Pediatric Sepsis Care Processes and Needs in General Emergency Departments: A Qualitative Study

Background: While pediatric emergency care coalitions have launched substantial initiatives to improve pediatric readiness in general Emergency Departments (EDs), where most US children receive care, pediatric sepsis quality improvement and research has largely focused on children’s hospitals. Existing research has found that general EDs have overall lower rates of guideline-concordant care in children with sepsis. However, the pediatric sepsis priorities and needs of clinical leaders in general EDs have not been described. This study aimed to describe pediatric sepsis processes, strengths, and resources needed in general ED settings.

Methods: We conducted and analyzed semi-structured qualitative interviews with key informants in pediatric sepsis care from general EDs in our multi-state referral region. Key informants were physicians and nurses with leadership roles encompassing pediatric sepsis, including medical directors, nurse managers, quality improvement and education coordinators. Recruitment used solicitation via email and snowball sampling. Interviews were conducted until thematic saturation was reached.

Key informants were asked to describe current practices and needs in pediatric sepsis care, considering the initial steps of pediatric sepsis recognition and resuscitation: diagnosis, IV access, timely antibiotic administration, fluid resuscitation, and vasopressor administration. Interviews were conducted via Zoom by a physician trained in qualitative methods, using an iterative respondent debriefing process. Interviews were recorded, transcribed verbatim, and spot-checked. Transcripts were coded in Atlas.ti using deductive domains to capture key steps in pediatric sepsis care. Matrix analysis was used to summarize informant responses and analyze across interviews by domain. Duplicate analysis by independent reviewers was used; discrepancies were resolved through consensus.

Results: We conducted 19 hour-long interviews with 21 key informants (2 dyad interviews). Participants included 12 nurses and 9 physicians, representing 28 different EDs (physicians worked at multiple EDs). Sites included 5 rural hospitals, 6 free-standing EDs, and Trauma Levels 1-4. Major themes around pediatric sepsis care quality were variability in processes and personnel, diagnostic uncertainty in pediatric sepsis, and ‘sick kids make people nervous’ (Table 1).

Strengths, challenges and needs in each process domain are summarized in Table 2. High-priority processes with the most challenges were diagnosis and timely antibiotic administration. Preparedness to obtain pediatric IV access varied. Fluid resuscitation and vasopressor use were areas where interviewees expressed comfort with the quality of care and resources at their hospital.

Conclusion: Variability, diagnostic uncertainty, and the emotional response to a sick child were themes in pediatric sepsis care quality in general EDs. Processes that were most challenging were sepsis diagnosis and antibiotic administration. These processes are emphasized in pediatric sepsis guidelines, and are priorities of clinical leaders in general EDs, making them important targets for pediatric sepsis quality improvement and research in general EDs, where most children first receive emergency care.