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Treating Children Like Children

A Case for Simulating Pediatric Emergencies

Children are not just small adults. Obvious, right? But, if you were to ask those in pediatrics, they might say that a lot can get missed in the obvious.

Over the past twenty years, emergency departments (EDs) nationally have seen an increase in patients, and nearly 25 percent of these are children.1 Experts worry that, because children are being brought primarily to facilities that do not specialize in pediatric care, children may not be receiving the specialized treatment they deserve.2 Children, particularly infants less than one year old, have significant anatomical and physiological differences from adults, and the course of care necessary to diagnose and treat them is unique—unique and often missed.

In an emergency, a child's condition can deteriorate quickly, parents on scene can panic, and the care team at the bedside is likely to experience degrees of stress. Because of this, there is an urgent need to improve pediatric training—to ensure that when we say “children are not just small adults” we are not missing something.

Experts have put a training emphasis on determining the appropriate clinical pathway, administering medications, and working within an interdisciplinary team. Research suggests that training in these three areas can make a positive impact on pediatric patient outcomes.

In this article, we discuss how pediatric simulation can be used to train for:

Navigating Clinical Pathways

[Parents] have ‘expert’ knowledge of what is 'normal' or 'abnormal' behavior and it is vital that the clinical teams respect and listen to them, treating this parental knowledge with the same importance as test results and opinions of doctors and nurses.

- Louise Whittle, Parents' Association for Seriously Ill Children6

Many organizations have begun implementing full-scale pediatric simulation efforts, according to the American Academy of Pediatrics (AAP). One example is the Pediatric BASE Camp, an immersive simulation event supported by Laerdal and hosted by Weill Cornell Medical College, that focuses on fine-tuning and strengthening the clinical-pathway skills that providers use when faced with a pediatric emergency.4

Other organizations are using sequential simulation (SqS) to prepare front-line staff to participate in integrated, or person-centered, care at various points on the patient journey.5 This form of simulation focuses on important moments, such as hand-offs (i.e. from parent to physician, from ambulance to ED, etc.), information sharing, role assignments, and individual tasks.

Being able to assess symptoms, measure physiological differences and improvements, and perform interventions will allow learners to suspend disbelief and move through the simulation without roadblocks.

Medication Dosages

In pediatrics, the incidence of errors with medication can be as high as 1 in every 6 orders.7 This may be caused, in part, by the fact that children vary greatly in weight, body surface area, and organ system maturity, which affects their ability to metabolize and excrete medications.8

According to the AAP, the following are most important to include in pediatric patient safety programs:9
  • Weight calculations
  • Emotional and biological developmental issues, including communication ability
  • Patient and family involvement

In a study observing nursing students using simulation to address a complex pediatric patient case, only 22% of students provided correct medication administration before the training. After the training, 96% were successful in dilution techniques and eighty-eight percent were able to provide accurate IV pump rates.10

Simulation training prepares nurses and physicians for the inevitable stress, noise, and chaos that will come with an infant in critical condition.

Interdisciplinary Team Training

When an infant is brought to the ED, it's quite possible that a team can form that has little familiarity with each other and yet must perform like a well oiled machine. So, why not give them that training opportunity?

Research by the Cincinnati Children's Hospital Medical Center asserts high-fidelity simulation as an effective method of enhancing and evaluating interdisciplinary team training in the context of pediatric trauma patients.11 This same study concluded that improved team performance directly correlated with more efficient care and fewer errors.

Emergency Medical Services (EMS) are an added dynamic, as approximately 7%-13% of all EMS calls involve pediatric patients.12 Training to incorporate all possible caregivers can lead to a more effective team dynamic, and certainly a more accurate clinical pathway.

Additionally, emphasizing closed-loop communication techniques in simulations can not only help to reduce the risk of error, but also increase the speed and efficiency when treating a pediatric patient in crisis.

Root Causes of
Pediatric Errors:13

  • Impaired calculation ability under stress
  • Inaccurate weight estimate
  • Faulty recall of doses
  • Unaided calculations
  • Wrong milligram/kilogram dose for the route of administration
  • Errors converting the dose in milligrams to volume administered in milliliters
  • Volume measured from the wrong end of prefilled syringe

In a pediatric critical care setting, where an infant’s life may be at stake, a single error can have reverberating repercussions. Affording healthcare providers the chance to practice using simulation allows them to set expectations and exercise effective team communication skills before encountering a real patient.

Summary: How You Can Prepare for Pediatric Emergencies

Of the nine million children under the age of five that die each year, it is estimated that seventy percent of these are due to conditions that can be prevented or treated if diagnosed correctly.14 Experts recommend concentrating pediatric training efforts on the decision-making process in a clinical pathway, practicing administering medication in small doses required for children, and training with interdisciplinary teams to improve overall communication.

Simulation is an effective method of training that can incorporate each of these skills. Following a patient case from start to end, with the many ups and downs that a real patient would experience, can enhance existing pediatric training curricula by increasing skills and clinical expertise.15

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  1. Wier, L.M., Yu, H., Owens, P., & Washington, R. (2013). Overview of children in the emergency department, 2010. Agency for Healthcare Research and Quality. Retrieved from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf
  2. Ibid
  3. Audimoolam, S., Nair, M., Galkwad, R., & Qing, C. (2005). The role of clinical pathways in improving patient outcomes. Retrieved from: http://www.academia.edu/6850634/The_Role_of_Clinical_Pathways_in_Improving_Patient_Outcomes
  4. Pediatric BASE CAMP. Retrieved from: http://pembasecamp.org/
  5. Weldon, S.M., Ralhan, S., Paice, E., Kneebone, R., & Bello, F. (2015). Sequential simulation (SqS): An innovative approach to educating GP receptionists about integrated care via a patient journey- a mixed methods approach. BMC Family Practice, 16, p.109. DOI: 10.1186/ s12875-015-0327-5
  6. Breathnach, T. (2017). Sepsis: what every parent needs to know. Retrieved from: http://www.madeformums.com/baby/sepsis-what-every-parent-needs-to-know/40944.html
  7. American Academy of Pediatrics. (2003). Prevention of medication errors in the pediatric inpatient setting. Pediatrics, 112(2). Retrieved from: http://pediatrics.aappublications.org/content/112/2/431..info
  8. Ibid
  9. American Academy of Pediatrics (2003). See reference #7.
  10. Pauly-O’Neill, S. (2009). Beyond the five rights: Improving patient safety in pediatric medication administration through simulation. Clinical Simulation in Nursing, 5(5). DOI: https://doi.org/10.1016/j.ecns.2009.05.059
  11. Falcone, R.A., Daugherty, M., Schweer, L., Patterson, M., Brown, R.L., & Garcia, V.F. (2008). Multidisciplinary pediatric trauma team training using high-fidelity trauma simulation. Journal of Pediatric Surgery, 43(6). DOI: 10.1016/j.jpedsurg.2008.02.033.
  12. Shocket, D.R., & Braude, D. (2017). An overview of EMS pediatric airway management. Journal of Emergency Medical Services. Retrieved from: http://www.jems.com/articles/print/volume-42/issue-3/features/an-overview-of-ems-pediatric-airway-management.html
  13. Sullivan, B. (2016). Reality training: Administering pediatric medication. Retrieved from: https://www.ems1.com/ems-products/education/articles/102602048-Reality-training-Administering-pediatric-medication/
  14. The Partnership for Maternal, Newborn & Child Health. (2011). Child mortality. World Health Organization. Retrieved from: http://www.who.int/pmnch/media/press_materials/fs/fs_mdg4_childmortality/en/
  15. Eppich, W.J., Adler, M.D., & McGaghie, W.C. (2006). Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies. Current Opinion in Pediatrics, 18(3). DOI: 10.1097/01.mop.0000193309.22462.c9