Letter to the Editor

Abstract

Feasibility of using a Single Uniform Simulated Megacode Scenario (SUSMS) during assessment in the Paediatric Advanced Life Support (PALS) courseHealth workers involved in taking care of children preferably should undertake the Paediatric Advanced Life Support (PALS) course. The PALS course consists of lectures, tutorial and skill stations [1Hazinski M.F. Zaritsky A.L. Nadkari V.M. Hickey R.W. Schexnayder S.M. Berg R.A. PALS Provider Manual. American Heart Association, 2002Google Scholar, 2Chameides L. Hazinski M.F. Pediatric Advanced Life Support. American Heart Association, 1997Google Scholar]. It provides an opportunity for hands-on practice to the participants by using simulation techniques on a manikin. Simulated cases are presented during the practice sessions to the participant to enhance and assess their knowledge and approach towards the sick child in different emergency situations. During the evaluation of the candidate different case scenarios are presented to the participant to assess their performance. Based on the approach of the candidate a decision to pass or fail is made. However, the presentation of a number of dissimilar cases to different participants during evaluation station has some disadvantages and may result in subjective variability in the assessment of the candidate [[3]Perkins G.D. Hulme J. Tweed M.J. Variability in the assessment of advanced life support skills.Resuscitation. 2001; 50: 281-286Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. Thus, there is a need to develop a uniform single case scenario assessment format that both serves the purpose of objective assessment and conforms to the objectives of the course. In an attempt to meet these objectives, we devised a Single Uniform Simulated Megacode Scenario (SUSMS) format for PALS evaluation station. To look at the feasibility of SUSMS and the response of the participants to this new intervention, we carried out this study.The study was conducted in the department of Postgraduate Center (PGC) at Royal Hospital, Muscat, Sultanate of Oman. The PALS courses are conducted quarterly in the center by PALS certified instructors [[4]Manzar S. Paediatric advanced life support (PALS) course: the Oman experience.J Bahrain Med Soc. 2000; 12: 95-96Google Scholar]. The course programme of the American Heart Association and American Academy of Paediatrics is used [1Hazinski M.F. Zaritsky A.L. Nadkari V.M. Hickey R.W. Schexnayder S.M. Berg R.A. PALS Provider Manual. American Heart Association, 2002Google Scholar, 2Chameides L. Hazinski M.F. Pediatric Advanced Life Support. American Heart Association, 1997Google Scholar]. During the recent PALS course, we piloted the new SUSMS format (Box 1) while assessing the participants. The modification in the evaluation segment of the course was made in accordance with the suggestions made by Siedel et al. [[5]Siedel J.S. Henderson D.P. Spencer P.E. Education in pediatric basic and advanced life support.Ann Emerg Med. 1993; 22: 489-494Abstract Full Text PDF PubMed Scopus (17) Google Scholar]. A structured performance checklist was included in the scenario to rate the performance objectively. This approach has shown to have an excellent interobserver reliability [[6]Quan L. Shugerman R.P. Kunkel N.C. Brownlee C.J. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course.Pediatrics. 2001; 108: E110Crossref PubMed Scopus (59) Google Scholar].Box 1The uniform Single Simulated Megacode Scenario formatCase scenario:An 8-month-old infant with 3-day history of vomiting and diarrhoea comes to the emergency department. On examination the baby looks drowsy. No cyanosis was noted. Chest is clear to auscultation with good bilateral air entry. The respiratory rate is 50/min. Infant is afebrile, the heart rate is 180/min with blood pressure of 70/40 mmHg. Pulses are feeble and capillary refill time is >4 s.Question: What do you do now?Right approach:•Place on oxygen/monitor•Attempt IV access. 90 s… if fails, think of intraosseous line•Give fluids 20 ml/kg Ringer lactate or normal saline, fast over 5–10 min•Reassess ABCDEWrong approach:•Treat heart rate/cardioversion/ask for cardiac rhythm•Perform airway intervention before IV access•Administer hypotonic saline 0.18%, wrong dose (10 ml/kg)•Prolonged IV access attempt, delay of intraosseous approachCase progression:Access to the circulation with a tibial intraosseous needle is obtained, Electrocardiogram (ECG) shows SVTSupra ventricular tachycardia (SVT) is shown on the simulatorAppropriate action: Adverse signs—including hypotension and poor perfusionVagal stimulation by applying ice to the face•Adenosine 0.1–0.2 mg/kg, fast (for stable SVT)•Synchronized cardioversion 0.51 J/kg and then 1–2 J/kg (for unstable SVT)The rhythm is then changed to ventricular tachycardia without a pulseAppropriate action:•Start CPR•Cardioversion (0.5–1 J/kg)•Lidocaine 1 mg/kg IV bolus, then infusion of 20–50 mcg/min.The rhythm is then changed to Ventricular FibrillationAppropriate action:Continue CPR•Shock 2 J/kg…shock 2 J/kg…shock 4 J/kg…adrenaline (epinephrine)…Correct dose & route•Selecting correct voltage & increase it accordinglyThe rhythm is changed to sinus bradycardia—check for adverse signs e.g. poor perfusion.Appropriate action:•Stabilize•Observe•Investigations ABG, full blood count, urea, creatinine and electrolytes•Arrange for transfer to ward/ICUThe checklist was self-explanatory with the correct and incorrect approach followed up by appropriate action. The same observer (SM) evaluated the candidates using the performance checklist to reduce the chance of interobserver variability.A total of 11 candidates, 6 doctors and 5 nurses, registered for the course and all participated in the study. All participants after successful completion of the multiple choice theory test (pass score of 85%), were presented with the SUSMS (Box 1). All candidates successfully passed the practical evaluation station. Their responses were noted down in a separate sheet. Informal feedback was taken from the participants after the assessment.During the feedback, comments were made regarding the fairness of the new system of evaluation. Most participants felt that the new system was very objective and the element of chance and luck was reduced to minimum by the use of a universal scenario. However, as none of the participants had taken the course before, a comparative analysis could not be performed between the old and new method of assessment.Simulation has widely been used as an innovative teaching tool in medical education both in training and assessment with wide range of available technologies [[7]Henderson S.O. Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest?.Resuscitation. 2001; 48: 111-116Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. The SUSMS used during assessment was developed in accordance with the concept of using objective methods for assessment [[8]Manzar S. A journey from subjectivity to objectivity in the assessment of undergraduate medical students.Emirates Med J. 2003; 21: 103-105Google Scholar]. We found SUSMS to be both user and time friendly. Use of 3–4 separate scenarios would have taken 15–20 min compared to only 5 min used for the single SUSMS scenario. The SUSMS was easy to administer and was more in line with a real clinical situation.It is evident from the stage by stage progression of the case in the SUSMS format (Box 1) that nearly all of the important components of the PALS course was covered. A balance was made between too much structure and too little specificity in the case scenario [[9]Schuwirth L.W. vander Vleuten C.P. The use of clinical simulation in assessment.Med Educ. 2003; 37: 65-71Crossref PubMed Scopus (144) Google Scholar]. A clinical case was presented and the candidate was expected to have a general idea of the possible diagnosis and patho-physiological state of the vital functions of the patient, an important component of the PALS course. With the progression of the scenario, the candidate needed to appreciate the urgency of the situation and the need for IV access. Different cardiac rhythm disturbances were introduced to assess interpreting abilities and appropriate actions. Finally the skill of cardio-pulmonary resuscitation (CPR) was evaluated.The use of a single scenario might not provide the candidate with a sufficient range of clinical situations needed for better assessment. The use of multiple simulated scenarios might be more effective and accurate in estimating candidates’ ability. But, we covered all the vital aspects of the PALS course in developing the SUSMS format, so reducing the chance of narrowing the spectrum of clinical situation during assessment.A further limitation of the study was the small sample size. For resuscitation courses, we follow the technique of small group interactive teaching. The use of small groups provides more opportunity for hand-on practice sessions and more interactive discussion to enhance adult learning. With PALS course running every 4 months at our institution we expect to repeat and further assess our findings in future groups of participants by improving the sample size. The other important group for piloting the SUSMS will be the re-takers of the course. These participants, could be used to carry out a comparative analysis between the old and new methods.Lastly, we noted no major difference between the scores of the nurses and doctors, which is in contradiction to a previous report [[10]Wiasman Y. Amir L. Mimouni M. Does the pediatric advanced life support course improved knowledge of pediatric resuscitation?.Pediatr Emerg Care. 2002; 18: 168-170Crossref PubMed Scopus (37) Google Scholar]. This further highlights the fact that the knowledge and skills in acute situations and emergencies of nurses should not be underrated and suggest that nurses should be encouraged to become an active member of the paediatric emergency team.In conclusion, the use of the SUSMS format for assessing the performance in the PALS course is feasible and practical and should be evaluated further as a strategy for assessment in future resuscitation courses. Feasibility of using a Single Uniform Simulated Megacode Scenario (SUSMS) during assessment in the Paediatric Advanced Life Support (PALS) courseHealth workers involved in taking care of children preferably should undertake the Paediatric Advanced Life Support (PALS) course. The PALS course consists of lectures, tutorial and skill stations [1Hazinski M.F. Zaritsky A.L. Nadkari V.M. Hickey R.W. Schexnayder S.M. Berg R.A. PALS Provider Manual. American Heart Association, 2002Google Scholar, 2Chameides L. Hazinski M.F. Pediatric Advanced Life Support. American Heart Association, 1997Google Scholar]. It provides an opportunity for hands-on practice to the participants by using simulation techniques on a manikin. Simulated cases are presented during the practice sessions to the participant to enhance and assess their knowledge and approach towards the sick child in different emergency situations. During the evaluation of the candidate different case scenarios are presented to the participant to assess their performance. Based on the approach of the candidate a decision to pass or fail is made. However, the presentation of a number of dissimilar cases to different participants during evaluation station has some disadvantages and may result in subjective variability in the assessment of the candidate [[3]Perkins G.D. Hulme J. Tweed M.J. Variability in the assessment of advanced life support skills.Resuscitation. 2001; 50: 281-286Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. Thus, there is a need to develop a uniform single case scenario assessment format that both serves the purpose of objective assessment and conforms to the objectives of the course. In an attempt to meet these objectives, we devised a Single Uniform Simulated Megacode Scenario (SUSMS) format for PALS evaluation station. To look at the feasibility of SUSMS and the response of the participants to this new intervention, we carried out this study.The study was conducted in the department of Postgraduate Center (PGC) at Royal Hospital, Muscat, Sultanate of Oman. The PALS courses are conducted quarterly in the center by PALS certified instructors [[4]Manzar S. Paediatric advanced life support (PALS) course: the Oman experience.J Bahrain Med Soc. 2000; 12: 95-96Google Scholar]. The course programme of the American Heart Association and American Academy of Paediatrics is used [1Hazinski M.F. Zaritsky A.L. Nadkari V.M. Hickey R.W. Schexnayder S.M. Berg R.A. PALS Provider Manual. American Heart Association, 2002Google Scholar, 2Chameides L. Hazinski M.F. Pediatric Advanced Life Support. American Heart Association, 1997Google Scholar]. During the recent PALS course, we piloted the new SUSMS format (Box 1) while assessing the participants. The modification in the evaluation segment of the course was made in accordance with the suggestions made by Siedel et al. [[5]Siedel J.S. Henderson D.P. Spencer P.E. Education in pediatric basic and advanced life support.Ann Emerg Med. 1993; 22: 489-494Abstract Full Text PDF PubMed Scopus (17) Google Scholar]. A structured performance checklist was included in the scenario to rate the performance objectively. This approach has shown to have an excellent interobserver reliability [[6]Quan L. Shugerman R.P. Kunkel N.C. Brownlee C.J. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course.Pediatrics. 2001; 108: E110Crossref PubMed Scopus (59) Google Scholar].Box 1The uniform Single Simulated Megacode Scenario formatCase scenario:An 8-month-old infant with 3-day history of vomiting and diarrhoea comes to the emergency department. On examination the baby looks drowsy. No cyanosis was noted. Chest is clear to auscultation with good bilateral air entry. The respiratory rate is 50/min. Infant is afebrile, the heart rate is 180/min with blood pressure of 70/40 mmHg. Pulses are feeble and capillary refill time is >4 s.Question: What do you do now?Right approach:•Place on oxygen/monitor•Attempt IV access. 90 s… if fails, think of intraosseous line•Give fluids 20 ml/kg Ringer lactate or normal saline, fast over 5–10 min•Reassess ABCDEWrong approach:•Treat heart rate/cardioversion/ask for cardiac rhythm•Perform airway intervention before IV access•Administer hypotonic saline 0.18%, wrong dose (10 ml/kg)•Prolonged IV access attempt, delay of intraosseous approachCase progression:Access to the circulation with a tibial intraosseous needle is obtained, Electrocardiogram (ECG) shows SVTSupra ventricular tachycardia (SVT) is shown on the simulatorAppropriate action: Adverse signs—including hypotension and poor perfusionVagal stimulation by applying ice to the face•Adenosine 0.1–0.2 mg/kg, fast (for stable SVT)•Synchronized cardioversion 0.51 J/kg and then 1–2 J/kg (for unstable SVT)The rhythm is then changed to ventricular tachycardia without a pulseAppropriate action:•Start CPR•Cardioversion (0.5–1 J/kg)•Lidocaine 1 mg/kg IV bolus, then infusion of 20–50 mcg/min.The rhythm is then changed to Ventricular FibrillationAppropriate action:Continue CPR•Shock 2 J/kg…shock 2 J/kg…shock 4 J/kg…adrenaline (epinephrine)…Correct dose & route•Selecting correct voltage & increase it accordinglyThe rhythm is changed to sinus bradycardia—check for adverse signs e.g. poor perfusion.Appropriate action:•Stabilize•Observe•Investigations ABG, full blood count, urea, creatinine and electrolytes•Arrange for transfer to ward/ICUThe checklist was self-explanatory with the correct and incorrect approach followed up by appropriate action. The same observer (SM) evaluated the candidates using the performance checklist to reduce the chance of interobserver variability.A total of 11 candidates, 6 doctors and 5 nurses, registered for the course and all participated in the study. All participants after successful completion of the multiple choice theory test (pass score of 85%), were presented with the SUSMS (Box 1). All candidates successfully passed the practical evaluation station. Their responses were noted down in a separate sheet. Informal feedback was taken from the participants after the assessment.During the feedback, comments were made regarding the fairness of the new system of evaluation. Most participants felt that the new system was very objective and the element of chance and luck was reduced to minimum by the use of a universal scenario. However, as none of the participants had taken the course before, a comparative analysis could not be performed between the old and new method of assessment.Simulation has widely been used as an innovative teaching tool in medical education both in training and assessment with wide range of available technologies [[7]Henderson S.O. Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest?.Resuscitation. 2001; 48: 111-116Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. The SUSMS used during assessment was developed in accordance with the concept of using objective methods for assessment [[8]Manzar S. A journey from subjectivity to objectivity in the assessment of undergraduate medical students.Emirates Med J. 2003; 21: 103-105Google Scholar]. We found SUSMS to be both user and time friendly. Use of 3–4 separate scenarios would have taken 15–20 min compared to only 5 min used for the single SUSMS scenario. The SUSMS was easy to administer and was more in line with a real clinical situation.It is evident from the stage by stage progression of the case in the SUSMS format (Box 1) that nearly all of the important components of the PALS course was covered. A balance was made between too much structure and too little specificity in the case scenario [[9]Schuwirth L.W. vander Vleuten C.P. The use of clinical simulation in assessment.Med Educ. 2003; 37: 65-71Crossref PubMed Scopus (144) Google Scholar]. A clinical case was presented and the candidate was expected to have a general idea of the possible diagnosis and patho-physiological state of the vital functions of the patient, an important component of the PALS course. With the progression of the scenario, the candidate needed to appreciate the urgency of the situation and the need for IV access. Different cardiac rhythm disturbances were introduced to assess interpreting abilities and appropriate actions. Finally the skill of cardio-pulmonary resuscitation (CPR) was evaluated.The use of a single scenario might not provide the candidate with a sufficient range of clinical situations needed for better assessment. The use of multiple simulated scenarios might be more effective and accurate in estimating candidates’ ability. But, we covered all the vital aspects of the PALS course in developing the SUSMS format, so reducing the chance of narrowing the spectrum of clinical situation during assessment.A further limitation of the study was the small sample size. For resuscitation courses, we follow the technique of small group interactive teaching. The use of small groups provides more opportunity for hand-on practice sessions and more interactive discussion to enhance adult learning. With PALS course running every 4 months at our institution we expect to repeat and further assess our findings in future groups of participants by improving the sample size. The other important group for piloting the SUSMS will be the re-takers of the course. These participants, could be used to carry out a comparative analysis between the old and new methods.Lastly, we noted no major difference between the scores of the nurses and doctors, which is in contradiction to a previous report [[10]Wiasman Y. Amir L. Mimouni M. Does the pediatric advanced life support course improved knowledge of pediatric resuscitation?.Pediatr Emerg Care. 2002; 18: 168-170Crossref PubMed Scopus (37) Google Scholar]. This further highlights the fact that the knowledge and skills in acute situations and emergencies of nurses should not be underrated and suggest that nurses should be encouraged to become an active member of the paediatric emergency team.In conclusion, the use of the SUSMS format for assessing the performance in the PALS course is feasible and practical and should be evaluated further as a strategy for assessment in future resuscitation courses. Health workers involved in taking care of children preferably should undertake the Paediatric Advanced Life Support (PALS) course. The PALS course consists of lectures, tutorial and skill stations [1Hazinski M.F. Zaritsky A.L. Nadkari V.M. Hickey R.W. Schexnayder S.M. Berg R.A. PALS Provider Manual. American Heart Association, 2002Google Scholar, 2Chameides L. Hazinski M.F. Pediatric Advanced Life Support. American Heart Association, 1997Google Scholar]. It provides an opportunity for hands-on practice to the participants by using simulation techniques on a manikin. Simulated cases are presented during the practice sessions to the participant to enhance and assess their knowledge and approach towards the sick child in different emergency situations. During the evaluation of the candidate different case scenarios are presented to the participant to assess their performance. Based on the approach of the candidate a decision to pass or fail is made. However, the presentation of a number of dissimilar cases to different participants during evaluation station has some disadvantages and may result in subjective variability in the assessment of the candidate [[3]Perkins G.D. Hulme J. Tweed M.J. Variability in the assessment of advanced life support skills.Resuscitation. 2001; 50: 281-286Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. Thus, there is a need to develop a uniform single case scenario assessment format that both serves the purpose of objective assessment and conforms to the objectives of the course. In an attempt to meet these objectives, we devised a Single Uniform Simulated Megacode Scenario (SUSMS) format for PALS evaluation station. To look at the feasibility of SUSMS and the response of the participants to this new intervention, we carried out this study. The study was conducted in the department of Postgraduate Center (PGC) at Royal Hospital, Muscat, Sultanate of Oman. The PALS courses are conducted quarterly in the center by PALS certified instructors [[4]Manzar S. Paediatric advanced life support (PALS) course: the Oman experience.J Bahrain Med Soc. 2000; 12: 95-96Google Scholar]. The course programme of the American Heart Association and American Academy of Paediatrics is used [1Hazinski M.F. Zaritsky A.L. Nadkari V.M. Hickey R.W. Schexnayder S.M. Berg R.A. PALS Provider Manual. American Heart Association, 2002Google Scholar, 2Chameides L. Hazinski M.F. Pediatric Advanced Life Support. American Heart Association, 1997Google Scholar]. During the recent PALS course, we piloted the new SUSMS format (Box 1) while assessing the participants. The modification in the evaluation segment of the course was made in accordance with the suggestions made by Siedel et al. [[5]Siedel J.S. Henderson D.P. Spencer P.E. Education in pediatric basic and advanced life support.Ann Emerg Med. 1993; 22: 489-494Abstract Full Text PDF PubMed Scopus (17) Google Scholar]. A structured performance checklist was included in the scenario to rate the performance objectively. This approach has shown to have an excellent interobserver reliability [[6]Quan L. Shugerman R.P. Kunkel N.C. Brownlee C.J. Evaluation of resuscitation skills in new residents before and after pediatric advanced life support course.Pediatrics. 2001; 108: E110Crossref PubMed Scopus (59) Google Scholar]. Case scenario:An 8-month-old infant with 3-day history of vomiting and diarrhoea comes to the emergency department. On examination the baby looks drowsy. No cyanosis was noted. Chest is clear to auscultation with good bilateral air entry. The respiratory rate is 50/min. Infant is afebrile, the heart rate is 180/min with blood pressure of 70/40 mmHg. Pulses are feeble and capillary refill time is >4 s.Question: What do you do now?Right approach:•Place on oxygen/monitor•Attempt IV access. 90 s… if fails, think of intraosseous line•Give fluids 20 ml/kg Ringer lactate or normal saline, fast over 5–10 min•Reassess ABCDEWrong approach:•Treat heart rate/cardioversion/ask for cardiac rhythm•Perform airway intervention before IV access•Administer hypotonic saline 0.18%, wrong dose (10 ml/kg)•Prolonged IV access attempt, delay of intraosseous approachCase progression:Access to the circulation with a tibial intraosseous needle is obtained, Electrocardiogram (ECG) shows SVTSupra ventricular tachycardia (SVT) is shown on the simulatorAppropriate action: Adverse signs—including hypotension and poor perfusionVagal stimulation by applying ice to the face•Adenosine 0.1–0.2 mg/kg, fast (for stable SVT)•Synchronized cardioversion 0.51 J/kg and then 1–2 J/kg (for unstable SVT)The rhythm is then changed to ventricular tachycardia without a pulseAppropriate action:•Start CPR•Cardioversion (0.5–1 J/kg)•Lidocaine 1 mg/kg IV bolus, then infusion of 20–50 mcg/min.The rhythm is then changed to Ventricular FibrillationAppropriate action:Continue CPR•Shock 2 J/kg…shock 2 J/kg…shock 4 J/kg…adrenaline (epinephrine)…Correct dose & route•Selecting correct voltage & increase it accordinglyThe rhythm is changed to sinus bradycardia—check for adverse signs e.g. poor perfusion.Appropriate action:•Stabilize•Observe•Investigations ABG, full blood count, urea, creatinine and electrolytes•Arrange for transfer to ward/ICU Case scenario: An 8-month-old infant with 3-day history of vomiting and diarrhoea comes to the emergency department. On examination the baby looks drowsy. No cyanosis was noted. Chest is clear to auscultation with good bilateral air entry. The respiratory rate is 50/min. Infant is afebrile, the heart rate is 180/min with blood pressure of 70/40 mmHg. Pulses are feeble and capillary refill time is >4 s. Question: What do you do now? Right approach:•Place on oxygen/monitor•Attempt IV access. 90 s… if fails, think of intraosseous line•Give fluids 20 ml/kg Ringer lactate or normal saline, fast over 5–10 min•Reassess ABCDE Wrong approach:•Treat heart rate/cardioversion/ask for cardiac rhythm•Perform airway intervention before IV access•Administer hypotonic saline 0.18%, wrong dose (10 ml/kg)•Prolonged IV access attempt, delay of intraosseous approach Case progression: Access to the circulation with a tibial intraosseous needle is obtained, Electrocardiogram (ECG) shows SVT Supra ventricular tachycardia (SVT) is shown on the simulator Appropriate action: Adverse signs—including hypotension and poor perfusion Vagal stimulation by applying ice to the face•Adenosine 0.1–0.2 mg/kg, fast (for stable SVT)•Synchronized cardioversion 0.51 J/kg and then 1–2 J/kg (for unstable SVT) The rhythm is then changed to ventricular tachycardia without a pulse Appropriate action:•Start CPR•Cardioversion (0.5–1 J/kg)•Lidocaine 1 mg/kg IV bolus, then infusion of 20–50 mcg/min. The rhythm is then changed to Ventricular Fibrillation Appropriate action: Continue CPR•Shock 2 J/kg…shock 2 J/kg…shock 4 J/kg…adrenaline (epinephrine)…Correct dose & route•Selecting correct voltage & increase it accordingly The rhythm is changed to sinus bradycardia—check for adverse signs e.g. poor perfusion. Appropriate action:•Stabilize•Observe•Investigations ABG, full blood count, urea, creatinine and electrolytes•Arrange for transfer to ward/ICU The checklist was self-explanatory with the correct and incorrect approach followed up by appropriate action. The same observer (SM) evaluated the candidates using the performance checklist to reduce the chance of interobserver variability. A total of 11 candidates, 6 doctors and 5 nurses, registered for the course and all participated in the study. All participants after successful completion of the multiple choice theory test (pass score of 85%), were presented with the SUSMS (Box 1). All candidates successfully passed the practical evaluation station. Their responses were noted down in a separate sheet. Informal feedback was taken from the participants after the assessment. During the feedback, comments were made regarding the fairness of the new system of evaluation. Most participants felt that the new system was very objective and the element of chance and luck was reduced to minimum by the use of a universal scenario. However, as none of the participants had taken the course before, a comparative analysis could not be performed between the old and new method of assessment. Simulation has widely been used as an innovative teaching tool in medical education both in training and assessment with wide range of available technologies [[7]Henderson S.O. Ballesteros D. Evaluation of a hospital-wide resuscitation team: does it increase survival for in-hospital cardiopulmonary arrest?.Resuscitation. 2001; 48: 111-116Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. The SUSMS used during assessment was developed in accordance with the concept of using objective methods for assessment [[8]Manzar S. A journey from subjectivity to objectivity in the assessment of undergraduate medical students.Emirates Med J. 2003; 21: 103-105Google Scholar]. We found SUSMS to be both user and time friendly. Use of 3–4 separate scenarios would have taken 15–20 min compared to only 5 min used for the single SUSMS scenario. The SUSMS was easy to administer and was more in line with a real clinical situation. It is evident from the stage by stage progression of the case in the SUSMS format (Box 1) that nearly all of the important components of the PALS course was covered. A balance was made between too much structure and too little specificity in the case scenario [[9]Schuwirth L.W. vander Vleuten C.P. The use of clinical simulation in assessment.Med Educ. 2003; 37: 65-71Crossref PubMed Scopus (144) Google Scholar]. A clinical case was presented and the candidate was expected to have a general idea of the possible diagnosis and patho-physiological state of the vital functions of the patient, an important component of the PALS course. With the progression of the scenario, the candidate needed to appreciate the urgency of the situation and the need for IV access. Different cardiac rhythm disturbances were introduced to assess interpreting abilities and appropriate actions. Finally the skill of cardio-pulmonary resuscitation (CPR) was evaluated. The use of a single scenario might not provide the candidate with a sufficient range of clinical situations needed for better assessment. The use of multiple simulated scenarios might be more effective and accurate in estimating candidates’ ability. But, we covered all the vital aspects of the PALS course in developing the SUSMS format, so reducing the chance of narrowing the spectrum of clinical situation during assessment. A further limitation of the study was the small sample size. For resuscitation courses, we follow the technique of small group interactive teaching. The use of small groups provides more opportunity for hand-on practice sessions and more interactive discussion to enhance adult learning. With PALS course running every 4 months at our institution we expect to repeat and further assess our findings in future groups of participants by improving the sample size. The other important group for piloting the SUSMS will be the re-takers of the course. These participants, could be used to carry out a comparative analysis between the old and new methods. Lastly, we noted no major difference between the scores of the nurses and doctors, which is in contradiction to a previous report [[10]Wiasman Y. Amir L. Mimouni M. Does the pediatric advanced life support course improved knowledge of pediatric resuscitation?.Pediatr Emerg Care. 2002; 18: 168-170Crossref PubMed Scopus (37) Google Scholar]. This further highlights the fact that the knowledge and skills in acute situations and emergencies of nurses should not be underrated and suggest that nurses should be encouraged to become an active member of the paediatric emergency team. In conclusion, the use of the SUSMS format for assessing the performance in the PALS course is feasible and practical and should be evaluated further as a strategy for assessment in future resuscitation courses. We wish to thank the staff of the Postgraduate Center for their assistance in the programme.