From the Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine.
Department of Biomedical Informatics, University of Utah, Salt Lake City, UT.
Pediatr Emerg Care. 2023 Aug 1;39(8):562-568. doi: 10.1097/PEC.0000000000002910. Epub 2023 Jan 22.
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.
许多学术性儿科急诊部门（PED）已经成功实施了小儿脓毒性休克护理路径。然而，大多数儿科急诊就诊的综合急诊部门（GED）并未实施。本研究旨在比较这两种环境下的工作流程、资源、沟通和决策，为在 GED 中为脓毒性休克患儿实施标准化护理路径提供信息。
我们使用关键事件技术，对一家 PED 和两家 GED 的 24 名急诊医生、护士和技师进行了小儿脓毒性休克护理的半结构化访谈。我们使用框架方法进行主题分析，通过归纳和演绎分析开发我们的编码方案。我们继续进行方案修订的迭代过程，直到达成共识和主题饱和。
我们确定了以下 6 个主题：（1）高效运作可能是高性能的关键；（2）对脓毒症患儿护理过程的序列具有不变性和可预测性可能是高质量表现的关键；（3）弹性和灵活性是高绩效的特征；（4）相信“责任止于此处”可能有助于提高问责制；（5）持续的系统学习至关重要；（6）计算机化的临床决策支持可能无法优化以在护理点驱动决策。来自 GED 和 PED 参与者的意见在 6 个主题上存在差异，为在 GED 中实施标准化护理路径提供了思路。
小儿脓毒性休克的工作流程、决策和系统性能在 PED 和 GED 之间存在差异。在 GED 中实施标准化护理路径需要采取有针对性的方法。具体建议包括（1）改善共享态势感知；（2）用于知识、技能和团队培训的模拟；（3）促进持续学习的文化。
