The Pediatric Emergency Department at the Johns Hopkins Children’s Center is the level 1 trauma center for the state of Maryland and draws patients from the mid-Atlantic region. The division of Pediatric Emergency Medicine works intensively with four community hospitals at a time. We provide quarterly simulation sessions with both real time and written feedback, including recommendations for areas on which to focus quality improvement initiatives. Ongoing support is provided during those projects. To date we have seen positive changes in staff comfort with seriously ill and injured pediatric patients. Multiple QI initiatives have been completed resulting in the adoption of new procedures and protocols (or revisions to previously existing ones), acquisition of new equipment and intensive training on pediatric procedures. We are also working on a separate project looking at the impact of simulation on pediatric patient care in rural community hospitals.