Minding the Gap: A Qualitative Study of Provider Experience to Optimize Care for Critically Ill Children in General Emergency Departments

Abstract

Background: Pediatric emergency care provision in the United States is uneven. Institutional barriers to readiness in the general emergency department (GED) are known, but little is understood about the frontline providers. Our objective was to explore the lived experiences of emergency medicine (EM) providers caring for acutely ill children in the GED and identify opportunities to optimize their pediatric practice.Methods: This grounded theory study used theoretical sampling with snowball recruitment to enroll EM physicians and advanced practice providers from 25 Wisconsin GEDs. Participants completed one-on-one, semistructured interviews. Audio recordings were transcribed and coded by a multi-investigator team drawing on theory produced from comparative analysis. Results:We reached theoretical saturation with 18 participants. The data suggested that providers felt competent managing routine pediatric care, but critically ill children outstripped their resources and expertise. They recognized environmental constraints on the care they could safely provide, which were intensified by unanticipated knowledge gaps and lack of awareness regarding pediatric practice guidelines. A fragmented medical network to support their pediatric practice was identified as a challenge to their care provision at critical junctures. Due to lack of guidance and feedback, providers internalized their experience with critically ill children with uncertainty, which limited learning and practice change. They benefited from meaningful relationships with pediatricians and pediatric subspecialists, targeted education, timely consults, and looped feedback about care provided and patient outcomes.Conclusions: General ED providers struggled with critically ill children because they could not anticipate their pediatric-specific knowledge gaps and only realized them at critical junctures. EM providers were isolated and frustrated when seeking help; without guidance and feedback they internalized their experience with uncertainty and were left underprepared for subsequent encounters. The data suggested the need for provider-focused interventions to address gaps in pediatric-specific continuing medical education, just-in-time assistance, and knowledge transfer.E ach year in the United States, approximately 35 million children are evaluated in an emergency department (ED). Secondary to hospital distribution and geographic limitations, 1 the large majority (95%) of these children are seen in a general emergency department (GED), 2 as opposed to a dedicated

Providers' Perceptions of Caring for Pediatric Patients in Community Hospital Emergency Departments: A Mixed‐methods Analysis

“…CED providers were astute to this issue and called on technologies like telemedicine to address this barrier. Further, we were encouraged to recently learn of similar themes generated in the state of Wisconsin, supporting our work's generalizability . Second, as is a standard limitation of qualitative work, our results and messages reflect the opinions of our protocol's participants.…”

Advanced Pediatric Emergency Airway Management: A Multimodality Curriculum Addressing a Rare but Critical Procedure

“…[1][2][3] Contributing to this challenge are the facts that actual pediatric critical care is uncommon (when compared to the adult population), the distribution of where children seek emergency medical care and who is there to care for them varies, and there are many competing demands on a health care providers' initial and continuing medical education. [4][5][6][7][8][9][10][11] Further compounding these facts is the variation in the rate and quality of procedural skill acquisition amongst each individual learner. This supports the need to utilize varied educational modalities and providing customizable frequencies of practice to meets all learners' needs.…”

“…26,27 We highlighted the latter groups of community hospital-based learners based on epidemiologic trends of where pediatric critical illness is often initially managed, and based on our author group's and others' prior experiences using insitu simulation as a tool to gain a deeper understanding of the challenges providers face with respect to their pediatric critical care skills. [4][5][6][7][8]11,25,[28][29][30] Our goal in sharing this curriculum was for future facilitators and their learners to appreciate how the use of multiple learning modalities helps reach a wide array of learners and can fill a training gap relevant to the care of acutely ill and injured children.…”

“… 26 , 27 We highlighted the latter groups of community hospital-based learners based on epidemiologic trends of where pediatric critical illness is often initially managed, and based on our author group's and others' prior experiences using in-situ simulation as a tool to gain a deeper understanding of the challenges providers face with respect to their pediatric critical care skills. 4 – 8 , 11 , 25 , 28 – 30 …”

‘Surviving to Thriving’: A Meta-Ethnography of the Experiences of Healthcare Staff Caring for Persons With COVID-19

“…Caring for critically ill persons is often associated with emotional and physical exhaustion (10)(11)(12)(13). The sudden occurrence of the COVID-19 pandemic, which healthcare systems were seemingly unprepared for alongside increasing mortality rates in some areas have contributed to the development of fear, worry and uncertainty (14).…”