Effects of High-Acuity Cases on Pediatric Emergency Department Flow: A Combined Quantitative and Qualitative Analysis

Introduction The impact of trauma team activations (TTAs) and other high-acuity cases on pediatric emergency department (PED) flow is not well understood. We sought to compare the operational impact of high-acuity cases on PED flow, both from the provider perspective and through analysis of patient visit data. We sought to elucidate the effects of trauma and other high-acuity cases on emergency department flow (and disruption), using a combined quantitative and qualitative approach.  Methods Visit data were analyzed for patient time-to-doctor during TTAs and non-TTA CTAS-1 (Canadian Triage and Acuity Scale) events between 2009 and 2019 at a single tertiary care trauma center. Time-matched control periods were similarly evaluated. A questionnaire was distributed to a multidisciplinary staff group at the same center, including 12 Likert-scale and five optional free-text questions. Quantitative results were compared using chi-square analyses, while grounded theory thematic analysis was applied to analyze free-text responses. Results Of 1305 eligible visits analyzed, TTAs did not significantly increase time-to-doctor. Non-TTA CTAS-1 visits (such as resuscitations due to sepsis) resulted in significantly longer time-to-doctor compared to TTAs and controls (p<0.001). Left without being seen rates were similar across groups. Among 51 respondents, 88% and 90% reported that TTAs and non-TTA CTAS-1 events, respectively, disrupt department flow. Nursing staff were significantly more likely than physicians to perceive a negative impact of non-TTA CTAS-1 cases on patient safety and clinical care (80% vs. 30%, p=0.012). Themes from free-text comments included staff shortages, care disruptions, resource strain, and quality improvement needs. Conclusion Non-trauma resuscitation ED visits may be more disruptive to department flow compared to TTAs. Aligning frontline staff perceptions with objective data will be critical for developing quality improvement strategies to optimize efficiency during high-acuity events.