Care Team Competencies

Develop a robust pediatric competency program that ensures staff maintain the knowledge, skills, and abilities necessary to safely and effectively manage critically ill and/or injured children.

This flow diagram is designed to help one think about how to break down this focus area into small steps. The questions in this flow diagram align with the environmental scan worksheet in the next section. Consider the primary drivers of a pediatric competency program as you review the following process map:

  1. Communication
  2. Education
  3. Policies & Procedures
  4. Resources & Tools
  5. Funding
  6. Culture

PWDC - Care Team Competencies -Flow Map

Children account for only 10% of EMS calls and 20-25% of emergency department visits every year in the United States [1, 2]. This translates to less than 3 pediatric emergencies per month for EMS practitioners and less than 15 children per day in emergency departments, on average [3, 4]. Given that fewer than 5% of these children ultimately require tertiary care, the opportunity for EMS practitioners, nurses, physicians, and other healthcare professionals to reinforce pediatric competencies is limited[5].

In the absence of frequent practice and continuing education, critical pediatric skills and knowledge can be difficult to maintain. Most national accreditation programs require pediatric competencies be demonstrated upon initial training and CE requirements for maintenance of certification or licensure supports maintenance of pediatric competencies[4]. Pediatric advanced life support courses have been shown to immediately increase provider knowledge, yet in the absence of regular opportunities to apply the knowledge, competency returns to baseline levels within 6-12 months[4]. While nationally registered EMS practitioners report that CE is the main source of knowledge and skills in pediatrics, cost, availability, and travel distance are often barriers to obtaining pediatric CE. Furthermore, pediatrics may account for only a small component if CE required—depending on the specialty or certification. Similarly, skills maintenance or demonstration of competency is not consistently included in re-certification processes[4]. As an example most EMS practitioners report having fewer than 8 CE hours in pediatric topics over the preceding 2 years[3].

While most national training courses do a thorough job of teaching the cognitive aspect of pediatric competencies (the knowledge of what needs to be done in a given situation) as well as the skill (physically performing the task correctly). However, to be fully competent includes not only the knowledge and skill (how to physically perform the task) but also ability. Ability includes the behavioral aspects of a task such as a calm, confident, reassuring manner, employing family-centered care, and anticipating potential complications being able to minimize or prevent those risks.

The development of a robust pediatric competency program within an organization can help ensure that staff maintain critical knowledge, skills, and behaviors to meet the needs of children throughout their individual professional practice as a physician, nurse, EMS practitioner or other healthcare provider.

  1. Gausche-Hill, M., et al., A National Assessment of Pediatric Readiness of Emergency Departments. JAMA Pediatrics, 2015. 169(6): p. 527-534.
  2. Shah, M.N., et al., The Epidemiology of Emergency Medical Services Use by Children: An Analysis of the National Hospital Ambulatory Medical Care Survey. Prehospital Emergency Care, 2008. 12(3): p. 269-276.
  3. Stevens, S.L. and J.L. Alexander, The impact of training and experience on EMS providers' feelings toward pediatric emergencies in a rural state. Pediatr Emerg Care, 2005. 21(1): p. 12-7.
  4. Remick, K., S. Caffrey, and K. Adelgais, Prehospital Provider Scope of Practice and Implications for Pediatric Prehospital Care. Clinical Pediatric Emergency Medicine, 2014. 15(1): p. 9-17.
  5. Cabalatungan, S.N., H.C. Thode, and A.J. Singer, Emergency medicine physicians infrequently perform pediatric critical procedures: a national perspective. Clinical and experimental emergency medicine, 2020. 7(1): p. 52-60.

Communication

Communicate to both staff and leadership the importance of incorporating pediatric competencies into training programs.

Leadership Support

  • Advocate for the importance of including pediatric considerations in existing training procedures
  • Identify key stakeholders that need to be engaged in the development of education & training content

Staff Buy-In

  • Identify potential safety events where additional education & training may have improved the care & safety of the child
  • Develop training centered on effective communication methods including transitions of care, handoffs, family involvement, and closed-loop communications.
  • Develop a process to assess staff's priority of learning needs

Patient and Family Engagement

  • Conduct targeted outreach to children and youth with special healthcare needs in your community to familiarize the staff with their needs

Education

Onboarding/Training

  • Develop training /evaluation materials that target not only psychomotor competencies (e.g., medication administration) but also cognitive (assessment and management) and behavioral (family-centered care) competencies

Competency Reinforcement

  • Review one piece of pediatric equipment per month with staff.
  • Host a pediatric skills day with supplies & equipment readily available
  • Schedule (or implement impromptu) simulation to practice team and family communication as well as assessment & management of the ill or injured child
  • Utilize hospital grand rounds or M&M conferences to revisit critical pediatric knowledge

Just In Time Training

  • Utilize telehealth technologies to obtain pediatric expertise (provider-provider consults)

Policies & Procedures

Create a policy on the evaluation of pediatric competencies

Training

  • Develop a—or augment an existing—policy to include ongoing pediatric continuing education requirements (see references for pediatric course recommendations)
  • Create a—or augment an existing—policy to outline pediatric competencies that staff must maintain.

Competency Evaluation

  • Determine a set frequency for the assessment of low frequency, high risk pediatric competencies. (Ensure the mechanism of competency evaluation is described in the policy).

Resources & Tools

Provide resources or tools to promote knowledge reinforcement and decrease reliance on recall (checklists, badge buddies, posters)

Training Tools / Equipment

  • Create checklists for pediatric-specific skills (e.g., advanced airway, sedation)
  • Create badge buddies with pertinent pediatric information (pain assessment, vital signs)
  • Contact local EMSC program for training support (e.g., mannequins)

Training Expertise

  • Implement training/shadowing opportunities with the local children's hospital or pediatric center.
  • Incorporate new technologies (high-fidelity SIM, teleSIM etc for training).
  • Engage with the ImPACTS network to implement simulation for skill maintenance

Funding

Consider budget implications--or identify methods with minimal or no additional cost--of adding additional training on pediatric competencies

Staff Resources

  • Estimate the impact that introduction of additional training will have on staff time.

Budgetary Implications

  • Assess the availability of internal and regional resources that can support training.
  • Determine the cost of purchasing new equipment, supplies, or technologies required as a direct result of the new training requirements.

Culture

Promote a culture of safe and effective care for pediatric patients throughout all system

Change Management

  • Engage influencers, champions, and opponents in the training development process
  • Define methods for effective and broad communication of proposed training changes and invite input.

System Hierarchies

  • Outline the organizational hierarchy and utilize that structure to communicate and support training and assessment of competencies.
  • Work to implement Just Culture, where mistakes are first thought of as a failure of systems (what went wrong) rather than an individual failure (who caused the problem).

Tools
  1. National Pediatric Readiness Project Toolkit: https://emscimprovement.center/domains/pediatric-readiness-project/readiness-toolkit/
  2. Prehospital Pediatric Readiness Project Toolkit: https://emscimprovement.center/domains/prehospital-care/prehospital-pediatric-readiness/pprp-toolkit/
  3. PECC Community of Practice Website (Agency PECCs): https://emscimprovement.center/collaboratives/pecclc/resources/agency-peccs
  4. EMS Education Toolkit for Pediatrics (NASEMSO)
  5. Autism First Responder Training Video (Autism Society of Texas)
  6. Emergency Care: Pregnancy Infants, and Children Course
  7. TeleSimBox EMS Case Simulations (Seizure and Non-Accidental Trauma) – ACEP
  8. Identifying Child Abuse – Online Module (University of Colorado & Colorado EMSC)
  9. Online Pediatric Education (University of Colorado & Colorado EMSC)
  10. Simulation-Based Pediatric Resuscitation Curriculum for Prehospital Providers (MedEd Portal)
  11. Comfort Positioning

From Dr. Auerbach's Simulation presentation

  1. The Virtual Resus Room https://virtualresusroom.com/
  2. TeleSimBox EMS Case Simulations (Seizure and Non-Accidental Trauma) – ACEP
  3. Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) https://www.aliem.com/emrescupeds-em-resident-simulation-curriculum-pediatrics/

Templates
  1. Equipment Competency Validation Record
  2. Physical Assessment Skills Checklist (Pediatric)
  3. Orientation Knowledge and Skills Checklist for the Registered Nurse
  4. PRIDE Pediatric Disaster Simulation Curriculum
  5. Skills Workshop Sample (Gaston County EMS)
  6. Skills Competencies (Gaston County EMS)
  7. Prehospital Pediatric Care Course Scenarios (New York)
  8. NREMT Advanced Level Psychomotor Exam

Articles

  1. Babl, F.E., et al., Pediatric Pre-Hospital Advanced Life Support Care in an Urban Setting. Pediatric Emergency Care, 2001. 17(1) https://journals.lww.com/pec-online/Fulltext/2001/02000/Pediatric_pre_hospital_advanced_life_support_care.2.aspx
  2. Burton, J.H., et al., Endotracheal Intubation in a Rural Ems State: Procedure Utilization and Impact of Skills Maintenance Guidelines. Prehospital Emergency Care, 2003. 7(3): p. 352-356 https://doi.org/10.1080/10903120390936554
  3. Krauss, B.A. and B.S. Krauss, Managing the Frightened Child. Annals of Emergency Medicine, 2019. 74(1): p. 30-35 https://doi.org/10.1016/j.annemergmed.2018.12.011
  4. Lammers, R.L., et al., Simulation-Based Assessment of Paramedic Pediatric Resuscitation Skills. Prehospital Emergency Care, 2009. 13(3): p. 345-356 https://doi.org/10.1080/10903120802706161
  5. Reisdorff, E.J., et al., Prehospital Interventions in Children. Prehospital Emergency Care, 1998. 2(3): p. 180-183 https://doi.org/10.1080/10903129808958868
  6. Shah, M.I., et al., Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management. Prehosp Emerg Care, 2016. 20(4): p. 499-507 https://www.tandfonline.com/doi/abs/10.3109/10903127.2016.1139217?journalCode=ipec20
  7. Tsai, A. and G. Kallsen, Epidemiology of Pediatric Prehospital Care. Ann Emerg Med, 1987. 16(3): p. 284-92 https://pubmed.ncbi.nlm.nih.gov/3813162/
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