Introduction During a public health emergency like the COVID-19 pandemic, emergency department (ED) clinicians may be able to save more lives if they rapidly identify and implement innovations that are safe and effective. However, there is little research examining clinician decision-making around innovation implementation during public health emergencies and when evidence-based information is limited.

Objective The goals of this study were to understand how ED clinicians decided to implement innovations and to describe the facilitators and challenges they faced during implementation.

Methods We conducted 3 pilot interviews and 13 focus group discussions with clinicians from eight hospital-based EDs across the USA. Seventeen physicians, seven advanced practice providers, 18 nurses and seven respiratory therapists participated. We used inductive and deductive techniques to perform content and thematic analysis of focus group transcripts.

Results Participants cited social media, clinician autonomy, limited resources, organisational culture, supportive leadership and outside experiences as facilitators of trying innovations. Challenges in trying new innovations included limited evidence-based information, evolving guidelines, fear, moral distress and clinician pushback. Facilitators of using innovations in practice included leadership advocating for continued use, signs of patient improvement, ease of adoption and adequate resources. Challenges were the lack of familiarity, no established protocol and limited information dissemination about best practices.

Conclusion Our study highlights factors that influenced innovation adoption and implementation in EDs during the COVID-19 pandemic, including how fear and moral distress affected decision-making. Organisations can support the implementation of promising innovations by selecting strong leaders, ensuring clinician psychological safety, providing protocols and resources and highlighting successes.