83:879–886.

14. Grant E, Grant VJ, Bhanji F, Duff JP, Cheng A, Lockyer JM. The development and assessment of an evaluation tool for pediatric resident competence in leading simulated pediatric resuscitations. Resuscitation. 2012;83:887–893.

15. Dreyfus SE, Dreyfus HL. A Five Stage Model of the Mental Activities Involved in Directed Skill Acquisition. Washington, DC: Storming Media; 1980.

16. Ericsson AK, Charness N, Feltovich P, et al. Cambridge Handbook On Expertise And Expert Performance. Cambridge, UK: Cambridge University Press; 2006.

17. Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond “see one, do one, teach one”: Toward a different training paradigm. Qual Saf Health Care. 2009;18:63–68.

18. 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;27:10–28.

19. Kneebone RL. Perspective: Simulation and transformational change: the paradox of expertise. Acad Med. 2009;84:954–957.

20. Ericsson KA. Deliberate practice and acquisition of expert performance: a general overview. Acad Emerg Med. 2008;15:988–994.

21. Barsuk JH, McGaghie WC, Cohen ER, Balachandran JS, Wayne DB. Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care cunit. J Hosp Med. 2009;4:397–403.

22. Niles D, Sutton RM, Donoghue A, et al. “Rolling refreshers”: A novel approach to maintain CPR psychomotor skill competence. Resuscitation. 2009;80:909–912.

23. Arthur W, Bennett W, Stanush PL, et al. Factors that influence skill decay and retention. A quantitative review and analysis. Hum Perform. 1998;57:101–116.