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Abstract

Background and objectives: Crowding in the pediatric emergency department (ED) is associated with decreased satisfaction and poorer patient outcomes. A high volume of non-urgent visits to the pediatric ED contributes to crowding. Redirection, which routes appropriate patients to community care, reduces the volume of patients managed in the pediatric ED and may improve flow. Since little is known about the acceptability, eligibility criteria, and impact of redirection programs, I examined these gaps. Methods: I completed a matched cross-sectional evaluation of a previous redirection program at Montreal Children’s Hospital, a tertiary Canadian pediatric ED. I described the eligible and redirected populations and evaluated program impact on ED flow. Next, I conducted semi-structured interviews with healthcare professionals in British Columbia to assess attitudes, perceptions, and eligibility considerations for pediatric ED redirection. I then completed an administrative records review to estimate and describe potentially eligible visits and used Monte Carlo simulations to forecast redirection effects on pediatric ED flow. Results and interpretation: The Montreal program redirected 14.6% of eligible patients (6.6% of total ED volume). This program was not associated with changes in measures of departmental flow. From my interviews, I created a visual model to depict attitudes and perceptions of pediatric ED redirection. Participants generally supported redirection, believing that with appropriate resources, operational guidance, and coordination, it could improve patient experience and flow. Three guiding principles were developed to support eligibility decisions. These align with previous work that focused on patient characteristics and medical complexity, and emphasizes the importance of family capacity, patient history, and shared decision making. Using these principles, eligibility criteria were tailored to BC Children’s Hospital. Among 2024 ED visits, 32% were eligible. Simulation models predicted, with 97.5% confidence, reductions of at least 35-minutes in median wait time and 29-minutes in median length of stay, with greater improvements as redirection increased. Through this work, I provide evidence that, with appropriate implementation, redirection programs may be an acceptable strategy to improve patient experience and improve flow in the pediatric ED.