Understanding Facilitators and Barriers to RRT Processes for Boarded Pediatric Patients in the ED

Introduction: The time pediatric patients spend boarding in children’s emergency departments (ED) has increased in recent years. Patients are considered boarding if they are admitted to an inpatient service, but remain housed in the ED. ED boarding contributes to overcrowding, which is associated with increased risk of patient harm. Pediatric rapid response teams (RRT) are designed to assess deteriorating patients throughout the hospital and, in our institution, the ED. Little is known about RRT processes for ED boarded patients. We hypothesize that there are differences in perceived RRT processes across stakeholders given differences in workflow for patients who are boarding in the ED.


Methods: We performed a qualitative study using five different focus groups with representatives from all pediatric RRT stakeholder groups within our institution, including 1) ED nurses, 2) pediatrics residents, 3) pediatric hospital medicine (PHM) fellows and faculty, 4) PICU fellows and nurse practitioners (NPs), and 5) pediatric RRT PICU nurses. Focus groups were transcribed, coded, and analyzed using inductive thematic analysis to identify themes for barriers and facilitators to RRT processes for boarded patients.


Results: Thirty-one individuals participated in our five focus groups, including 7 ED nurses, 7 pediatric residents, 6 PHM fellows/faculty, 5 PICU fellows (2) and NPs (3), and 6 pediatric RRT PICU nurses. Focus groups identified three major themes including: 1) differences in RRT processes due to ED care capabilities (e.g., ED can more quickly mobilize resources such as pharmacy and resuscitative equipment), 2) differences in RRT activations due to perceptions and knowledge of the level of care that can be provided on the floor versus the ED (e.g., monitoring or suctioning capabilities), and 3) challenges with provider communication as a reason for RRT activation.


Conclusions: Focus groups of RRT stakeholders identified differences between RRT activations and processes to evaluate decompensating pediatric patients boarding in the ED. These identified themes will require further exploration via surveys and semi-structured interviews with stakeholders to better understand facilitators and barriers to RRT activation and processes for decompensating patients who are boarding in the ED.