Journal of Pediatric Critical Care

P - ISSN : 2349-6592    |    E - ISSN : 2455-7099

Original article
Year : 2014 | Volume : 1 | Issue : 4 | Page : 240-244

Development and Implementation of Pediatric Critical Care Focused Simulation Workshop and Program in India

Utpal S. Bhalala1, Jesal Sadawarte2, Sameer Sadawarte2, Vishal Baldua2, Swati Garekar2, Rahul Pandit2, Maninder Dhaliwal3, Vinay Joshi4, Preetha Joshi4, Mahesh Mohite5, Chandrahas Deshmukh6, Rakshay Shetty7 and Praveen Khilnani8

1Johns Hopkins Hospital, Baltimore, MD, 2Fortis Hospital, Bombay, India, 3Medanta Hospital, Delhi, India, 4KD Ambani Hospital, Bombay, India, 5Sai Children’s Hospital, New Panvel, India, 6Seth GS Medical College, Bombay, India, 7Rainbow Children’s Hospital, Vijaywada, India, 8BLK Superspecialty Hospital, New Delhi, India

Correspondence Address:

Utpal S Bhalala, MD, FAAP
Assistant Professor of Anesthesiology Critical Care Medicine and Pediatrics; The Johns Hopkins University School of Medicine; Simulation Facilitator, Johns Hopkins Medicine Simulation Center, Baltimore, MD, USA
Chair In-Training Section of Society of Critical Care, Medicine, USA
The Johns Hopkins Hospital, Bloomberg Children’’s Center, 1800 Orleans Street, Suite 6349B, Baltimore, MD 21287, USA
Tel: (410) 955-6412; Email:
Received:14-Jul-2014/Accepted:24-Oct-2014 /Published online:15-Nov-2014

Source of Funding:None Conflict of Interest:None


Simulation-based learning has become a part of residency and fellowship training in many training programs in the United States. But, it has not been incorporated into the pediatric critical care medicine training in the developing countries like India. Simulation-based training allows rapid and repetitive learning of skills necessary to provide a high quality and safe care to critically ill children. There is a need to explore simulation as a tool to train pediatric and pediatric critical care medicine practitioners in the developing world. This is particularly pertinent to Indian subcontinent in which pediatric critical care medicine has grown by leaps and bounds over last decade. We hereby present one of the earliest reports of development and implementation of pediatric critical care focused simulation workshop and program in India. Key Words: Simulation, Critical Care, Child, Training, India
This abstract was presented as a poster at American Academy of Pediatrics, National Conference & Exhibition, San Diego, California, USA, 2014.

Simulation training incorporates didactics, case-based learning and hands-on skill training.1 Simulation based training programs geared towards pediatric critical care medicine have been successfully developed and implemented in western world2. But, simulation based training of pediatric healthcare providers is underutilized in developing countries like India. Also, simulation-based, Pediatric Critical Care Medicine (PCCM) courses must focus on basic and advanced PCCM training in keeping with some of the known challenges of delivery of critical care unique to the developing world. The challenges involved with care of critically ill children in the developing world are limitation of resources, fulminant infections unique to the developing world, transportation of critically ill children to higher level of care and teamwork and communication. We sought to evaluate development and implementation of one of the earliest PCCM focused simulation workshop and program in India. We hereby describe one of the first PCCM simulation workshops which was successful in providing training in basic and advanced PCCM including fulminant infectious cases pertinent to Indian subcontinent.

To develop and implement a PCCM focused simulation workshop and program in India.

A group of pediatricians and pediatric intensivists from different institutions of India collaborated with a simulation expert and pediatric intensivist of USA to develop and implement a PCCM simulation workshop and program in India.

Need Assessment: The group first performed an informal need assessment. Since pediatric critical care medicine is often practiced by general pediatricians not formally trained in pediatric critical care medicine, a need assessment was crucial to determine overall structure of the workshop. Also, it was important to assess the needs to characterize the cases, the objectives of the cases, design and on-site resources. Planning: Since one of the major regional suppliers of the simulation equipment was Laerdal Medical India Private Limited, the US-based faculty reached out to them and discussed about the workshop program, their willingness to participate and provide simulation resources (mannequins, simulation technicians and simulation software to run the scenario). The subsequent step was to design the workshop program and prepare the cases with the objectives geared towards the participant needs in keeping with the common critical care scenarios and the key challenges of the practice of critical care medicine in India. While designing the workshop, the organizers discussed about 1) The balance of didactic sessions, hands-on sessions and cases scenarios, 2) The objectives of Pediatric Advanced Life Support (PALS) scenarios, 3) The time allotment for each session, each case and time allotment for debriefing of each case. Since most the participants were anticipated to be PALS trained, the objectives of the PALS scenarios for the workshop were directed towards high-quality CPR, teamwork and communication. During the workshop planning phase, the organizers, faculty and members of Laerdal Medical India Pvt. Ltd. communicated on a frequent basis via email, teleconference and smart phone messenger (WhatsApp Inc, Mountain View, California, USA). The workshop faculty collected the latest guidelines on common critical care scenarios like difficult airway management guidelines, traumatic brain injury guidelines and circulated amongst the participants. The US-based simulation expert provided just-in-time ““training of the trainer”” course to the workshop faculty with dry runs of the case scenarios. The team utilized simulation resources and hospital-based resources to run the workshop. The team also designed skill stations for hands-on skill training in PCCM. The team evaluated the workshop and program through a just-in-time debriefing and post-session survey of the workshop participants.

The collaboration of pediatricians and pediatric intensivists from different parts of India with simulation expert from USA led to the development and implementation of a successful 2-day simulationbased PCCM workshop. A total of 12 Indian faculties and 1 US faculty participated in the workshop as simulation facilitators. The years of experience of pediatric practice beyond the basic pediatric training among the faculty ranged from 5-20 years. The entire faculty had in-depth knowledge and experience of PCCM and 10 out of 12 Indian faculties had PCCM training at centers of excellence abroad.

Based on the needs assessment, the organizers were able to design the workshop program, the cases, the objectives of the cases in keeping with the day-today critical care scenarios and challenges unique to the practice of critical care medicine in India. The didactics were restricted to 3 lectures - Simulation in healthcare, Cardiac Arrest and quality of CPR and Role of simulation in PCCM. A significant proportion of the workshop time was allotted to the case scenarios, bedside debriefing and hands-on training.

The first case scenario enacted by the faculty in front of the participants and displayed on the screen through a live video was aimed at highlighting the importance of the teamwork and communication in management of critically ill child. The remaining case scenarios for the participants were spread evenly over 2 days and intermixed with hands-on sessions to avoid monotony. There were 16 case scenarios run over 2 days and they comprised of rapid sequence intubation, difficult airway cases, septic shock, dengue hemorrhagic shock, Dengue with abdominal compartment syndrome, acute meningitis, acute myocarditis, ARDS, status epilepticus, cardiac triage, transport of critically ill child, polytrauma, cardiac tamponade, Pulseless Electrical Activity (PEA), Supraventricular Tachycardia (SVT) and Ventricular Fibrillation (VF).

There were 4 simulation technicians who followed the instructions for running the case scenarios using structured case files which were prepared, revised and finalized by the faculties before the workshop. For running the cases, the workshop used 1 sim junior, 1 sim man 3G, 1 resuscitation baby with CPR feedback, 1 adult resuscitation simulator with CPR feedbackand rhythm generating system; for hands-on training, the workshop used airway trainer,Ultrasound machine and intravenous line tissue blocks.The critical care ultrasound experts first went over the basic knobology. The hands-on training on use of critical care ultrasound for 4-view cardiac echocardiography, evaluation of inferior vena cava, evaluation of vessels for arterial and venous line placement and lung assessment was provided on a volunteer subject. Additional hands-on training on use of critical care ultrasound for peripheral intravenous line placement was provided on IV task trainer.

Of the 34 workshop participants, 11 were pediatric residents/pediatricians, 2 anesthesia trainees, 2 emergency medicine trainees and 19 nurses with interest in PCCM. The workshop cases focused on the learning objectives of teamwork and communication skills. The pediatric advanced life support cases focused on delivering high-quality resuscitation training. The program evaluation and debriefing at the end of the workshop revealed very high participant satisfaction with comments like –– ““Dedicated and knowledgeable faculty, Case based practical approach, Interactive format, Every Query answered, Excellent quality of the dummies, Hands on experience””.

Simulation-based training is rapidly becoming a standard of medical training in the western part of the globe. In 2011, a survey conducted by American Academy of Medical Colleges (AAMC) reported that all 90 medical schools and 64 teaching hospitals that responded to the survey indicated that they use simulation during medical school3. There are well established institutional, regional and national simulation programs and training courses in the US.In the developing world, the simulation in health care is in its developing phase.4Over last 5-7 years, a handful of centers have begun simulation-based medical training in India - a few notable names being - TACT (The Academy for Clinical Training), The Apollo Learning and Medical Simulation Center andSRM/STRATUS Centre for Medical Simulation. A group of physicians have been successful in introducing simulationbased training in emergency medicine in India.5 Also, inception of Pediatric Simulation Society of India(pediSTARS India) has marked the introduction of simulation training in pediatric medicine.

Pediatric critical care training programs in northeast region of the US have successfully established a rigorous, two day, multi-institutional, high-fidelity simulation-based ““boot camp”” for junior and senior level pediatric intensive care fellows.6Unfortunately, the applications of simulationfortraining focused towards common challenges of management of critically ill children in India are far and few.The hi- fidelity mannequins enhance the realism of medical scenarios and promote the concept of ““suspension of disbelief.””7The concept is to create a learning mechanism to improve patient care without risk to an actual patient.8-11PCCM has grown by leaps and bounds in India over last decade. Many children’’s centers of excellence have been established under banners of large tertiary care hospitals or healthcare systems. Also, most of the advanced PCCM centers have started formal PCCM training programs. It is about time for growing awareness of the advanced simulation-based learning technology within PCCM community of India. In a developing country like India, the sheer numbers of patients attending the acute care settings like emergency room and PICU makes the work of PICU physicians extremely stressful. Adequate training of these physicians in such reallife scenarios is important to improve the quality of patient care. In this regard, hi-fidelity simulation technology can become an integral part of PCCM training. The concept of the workshop was not only to give specific training of PCCM scenarios to the physicians, but also to introduce them to the concept of PCCM training through hi-fidelity simulators.Our workshop was one of the earliest PCCM workshops in India which combined the high-fidelity technology to common critical care scenarios and critical care challenges of India.

A successful PCCM focused simulation training workshop and program were developed and implemented through collaboration of faculty from different parts of India under guidance of simulation expert from US. Simulation has a huge potential for improving PCCM training in developing countries like India.

We are thankful to the administrators of Fortis Hospital, Mulund, Mumbai for providing us the necessary support for the workshop and Laerdal Medical India Pvt. Ltd. for providing simulation resources for the workshop at no cost.

1. Bradley P. The history of simulation in medical education and possible future directions. Med Educ. 2006; 40:254-62.
2. Cheng A, Hunt EA, Donoghue A, et al. Examining pediatric resuscitation education using simulation and scripted debriefing: a multicenter randomized trial. JAMA Pediatr. 2013 Jun; 167(6):528-36.
3. Gabriel BA. Prepping for Performance: The Value of Simulation in Medical Education. AAMC Reporter 2012; Available from: june2012/285322/simulation.html
4. Clinical Training. Available from: clinical-training
5. Oak SN. Medical simulation: A virtual world at your doorstep. J Postgrad Med 2014;60:171-4.
6. Gupta A, Peckler B, Schoken D. Introduction of hi-fidelity simulation techniques as an ideal teaching tool for upcoming emergency medicine and trauma residency programs in India. J Emerg Trauma Shock. 2008 Jan-Jun; 1(1): 15––18.
7. Ogden PE, Cobbs LS, Howell MR, Sibbitt SJ, DiPette DJ. Clinical simulation: importance to the internal medicine educational mission. Am J Med. 2007 Sep; 120(9):820-4.
8. Leach DC. Simulation: It’’s about respect. ACGME Bulletin. 2005. Dec, pp. 2––3. Available from: acWebsite/bulletin/bu_indexasp
9. Gordon JA, Wilkerson WM, Shaffer DW, Armstrong EG. ““Practicing”” medicine without risk: Students’’ and Educators’’ responses to high-fidelity patient simulation. Acad Med. 2001; 76:469––7.
10. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical education: An ethical imperative. Acad Med. 2003; 78:783-8.
11. Sachdeva AK. Acquisition and maintenance of surgical competence. SeminVasc Surg. 2002;15:182-90.