Implementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital: A Feasibility Study.

OBJECTIVES: Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap. METHODS: A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability. RESULTS: Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort. CONCLUSIONS: It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study.

BACKGROUND: The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics. RESULTS: We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05). CONCLUSIONS: During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

A Prospective Examination of the Interpersonal-Psychological Theory of Suicidal Behavior in Adolescents.

OBJECTIVE: Given the large and complex array of suicide risk factors, theoretical frameworks are critical to furthering our understanding of risk. This study prospectively examined several key constructs of the interpersonal-psychological theory of suicidal behavior (IPTS) in a large, geographically diverse sample of U.S. adolescents. METHOD: Conducted in collaboration with the Pediatric Emergency Care Applied Research Network, adolescents, ages 12 to 17, were recruited from emergency departments. Baseline and 6-month follow-up samples were comprised of 6,448 (59% female sex) and 2,009 (64% female sex) adolescents, with self-identified race/ethnicity as follows (baseline/follow-up): White (52%/54%), Black (22%/23%), Multiracial (6%/6%), American Indian (3%/3%), other/unknown race (15%/14%), and Latinx (25%/23%). Youth and parents completed adolescent suicide risk surveys at baseline and 6-month follow-up (retention, 69%). Latent class analysis was used to identify classes of painful and provocative events (PPE), considered a precursor to acquired capability. RESULTS: In keeping with IPTS tenets, thwarted belongingness (TB), perceived burdensomeness (PB), and the interaction between TB and PB were each significant predictors of suicidal ideation at baseline and follow-up. However, only PB and PPE were significant predictors of cross-sectional suicide attempts and only TB and PPE were significant predictors of prospective suicide attempts in models that adjusted for baseline suicidal ideation. The three-way interaction among PB, TB and PPE was nonsignificant. CONCLUSIONS: Results from this large-scale prospective study suggest the importance of TB, PB, and PPE to our understanding of suicidal thoughts and suicide attempts among adolescents, pointing to promising prevention and intervention targets.

Management of suicidal risk in the emergency department: A clinical pathway using the computerized adaptive screen for suicidal youth.

Objective: Given the critical need for efficient and tailored suicide screening for youth presenting in the emergency department (ED), this study establishes validated screening score thresholds for the Computerized Adaptive Screen for Suicidal Youth (CASSY) and presents an example of a suicide risk classification pathway. Methods: Participants were primarily from the Study One derivation cohort of the Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) enrolled in collaboration with Pediatric Emergency Care Applied Research Networks (PECARN). CASSY scores corresponded to the predicted probabilities of a suicide attempt in the next 3 months and risk thresholds were classified as minimal (<1%), low (1%-5%), moderate (5%-10%), and high (>10%). CASSY scores were compared to risk thresholds derived from clinical consensus and ED complaints and dispositions. CASSY risk thresholds were also examined as predictors of future suicide attempts in the Study Two validation cohort of ED-STARS. Results: A total of 1452 teens were enrolled with a median age of 15.2 years, 59.5% were female, 55.6% were White, 22% were Black, 22.3% were Latinx, and 42.8% received public assistance. The clinical consensus suicide risk groups were strongly associated with the CASSY-predicted risk thresholds. Suicide attempts in the Study Two cohort occurred at a frequency consistent with the CASSY-predicted thresholds. Conclusions: The CASSY can be a valuable tool in providing patient-specific risk probabilities for a suicide attempt at 3 months and tailor the threshold cutoffs based on the availability of local mental health resources. We give an example of a clinical risk pathway, which should include segmentation of the ED population by medical versus psychiatric chief complaint.

24-Hour warning signs for adolescent suicide attempts.

BACKGROUND: Little is known about when youth may be at greatest risk for attempting suicide, which is critically important information for the parents, caregivers, and professionals who care for youth at risk. This study used adolescent and parent reports, and a case-crossover, within-subject design to identify 24-hour warning signs (WS) for suicide attempts. METHODS: Adolescents (N = 1094, ages 13 to 18) with one or more suicide risk factors were enrolled and invited to complete bi-weekly, 8-10 item text message surveys for 18 months. Adolescents who reported a suicide attempt (survey item) were invited to participate in an interview regarding their thoughts, feelings/emotions, and behaviors/events during the 24-hours prior to their attempt (case period) and a prior 24-hour period (control period). Their parents participated in an interview regarding the adolescents' behaviors/events during these same periods. Adolescent or adolescent and parent interviews were completed for 105 adolescents (81.9% female; 66.7% White, 19.0% Black, 14.3% other). RESULTS: Both parent and adolescent reports of suicidal communications and withdrawal from social and other activities differentiated case and control periods. Adolescent reports also identified feelings (self-hate, emotional pain, rush of feelings, lower levels of rage toward others), cognitions (suicidal rumination, perceived burdensomeness, anger/hostility), and serious conflict with parents as WS in multi-variable models. CONCLUSIONS: This study identified 24-hour WS in the domains of cognitions, feelings, and behaviors/events, providing an evidence base for the dissemination of information about signs of proximal risk for adolescent suicide attempts.

Children and Adolescents With Suicidal Ideation and the Emergency Department.

This Viewpoint discusses the need for formal training in suicide prevention for frontline emergency clinicians and staff, including standardized screening practices, assessment and targeted interventions, and increased connection to outpatient mental health services after discharge from the emergency department.

Pediatric Firearm Injury Emergency Department Visits From 2017 to 2022: A Multicenter Study.

BACKGROUND AND OBJECTIVE: Pediatric firearm injuries increased during the coronavirus disease 2019 pandemic, but recent trends in firearm injury emergency department (ED) visits are not well described. We aimed to assess how pediatric firearm injury ED visits during the pandemic differed from expected prepandemic trends. METHODS: We retrospectively studied firearm injury ED visits by children <18 years old at 9 US hospitals participating in the Pediatric Emergency Care Applied Research Network Registry before (January 2017 to February 2020) and during (March 2020 to November 2022) the pandemic. Multivariable Poisson regression models estimated expected visit rates from prepandemic data. We calculated rate ratios (RRs) of observed to expected visits per 30 days, overall, and by sociodemographic characteristics. RESULTS: We identified 1904 firearm injury ED visits (52.3% 15-17 years old, 80.0% male, 63.5% non-Hispanic Black), with 694 prepandemic visits and 1210 visits during the pandemic. Death in the ED/hospital increased from 3.1% prepandemic to 6.1% during the pandemic (P = .007). Firearm injury visits per 30 days increased from 18.0 prepandemic to 36.1 during the pandemic (RR 2.09, 95% CI 1.63-2.91). Increases beyond expected rates were seen for 10- to 14-year-olds (RR 2.61, 95% CI 1.69-5.71), females (RR 2.46, 95% CI 1.55-6.00), males (RR 2.00, 95% CI 1.53-2.86), Hispanic children (RR 2.30, 95% CI 1.30-9.91), and Black non-Hispanic children (RR 1.88, 95% CI 1.34-3.10). CONCLUSIONS: Firearm injury ED visits for children increased beyond expected prepandemic trends, with greater increases among certain population subgroups. These findings may inform firearm injury prevention efforts.

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol.

INTRODUCTION: Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS: Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION: Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

Social connectedness and adolescent suicide risk.

BACKGROUND: Despite evidence of the importance of interpersonal connectedness to our understanding of suicide risk, relatively little research has examined the protective and buffering effects of connectedness among adolescents. The aims of this study were to determine: (a) whether overall connectedness (composite of family, peer, and school) and specific domains of connectedness were related to a lower likelihood of suicide attempts, and (b) whether these factors buffer the prospective risk of suicide attempt for high-risk subgroups (i.e., recent suicidal ideation and/or lifetime history of suicide attempt, peer victimization, or sexual and gender minority status). METHODS: Participants were 2,897 adolescents (64.7% biological female), ages 12 to 17 (M = 14.6, SD = 1.6), recruited in collaboration with the Pediatric Emergency Care Applied Research Network (PECARN) from 14 emergency departments for the Emergency Department Screen for Teens at Risk for Suicide Study (ED-STARS). Suicide risk and protective factors were assessed at baseline; 3- and 6-month follow-ups were completed (79.5% retention). Multivariable logistic regressions were conducted, adjusting for established suicide risk factors. RESULTS: Higher overall connectedness and, specifically, school connectedness were associated with decreased likelihood of a suicide attempt across 6 months. Overall connectedness and connectedness domains did not function as buffers for future suicide attempts among certain high-risk subgroups. The protective effect of overall connectedness was lower for youth with recent suicidal ideation or a suicide attempt history than for those without this history. Similarly, overall connectedness was protective for youth without peer victimization but not those with this history. Regarding specific domains, family connectedness was protective for youth without recent suicidal ideation or a suicide attempt history and peer connectedness was protective for youth without peer victimization but not youth with these histories. CONCLUSIONS: In this large and geographically diverse sample, overall and school connectedness were related prospectively to lower likelihood of suicide attempts, and connectedness was more protective for youth not in certain high-risk subgroups. Results inform preventive efforts aimed at improving youth connectedness and reducing suicide risk.

The Cost of Universal Suicide Risk Screening for Adolescents in Emergency Departments.

Suicide is the second leading cause of death among adolescents. As nearly 20% of adolescents visit emergency departments (EDs) each year, EDs have an opportunity to identify previously unrecognized suicide risk. A novel Computerized Adaptive Screen for Suicidal Youth (CASSY) was shown in a multisite study to be predictive for suicide attempts within 3 months. This study uses site-specific data to estimate the cost of CASSY implementation with adolescents in general EDs. When used universally with all adolescents who are present and able to participate in the screening, the average cost was USD 5.77 per adolescent. For adolescents presenting with non-behavioral complaints, the average cost was USD 2.60 per adolescent. Costs were driven primarily by time and personnel required for the further evaluation of suicide risk for those screening positive. Thus, universal screening using the CASSY, at very low costs relative to the cost of an ED visit, can facilitate services needed for at-risk adolescents.

Physical restraint use in children with mental and behavioral health emergencies in the prehospital setting.

Objective: Emergency medical services (EMS) transport for mental and behavioral health (MBH) emergencies occurs frequently in children, yet little is understood regarding prehospital physical restraint use despite the potential for serious adverse events. We aim to describe restraint use prevalence and primary impressions among children with MBH emergencies. Methods: This is a retrospective cross-sectional study of children with MBH emergencies evaluated by Alameda County (ALCO), California EMS from January 1, 2012 to December 31, 2018. Patient demographics and clinical variables were collected from the EMS records including sex, age at time of encounter, year of encounter, transport destination, medication use, and primary impression(s). The primary outcome was the use of physical restraints. Descriptive statistics were used to characterize the primary outcome and associated demographic and diagnostic features, as well as temporal use patterns. Sex and age were compared between restrained and non-restrained youth using chi-square analysis. Results: Over the 7-year study period, ALCO EMS transported 9775 children with MBH emergencies. Of these transports, 1205 (12.3%) were physically restrained. Most children restrained had the primary impression of "behavioral/psychiatric crisis" (51.1%), "psychiatric crisis" (27.4%), and "behavioral-other" (12.4%) and the remaining children (9.1%) had a non-psychiatric/behavioral health primary impression. Over time, there was no statistically significant change in either number of children with MBH emergencies transported or physical restraint rate. Conclusions: More than 1 in 8 children with MBH emergencies are being physically restrained during EMS transport. Restraint rate did not substantially change over time. Further studies to understand existing restraint rates and EMS resources available to address acute agitation in children are needed to inform quality and care enhancing initiatives.

Variability in firearm injury among major pediatric trauma centers across the USA.

Objectives: In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA. Methods: We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ2 test or Fisher's exact test was conducted for categorical comparisons. Results: Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (ß=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (ß=-0.15 (SE 0.04), p=0.002; ß=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site. Conclusion: The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study.

Safety of a prehospital emergency medical services protocol for an alternative destination for pediatric behavioral emergencies in Alameda County.

Background: Pediatric patients with behavioral health emergencies (BHEs) are often transported to an emergency department (ED) by emergency medical services (EMS), despite having no physical medical complaints, to await psychiatric evaluation and treatment. This process leads to significant delays in their care. We examined the safety of directly transporting pediatric patients with BHEs from the field to an alternative destination of a psychiatric emergency service (PES) facility using an EMS protocol. Methods: A retrospective review from November 1, 2011, to November 1, 2016, was conducted for pediatric EMS encounters using EMS data from Alameda County, California. Our primary outcome was the safety of a prehospital alternative destination protocol. We identified the proportion of patients who required retransport to an ED within 24 h after arriving at PES (defined as a failed diversion). We also describe the mortality of all patients being transported for a BHE. Results: There were 38,241 total pediatric encounters, with 20.1% for BHEs. A total of 3122 (41%) BHE encounters met protocol criteria and were transported directly to the PES. Only 16 (0.5%) patients had a secondary transport (failed diversion) to an ED within 24 h of arrival. No patients with a BHE transported to the PES died within 30 days of the EMS encounter. Conclusion: Death and adverse clinical outcomes are extremely rare in pediatric patients using a prehospital alternative destination protocol. This information could significantly improve the care of children with BHEs.

Toxic Exposures Among Young Children One Year into the COVID-19 Pandemic: A Retrospective Review of Three San Francisco Bay Area Emergency Departments.

BACKGROUND: Daycare and school closures prompted by shelter-in-place orders may have increased opportunities for unintentional ingestions among young children. OBJECTIVES: We examined emergency department (ED) presentations for toxic exposures among young children during the COVID-19 pandemic in the San Francisco Bay Area, which had some of the strictest and most prolonged shelter-in-place policies in the United States. METHODS: We performed a retrospective cross-sectional study of children 0 to 5 years of age who presented with an ED International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of toxic exposure within a tertiary care hospital system between March 16, 2016 and March 15, 2021. We considered the period after March 16, 2020 to represent the pandemic. RESULTS: During the pandemic, the absolute number of poisonings among young children remained stable. Overall, ED encounters within this cohort decreased by 55%, which doubled the relative toxic exposure rate per 1000 ED encounters from 4.99 (95% confidence interval [CI] 3.19-5.90) to 9.79 (95% CI 8.09-11.49). Rates of admission, severe medical complications, operating room case requests, and length of stay were not significantly different. Shelter-in-place was associated with significantly higher odds of cannabis ingestion (odds ratio = 2.70, 95% CI 1.60-4.49). CONCLUSION: Despite dramatic decreases in overall ED patient volumes, the absolute number and severity of toxic exposures were similar during the pandemic compared with previous years. © 2022 Elsevier Inc.

Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments.

Importance: Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool. Objective: To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata. Design, Setting, and Participants: The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023. Main Outcomes and Measures: This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA. Results: Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively). Conclusions and Relevance: This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.

Predictability and stability testing to assess clinical decision instrument performance for children after blunt torso trauma.

OBJECTIVE: The Pediatric Emergency Care Applied Research Network (PECARN) has developed a clinical-decision instrument (CDI) to identify children at very low risk of intra-abdominal injury. However, the CDI has not been externally validated. We sought to vet the PECARN CDI with the Predictability Computability Stability (PCS) data science framework, potentially increasing its chance of a successful external validation. MATERIALS & METHODS: We performed a secondary analysis of two prospectively collected datasets: PECARN (12,044 children from 20 emergency departments) and an independent external validation dataset from the Pediatric Surgical Research Collaborative (PedSRC; 2,188 children from 14 emergency departments). We used PCS to reanalyze the original PECARN CDI along with new interpretable PCS CDIs developed using the PECARN dataset. External validation was then measured on the PedSRC dataset. RESULTS: Three predictor variables (abdominal wall trauma, Glasgow Coma Scale Score <14, and abdominal tenderness) were found to be stable. A CDI using only these three variables would achieve lower sensitivity than the original PECARN CDI with seven variables on internal PECARN validation but achieve the same performance on external PedSRC validation (sensitivity 96.8% and specificity 44%). Using only these variables, we developed a PCS CDI which had a lower sensitivity than the original PECARN CDI on internal PECARN validation but performed the same on external PedSRC validation (sensitivity 96.8% and specificity 44%). CONCLUSION: The PCS data science framework vetted the PECARN CDI and its constituent predictor variables prior to external validation. We found that the 3 stable predictor variables represented all of the PECARN CDI's predictive performance on independent external validation. The PCS framework offers a less resource-intensive method than prospective validation to vet CDIs before external validation. We also found that the PECARN CDI will generalize well to new populations and should be prospectively externally validated. The PCS framework offers a potential strategy to increase the chance of a successful (costly) prospective validation.

Understanding adolescent responses to differently worded suicide attempt questions: results from a large US pediatric sample.

BACKGROUND: Clinical assessments are a primary method for ascertaining suicide risk, yet the language used across measures is inconsistent. The implications of these discrepancies for adolescent responding are unknown, which is troubling as multiple research areas (i.e. on culture, mental health language, and suicide communication) indicate individuals from varying sociodemographic backgrounds may communicate differently regarding mental health concerns. The aims of the current study are to investigate whether a geographically diverse sample of adolescents respond differently to directly and indirectly phrased suicide attempt questions (i.e. directly phrased includes the term 'suicide' and indirectly asks about suicidal behavior without using 'suicide'), and to examine whether sociodemographic factors and history of mental health service usage relate to endorsement differences. METHODS: Participants were N = 5909 adolescents drawn from the Emergency Department Screening for Teens at Risk for Suicide multi-site study. The lifetime suicide attempt was assessed with two items from an adapted version of the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008): (1) a directly phrased question asking about 'suicide attempts' and (2) an indirectly phrased question providing the definition of an attempt. RESULTS: An adolescent majority (83.7%) consistently reported no lifetime suicide attempt across items, 10.1% consistently reported one or more lifetime attempts across items, and 6.2% of adolescents responded discordantly to the items. CONCLUSIONS: Multivariable models indicated multiple demographic and mental health service variables significantly predicted discordant responding, with a notable finding being that father/stepfather education level at or below high school education predicted endorsing only the direct question.

Development and Validation of a Deep Learning Strategy for Automated View Classification of Pediatric Focused Assessment With Sonography for Trauma.

OBJECTIVE: Pediatric focused assessment with sonography for trauma (FAST) is a sequence of ultrasound views rapidly performed by clinicians to diagnose hemorrhage. A technical limitation of FAST is the lack of expertise to consistently acquire all required views. We sought to develop an accurate deep learning view classifier using a large heterogeneous dataset of clinician-performed pediatric FAST. METHODS: We developed and conducted a retrospective cohort analysis of a deep learning view classifier on real-world FAST studies performed on injured children less than 18 years old in two pediatric emergency departments by 30 different clinicians. FAST was randomly distributed to training, validation, and test datasets, 70:20:10; each child was represented in only one dataset. The primary outcome was view classifier accuracy for video clips and still frames. RESULTS: There were 699 FAST studies, representing 4925 video clips and 1,062,612 still frames, performed by 30 different clinicians. The overall classification accuracy was 97.8% (95% confidence interval [CI]: 96.0-99.0) for video clips and 93.4% (95% CI: 93.3-93.6) for still frames. Per view still frames were classified with an accuracy: 96.0% (95% CI: 95.9-96.1) cardiac, 99.8% (95% CI: 99.8-99.8) pleural, 95.2% (95% CI: 95.0-95.3) abdominal upper quadrants, and 95.9% (95% CI: 95.8-96.0) suprapubic. CONCLUSION: A deep learning classifier can accurately predict pediatric FAST views. Accurate view classification is important for quality assurance and feasibility of a multi-stage deep learning FAST model to enhance the evaluation of injured children.

Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth.

Importance: The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services. Objective: To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs). Design, Setting, and Participants: Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts. Exposures: Presentation at an ED. Main Outcome and Measure: A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report. Results: The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1. Conclusions and Relevance: In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.

A Pilot Study of a Measure of Parental Trust in Pediatric Emergency Department Care Teams.

OBJECTIVE: To modify and test an existing measure of trust validated in a primary care setting for use in a pediatric emergency department (PED). METHODS: The study population was parents/guardians who brought their child to an urban PED with a chief complaint of abdominal pain or head injury. We used a 2-phase design with modifications resulting from cognitive interviews with 15 participants followed by a field test with 150 participants. We measured usefulness by percent missing responses and ceiling effects. Cronbach's alpha and greatest lower bound measured reliability. As evidence of validity, we calculated a total trust score by summing the item scale values and correlating the score with measures of constructs shown to be positively associated with trust in other settings. We conducted a similar analysis to test a published shortened version of the same scale. RESULTS: Four items were modified prior to field testing. Ceiling effects for each item ranged from 53% to 67%. Missing data were minimal affecting only 2 items. The modified measure exhibited high reliability (Cronbach's alpha = .88, greatest lower bound = 0.93). Total trust scores ranged from 27 to 50 with mean (standard deviation) = 45.1 (4.9). The trust score exhibited a high positive correlation with communication and overall satisfaction, and moderate correlation with intent to adhere to physician recommendations. The short version of the scale performed similarly. CONCLUSIONS: This study provides evidence that the modified Wake Forest measure of trust is applicable and useful in the PED setting for this patient population.