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Pediatric Septic Shock Care Pathways in General Emergency Departments: A Qualitative Study Targeting How to Really
Jennifer K Workman, Heather T Keenan1, Charlene R Weir2
1From the Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine.
Insights
Pediatric septic shock care differs between specialized and general emergency departments. Tailored approaches are needed for implementing standardized care pathways in general emergency departments, focusing on teamwork and continuous learning.
Area of Science:
- Emergency Medicine
- Pediatrics
- Critical Care
Background:
- Pediatric emergency departments (PEDs) have established septic shock care pathways.
- General emergency departments (GEDs) manage most pediatric emergency visits but often lack these pathways.
Purpose of the Study:
- Compare workflow, resources, communication, and decision-making in PEDs versus GEDs for pediatric septic shock.
- Inform the development of standardized care pathways for septic shock in GEDs.
Main Methods:
- Semistructured interviews using the critical incident technique with 24 ED physicians, nurses, and technicians.
- Thematic analysis using the Framework Method with iterative schema refinement to achieve consensus and saturation.
Main Results:
- Six key themes emerged: high performance relies on smooth functioning, predictable care sequences, resilience, accountability, continuous learning, and optimized decision support.
- Differences in participant commentary between GEDs and PEDs highlight specific implementation needs for GEDs.
Conclusions:
- Significant differences exist in pediatric septic shock workflow and decision-making between PEDs and GEDs.
- Standardized care pathway implementation in GEDs requires a tailored strategy.
- Recommendations include enhancing shared awareness, utilizing simulation for training, and fostering a culture of continuous learning.
Objectives:
Many academic pediatric emergency departments (PEDs) have successfully implemented pediatric septic shock care pathways. However, many general emergency departments (GEDs), who see the majority of pediatric ED visits, have not. This study aims to compare the workflow, resources, communication, and decision making across these 2 settings to inform the future implementation of a standardized care pathway for children with septic shock in the GED.
Methods:
We used the critical incident technique to conduct semistructured interviews with 24 ED physicians, nurses, and technicians at one PED and 2 GEDs regarding pediatric septic shock care. We performed a thematic analysis using the Framework Method to develop our coding schema through inductive and deductive analyses. We continued an iterative process of revising the schema until we reached consensus agreement and thematic saturation.
Results:
We identified the following 6 themes: (1) functioning like a "well-oiled machine" may be key to high performance; (2) experiencing the sequence of care for children with sepsis as invariant and predictable may be essential to high-quality performance; (3) resilience and flexibility are characteristic of high levels of performance; (4) believing that "the buck stops here" may contribute to more accountability; (5) continuous system learning is essential; and (6) computerized clinical decision support may not be optimized to drive decision-making at the point of care. Commentary from GED and PED participants differed across the 6 themes, providing insight into the approach for standardized care pathway implementation in GEDs.
Conclusions:
Pediatric septic shock workflow, decision making, and system performance differ between the PED and GEDs. Implementation of a standardized care pathway in GEDs will require a tailored approach. Specific recommendations include (1) improving shared situation awareness; (2) simulation for knowledge, skill, and team-based training; and (3) promoting a culture of continuous learning.
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