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.
