Administration and Leadership, Columns

Study Links Simulation Training with Improved Prehospital Pediatric Care

Issue 7 and Volume 41.

Training Effectiveness

Shah MI, Carey JM, Rapp SE, et al. Impact of high-fidelity pediatric simulation on paramedic seizure management. Prehosp Emerg Care. March 8, 2016. [Epub ahead of print.]

With increased emphasis on culture of safety and rising concerns over medical errors, our attention this month turns to this study from Baylor College of Medicine in conjunction with the Houston Fire Department (HFD).

As we reported in the March issue, we know that the cognitive load theory (CLT) of education impacts high-fidelity simulation in EMS training. Progressive introduction of new materials and effective simulation benefits learners and presumably patient care. Kudos to the authors for taking a scientific approach to measure the effectiveness of simulation and potentially decrease medical errors in high-acuity and low-frequency critical pediatric cases. 

To frame this study, it’s important to note that the Agency for Health Care Research and Quality (AHRQ) and the Department of Defense teamed up years ago to implement TeamSTEPPS (, a free educational curriculum introducing culture of safety to healthcare organizations. The authors worked with the HFD and Texas Children’s Hospital to implement a Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs) curriculum and test its effectiveness.

Background: Pediatric patients with high-acuity conditions, such as status-seizures, are as challenging as they are rare for EMS practitioners. This study measured the effects of a high-fidelity simulation training on pediatric seizure protocol compliance by paramedics. The secondary aim of the study was to develop a better understanding of the care EMS and EDs are providing to pediatric seizure patients.

Methods: This was a retrospective cohort study comparing EMS practitioners within the HFD who participated in a specialty simulation training against those who didn’t. PediSTEPPs is a one-day, nine-hour, training that was offered to both BLS and ALS personnel.

The researchers pulled EMS records from a two-year time period for a retrospective review. To meet inclusion criteria, the patients had to be less than 18 years old, actively seizing, cared for by ALS practitioners and transported to an ED. A total of 250 patients met the criteria for inclusion and 65 (26%) of these patients were cared for by a paramedic who had taken a PediSTEPPs course. Protocol compliance was judged by whether the paramedic measured the patient’s blood glucose and administered midazolam to an actively seizing patient.

Results: PediSTEPPs-trained paramedics were 35% more likely to obtain a blood glucose measurement (OR = 1.35, 95% CI = 0.72–2.51, p = 0.35) and 39% more likely to administer midazolam (OR = 1.39, 95% CI = 0.77–2.49, p = 0.28). Neither of these results were statistically significant and could therefore have been due to random chance. An interesting finding was that in over 25% of the cases blood glucose wasn’t obtained and midazolam wasn’t administered.

Discussion: It’s refreshing to see a group of researchers who are rigorously measuring the blend of simulation, safety, pediatrics and outcome measures. It’s unfortunate that no statistical significance was found, but that’s due to sample size. We would argue that clinical significance was found: More children received medication to stop their seizure.

Most simulation studies measure outcomes by student satisfaction. This study focused on actual patient care changes in the field.

We also have to report this study adds to previous, and alarming, reports of medication dosage errors. Only 51% of children received the correct dose of benzodiazepines and only 36% of charts included the patient’s weight. Most of the errors (89%) came from under-dosing. Unlike previous studies that were based on simulation only, these data are for real patients.

Conclusion: The authors should be commended for their study design. More of us should undertake this kind of measurement when we introduce a new course. This study clearly supports the use of high-fidelity simulation training for low-frequency but high-criticality procedures and is a sobering reminder that we have much work ahead to improve our medication administration processes.

Bottom Line

What we already know: Caring for critical pediatrics patients can be some of the most challenging calls faced by EMS practitioners. High-fidelity simulation is correlated with improved student satisfaction. There’s a high rate of medication errors in simulation

What this study adds: Evidence that high-fidelity simulation training improves care of high-acuity and low-frequency cases. New evidence suggesting medication errors occur in the field as well as in simulation.

This study will be the focus of this month’s PCRF Journal Club webcast on on Monday, June 13, 2016 at 12:00 PM CDT. Register here