I-CARE: The Effectiveness of a Modular Digital Intervention to Reduce Suicidal Ideation and Emotional Distress during Pediatric Psychiatric Boarding

项目摘要 2019冠状病毒病大流行导致自杀意念、自杀企图和 美国青少年自杀死亡人数急诊科（ED）在急性护理医院越来越多 作为照顾有自杀倾向的青少年的门户;这一趋势在COVID-19期间进一步加剧。 当有自杀意念或企图的青少年被视为需要住院精神科护理时， 床位往往供过于求，导致精神病患者寄宿。在这段时间里，年轻人可能会等待几天到几个星期， 艾德或住院医疗单位，直到精神病入院;寄宿频率和持续时间 在COVID-19期间增加。经历寄宿的青年很少接受循证心理治疗 鉴于全国精神卫生专业人员短缺和分布不均，为了弥补这一差距， 由儿科医生、心理学家、临床社会工作者和患者合作伙伴组成的多学科团队制定了一项 模块化数字干预，为有自杀倾向的青年提供基于证据的心理社会技能 登机该计划被称为I-CARE（改善护理，加速康复和教育），包括一个 一系列基于网络的动画视频和活动，以认知行为疗法为基础，优先考虑 通过严格的德尔菲程序。I-CARE旨在由安全服务员提供便利， 为青少年寄宿期间提供1对1安全监管。因此，I-CARE需要最少的额外费用， 资源超出了急症护理医院现有的资源。在试点项目评估中，I-CARE 已被证明是可行的实施和接受的青年，临床医生，和他们的照顾者， 参与后情绪困扰显著减少。基于这些初步数据，这款混合动力车 1型有效性试验将在6家医院（960名12-17岁的青少年）采用随机分组的阶梯楔形设计 （1）应用动态适应过程优化I-CARE 培训和实施，同时保持干预保真度，并考虑到COVID-19， 不同医院之间的差异;（ii）确定I-CARE的有效性，以减少情绪困扰，自杀 与常规护理相比，使用经验证的测量方法评估I-CARE的效果 改变的动机（目标机制），并确定是否更大的改变动机介导 I-CARE对情绪困扰、自杀意念和企图的影响，以及（iii）将RE-AIM框架应用于 确定I-CARE覆盖面、有效性、采用、实施和维护的障碍和促进因素 从年轻人、护理人员和临床医生的角度来看。这项研究的结果有可能 为目前卫生系统服务不足的人口提供医疗保健服务， 在应用新型数字干预的同时， 具有很大的可扩展性潜力。

PROJECT SUMMARY The COVID-19 pandemic has contributed to a substantial increase in suicidal ideation, suicide attempts, and suicide deaths among US adolescents. Emergency departments (EDs) at acute care hospitals increasingly serve as gateways to care for youth with suicidality; this trend has been further exacerbated during COVID-19. When youth with suicidal ideation or attempt are deemed to require inpatient psychiatric care, the demand for beds often exceeds supply, leading to psychiatric boarding. During this time, youth may wait days to weeks in an ED or inpatient medical unit until psychiatric admission; boarding frequencies and durations have both increased during COVID-19. Youth experiencing boarding rarely receive evidence-based psychotherapies given a national shortage and uneven distribution of mental health professionals. To address this gap, a multidisciplinary team of pediatricians, psychologists, clinical social workers and patient partners developed a modular digital intervention to deliver evidence-based psychosocial skills to youth with suicidality during boarding. This program, called I-CARE (Improving Care, Accelerating Recovery & Education), consists of a series of web-based animated videos and activities grounded in cognitive behavioral therapy, prioritized through a rigorous Delphi process. I-CARE is designed to be facilitated by safety attendants who currently provide 1-on-1 safety supervision for youth during boarding. Accordingly, I-CARE requires minimal additional resources beyond those already available at acute care hospitals. In a pilot program evaluation, I-CARE has been shown to be feasible to implement and acceptable to youth, clinicians, and their caregivers, with levels of emotional distress significantly decreased following participation. Building on this preliminary data, this Hybrid Type 1 effectiveness trial will use a cluster randomized stepped wedge design at 6 hospitals (960 youth 12-17 years with suicidal ideation or attempt) to: (i) apply the Dynamic Adaptation Process to optimize I-CARE training and implementation while maintaining intervention fidelity and taking into account COVID-19 and variation across hospitals; (ii) determine the effectiveness of I-CARE to reduce emotional distress, suicidal ideation and suicide attempts using validated measures compared to usual care, assess the effects of I-CARE on motivation for change (target mechanism), and determine whether greater motivation for change mediates I-CARE effects on emotional distress, suicidal ideation and attempts, and (iii) apply the RE-AIM framework to identify barriers to and facilitators of I-CARE reach, effectiveness, adoption, implementation and maintenance from the perspectives of youth, caregivers, and clinicians. The results of this study have the potential to transform healthcare delivery for a population currently underserved by the health system, increasing access to mental health services during a period of tremendous vulnerability while applying a novel digital intervention with substantial potential for scalability.