OBJECTIVES: Variation exists between the qualities of emergency department (ED) care provided to urban versus rural pediatric patients. We implemented a pediatric simulation program in the Critical Access Hospital (CAH) ED setting and evaluated whether this training would increase provider comfort with seriously ill children. METHODS: Five CAH hospitals conducted 6 scenarios for 12 months. Baseline surveys assessed ED staff exposure to and comfort with children. Surveys were repeated after 6 and 12 months. Respondents' answers were matched longitudinally. Changes in responses over time were analyzed using paired t tests for continuous variables. Changes in frequencies and percentages of categorical variables over time were analyzed using χ test. Scenario participants completed an additional survey at the end of each simulation. RESULTS: The baseline survey was completed by 104 of 150 eligible participants, giving a 71% response rate. Fifty-eight percent completed at least 1 additional survey. On survey 1, mean provider comfort score for procedures was 69 (0-100 point scale). Scores increased 6 points from surveys 1 to 2 and a total of 6.5 points from surveys 1 to 3 (P < 0.05).One hundred fifty postscenario surveys were completed. Of the providers, 83.7% believed that scenario participation increased their comfort with children. One hundred percent of the providers in month 12 felt that they would benefit from additional scenarios. CONCLUSIONS: An in situ pediatric simulation program can be implemented effectively in CAH EDs and results in increased comfort with pediatric patients. Such a program could be used as the core feature of a CAH education program aimed at improving the quality of pediatric emergency services provided at these safety net institutions.