The Pediatric Emergency Care Applied Research Network and Knowledge Translation

After 17 years, the Pediatric Emergency Care Applied Research Network has demonstrated its significant contribution to the care of acutely ill and injured children through the successful completion of more than 35 research studies. Despite the importance of research findings and the numerous publications in medical journals, the information is not easily accessible by parents, families, or nonresearch medical providers. Another group of investigators has developed knowledge translation and dissemination using social media through the Translating Emergency Knowledge for Kids knowledge mobilization network. This model is an example for other networks and outlines the challenges of dissemination of findings. The network’s research is widely published and has been incorporated into national guidelines, but the Pediatric Emergency Care Applied Research Network’s next challenge is translation of network findings into practice so every child who seeks emergency care in the United States in large or small emergency departments can be treated with evidence-based medicine.     

The Current State of the Pediatric Emergency Medicine Workforce and Innovations to Improve Pediatric Care

Many hospitals and emergency departments lack resources to optimally care for ill and injured children, perpetuating risks of receiving fragmented and “uneven” care. In this article, we describe the present state of our pediatric emergency medicine workforce as well as the impact that different innovations could have on the future of pediatric emergency care. Many innovative initiatives, including physician and advanced practice provider education and training, pediatric readiness recognition programs, telemedicine and in-situ simulation outreach, and community paramedicine are being utilized to help bridge access gaps and augment the reach of the pediatric emergency medicine workforce. Advocacy for reimbursement for novel care delivery models, such as community paramedicine and telemedicine, and funding for outreach education is essential. Also, better understanding of our current training models for and utilization of advanced practice practitioners in pediatric emergency medicine is crucial to understanding the diversity of workforce growth and opportunity.     

The Future(s) of Pediatric Primary Care

Pediatric primary care (PPC) arose in the early 20th century as the fusion of acute and chronic pediatric illness care with preventive elements borrowed from public and maternal and child health. Well-established and thriving by the 1930s, PPC saw major changes in childhood morbidity and mortality in the latter half of the 20th century with the recognition of the “new morbidity” of school, behavior, and social problems. At the same time, PPC experienced changes in its workforce, which became increasingly female and added nurse practitioners and physician assistants as practitioners. Independent practice, previously the dominant business model, decreased in prominence at the end of the 20th century as health systems bought practices and other sites morphed into federally qualified health centers. In the present century, electronic health records (EHRs) have brought profound changes in PPC workflows and practitioner experience. In addition, disruptive market competition such as retail clinics and corporate telemedicine providers coupled with changes in health insurance from fee-for-service to value-based payment further challenge the care model and economics of PPC. Finally, recognition of family social circumstances as major determinants of children's health presents another challenge to the status quo. As such, although one PPC future may resemble its present state, a more innovative future is likely to include clinics and practices more oriented toward and linked to communities and directed at the social determinants of health. In addition, the rise in physical, behavioral, and social problems in practice call for a growing focus on wellness, including sleep, nutrition, and activity, that promises to reorient the PPC future in productive new directions. The half-way technology of current EHR systems will ideally be spun into electronic hubs that facilitate teamwork between PPC, specialists, and community groups. Research and practice improvement strategies including involvement in “learning health systems” will be critical to making PPC effective in an evolving society. Although threatened by 21st century forces and hard-to-anticipate change, PPC is ideally positioned to build upon its core functions to create multidisciplinary teams that reach into the community, promoting a holistic wellness for children consistent with the broadest definition of health.     

National Pediatric Readiness Project: Making a Difference Through Collaboration,Simulation, and Measurement of the Quality of Pediatric Emergency Care

The National Pediatric Readiness Project is a national quality initiative sponsored by the American College of Emergency Physicians, the American Academy of Pediatrics, and the Emergency Nurses Association. Multiple efforts across numerous states are in process to optimize pediatric readiness of emergency departments. This article describes past, current, and future efforts to ensure pediatric readiness of our nations' emergency departments and to understand the relationship between pediatric readiness and quality of pediatric emergency care.     

Pediatric Functional Constipation Questionnaire-Parent Report (PedFCQuest-PR): development and validation

ObjectiveDeveloping and validating a disease-specific instrument in the Brazilian Portuguese language to assess the Health-Related Quality of Life of children with functional constipation, applied to parents/caregivers.MethodsThe process of developing the questionnaire was carried out in the following steps: items generation concerning functional constipation; elaboration of the preliminary questionnaire; assessment by health professionals; identifying problems or inconsistencies by the researchers; improvement of the questions; obtaining a final questionnaire named Pediatric Functional Constipation Questionnaire-Parent Form (PedFCQuest-PR) with 26 questions divided into four domains. Responses options use a Likert scale based on the events of the last four weeks. The process of validation was an observational, cross-sectional study in a sample of 87 parents/caregivers of children from 5 to 15 years of age diagnosed with Functional constipation according to the Rome IV Criteria. The questionnaire was applied simultaneously to the Pediatric Quality of Life Inventory 4.0 (PedsQL TM 4.0) as a control.ResultsThe questionnaire validation included 87 parents/caregivers. The children's median age was 8.2 years, with a long time of constipation symptoms associated with fecal incontinence in approximately two-thirds. Internal consistency reliability for the Total Scale Score of PedFCQuest-PR by Coefficient Alpha of Cronbach score was 0.86. Convergent and divergent validity of PedFCQuest-PR was demonstrated by correlating the domains of both questionnaires.ConclusionThis study provides evidence that PedFCQuest-PR is a reliable instrument. The results showed a high degree of internal consistency and validity of the instrument for future applications.     

Pediatric Research and Health Care for Transgender and Gender Diverse Adolescents and Young Adults: Improving (Biopsychosocial) Health Outcomes

Adolescent and young adult (AYA) transgender health care and research have expanded rapidly in the United States and abroad, but the effects of gender-affirming social, hormonal, or surgical care on overall health remain unclear. Gender diverse identities, also termed nonbinary, have often been neglected in favor of (male/female) binary identities, even in the context of transgender health care and research. No high quality studies have assessed how gender-affirming medical care impact health inequities in transgender and gender diverse (TG/GD) adults, much less in AYAs, despite the fact that that TG/GD adults have higher than average morbidity and mortality across a host of health concerns, from human immunodeficiency virus infection to thromboembolism, and that reported depression with suicidal ideation is >10 times higher in TG/GD adults than in the general population.TG/GD youth have related but different needs from TG/GD adults. TG/GD AYA are embedded in family and schools, where stigma may be difficult to escape; mental health during adolescence has areas of increased risk as well as resilience; and the effects of early hormonal and surgical interventions on long-term health are insufficiently studied. Because of this, an inclusive and proactive approach to addressing the needs of TG/GD AYA by pediatric clinicians, researchers, and educators is particularly crucial.This article focuses on what is known and unknown about clinical practice, research, and education related to TG/GD health. We highlight the role of gender affirmation by clinicians as they care and advocate for TG/GD AYAs; the potential challenges of hormonal treatment for peripubertal youth; and short- and long-term effects on physical and reproductive health of medical or surgical interventions. We also discuss how social context influences knowledge gaps and the health-relevant risks faced by TG/GD AYA. The challenges are formidable, but opportunities await: high priority research questions to explore, educational gaps to be filled, and advocacy that needs the voices of pediatricians to promote policies to facilitate positive health outcomes for TG/GD AYA.