Pediatric Septic Shock Care Pathways in General Emergency Departments: A Qualitative Study Targeting How to Really Make it Work.

Abstract

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. 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. 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. 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.