Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach.

BACKGROUND: Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide. PURPOSE: The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide. HIGHLIGHTS: Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors. OUTCOMES: The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised. PRACTICAL APPLICATIONS: Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

The Need for Improved Collaboration between Schools and Child Death Review Teams.

BACKGROUND: Schools are essential public health partners for safeguarding students' health. Child Death Review (CDR) is one public health activity where collaboration with schools is integral for developing strategies to prevent child death but the degree of collaboration is unknown. This study assessed school participation in CDR and the prevalence of school problems in reviewed child death cases, comparing non-suicide and suicide-related deaths. METHODS: Using the National Fatality Review-Case Reporting System, we created a dataset of school-aged children (5 to 20 years) whose death was reviewed from 2005 to 2017 and used frequencies, proportions, and chi-squared statistics on selected measures. RESULTS: Educational representatives infrequently participated in CDRs (24.9%). School records were rarely accessed for reviewed deaths (5.2%). Less than half (41.2%) of reviewed deaths had any school information and of these, 35.5% of children were indicated as having problems in school. Compared with non-suicide deaths, a larger proportion of suicide deaths had school representatives attend CDRs (28.4% vs 24.1%, P < .0001), and access to educational records (4.2% vs 9.2%, P < .0001). IMPLICATIONS: Efforts are needed to address potential barriers to systems integration, including state policies and federal educational privacy laws. CONCLUSIONS: School participation in CDRs is lacking for both suicide and non-suicide deaths.

A Novel Use of NEMSIS to Create a PECARN-Specific EMS Patient Registry.

Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies' data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN's EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.

Comparing prevalence estimates of concussion/head injury in U.S. children and adolescents in national surveys.

BACKGROUND AND OBJECTIVES: Reports on pediatric lifetime concussions/head injuries (LCHI) from national surveys have offered estimates on prevalence that range from 2.5% to 18% in the general population. The purpose of this study is to examine national surveys to compare methodologies and limitations pertaining to LCHI data collection. METHODS: Three nationally representative surveys that measure LCHI in children, including the National Survey of Children's Health, the National Health Interview Survey, and the Monitoring the Future Survey were examined. Children were grouped by ages 3-17 years and adolescent ages 13-17 years, stratified by selected demographic characteristics. Participants in the surveys included parents (NSCH and NHIS) and adolescents (MTF survey). The primary outcome measure is an estimate of LCHI in children. RESULTS: Estimates of prevalence of LCHI ranged from 3.6% to 7.0% for children ages 3-17 years and from 6.5% to 18.3% for adolescents 13-17 years. Survey modality, question wording, and respondent may contribute to differing estimates. Prevalence showed consistent variation by age, sex, and race/ethnicity across surveys. Associations were inconsistent between LCHI and insurance status, parental education, and household primary language. CONCLUSIONS: Although there are methodological differences in capturing pediatric LCHI across surveys, the prevalence estimates and correlational associations generated can offer awareness about the burden of these injuries and insights to research and clinical care.

Pediatric Readiness in Critical Access Hospital Emergency Departments.

PURPOSE: Critical Access Hospitals (CAHs), often the first point of access for emergency care, see few children and are challenged to remain proficient in caring for pediatric patients. Our analysis provides guidance to facilitate increasing CAHs staffs' ability to provide effective pediatric emergency care. METHODS: The National Pediatric Readiness Project (NPRP) assessment of 4,146 emergency departments (EDs) was linked with the CAHs list from Centers for Medicare and Medicaid Services. Pediatric readiness was assessed using the weighted pediatric readiness score (WPRS). A WPRS of 100 indicates that the ED meets essential guidelines for pediatric readiness. Using descriptive statistics, we also compared low (fewer than 5 children a day) and medium patient volume (5-14 children a day) EDs in 6 core areas of readiness. FINDINGS: Eighty-six percent (1,140) of CAHs were linked to the NPRP. In the study, 80% were low and 20% medium volume. The median WPRS was 59.0 for low and 67.3 for medium volume. While some differences were found by patient volume, overall 63% of CAHs had a pediatric emergency care coordinator, 34% had a pediatric patient care review process, 62% had interfacility transfer guidelines, and 45% weighed children only in kilograms. CAHs participating in a facility recognition program had significantly higher median WPRS scores (84.3) compared to those not participating (59.5). CONCLUSION: CAHs have challenges in being ready to care for children in the areas of pediatric emergency care coordinators, policies, procedures, and patient safety. Minimal cost interventions are available to increase the readiness of CAHs to care for children.

Ready for Children: Assessing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting.

Objective: Pediatric patients represent low frequency but potentially high-risk encounters for emergency medical services (EMS) providers. Scant information is available from EMS agencies on the frequency of pediatric skill evaluation and the presence of pediatric emergency care coordination, both which may help EMS systems optimize care for children. The objective of our study was to assess the frequency and type of methods used to assess psychomotor skills competency using pediatric-specific equipment and pediatric care coordination in EMS ground transport agencies. Methods: A web-based assessment was sent to EMS agency directors in 58 states/territories to determine the presence of pediatric care coordination defined as an individual who oversees pediatric issues (Pediatric Care Coordinator or PECC) and the process for evaluating psychomotor skills of EMS providers using of pediatric equipment. Basic demographic information of each agency was collected. Descriptive statistics, odds ratios, and 95% confidence intervals were used for analyses. Results: The response rate was 78% (8,166/10,463 agencies). Almost 80% of agencies respond to fewer than 100 pediatric calls a year; over half of the agencies are located in urban areas and provide Advanced Life Support care. Twenty-three percent (23%) of EMS agency administrators report having a PECC and 28% have plans or interest in adding one. Of those agencies with a PECC, 26% report sharing the position among several agencies. Almost half (47%) of EMS agencies evaluate pediatric psychomotor skills at least twice a year. Agencies with a PECC, those with a medium to medium high pediatric call volume and agencies located in urban areas are more likely to evaluate psychomotor skills at least twice a year. Conclusions: Although few EMS agencies currently have a PECC, there is interest among EMS agency administrators to integrate one into their system. Pediatric-specific psychomotor skills testing is more common in EMS agencies that respond to a higher pediatric call volume and have a PECC. For EMS agencies that infrequently treat children, the presence of a PECC may enhance the frequency of pediatric psychomotor skills evaluation. The presence of a PECC can potentially increase provider confidence and safety for all pediatric prehospital patients regardless of volume and location.

Analysis of paediatric drowning deaths in Washington State using the child death review (CDR) for surveillance: what CDR does and does not tell us about lethal drowning injury.

BACKGROUND: Drowning is second cause of paediatric injury death in Washington State. Child death review (CDR) data provide the unique opportunity to identify regional risk factors and opportunities for drowning prevention. METHODS: CDR teams' data for drowning deaths of children <18 years between 1999 and 2003 were analysed for victim and event characteristics, and existing prevention/protective factors. A working group made data driven recommendations. Subsequent interventions were noted. RESULTS: Drowning death rates were significantly higher among Asian Pacific Islander children (3.3 per 100,000). Disproportionately, 32% of deaths involved families with prior child protective services (CPS) referrals. Most deaths (73%) occurred in open water; the proportion in open water increased from 42% of <5-year-olds, 83% of 5-9-year-olds, to 90% of 10-17-year-olds. Thirty per cent drowned at parks; 29% drowned in residential settings. Pre-drowning activity for 42% was swimming or playing in the water. Alcohol and drug use were low. Neglect/poor supervision was considered a factor in 68% (21/31) of the deaths of children <5 years of age. State CDR recommendations led to the development of a drowning prevention campaign targeted to an Asian American community, intra-agency changes resulting in reinstatement of lifeguard staffing and addition of lifejacket loaner programmes, collaboration with state commissions to enforce a state pool fencing ordinance, and model legislation prohibiting swimming in dangerous waterways. CONCLUSION: CDR data collection and review process was an effective surveillance tool. It identified specific regional high risk groups and sites for drowning prevention and led to recommendations and implementation of effective local and state injury prevention interventions.

Collaborative process improvement to enhance injury prevention in child death review.

OBJECTIVE: To increase the number and quality of injury prevention recommendations made by Washington State (USA) child death review teams. DESIGN: Before and after study design involving four intervention teams and 21 comparison teams. METHODS: Intervention teams received injury prevention training, collaborative process improvement coaching, and access to web based prevention resources. An equal number of randomly selected child death review case reports filed with the state before the intervention by the intervention and comparison teams were included in the baseline sample. All reports submitted by the intervention and comparison teams after the intervention were included in the follow-up sample. Reports were scored on the completeness of prevention related data elements and on the quality of written prevention recommendations. RESULTS: Data completion for prevention relevant items increased in intervention teams from 73% at baseline to 88% at follow-up. In comparison teams, this measure fell from 77% to 56% over the same period. The quality of written recommendations produced by intervention teams increased from 4.3 (95% CI 3.4 to 5.1) to 7.6 (95% CI 6.7 to 8.5), while comparison teams showed no significant change (4.0 (95% CI 2.5 to 5.3) to 3.7 (95% CI 2.2 to 5.2)). Specifically, improvements were noted in the identification of evidence based best practices and the development of clear, actionable written recommendations. CONCLUSION: Injury prevention recommendations are generated in the systematic local review of child deaths. This process can be analysed, measured, supported, and improved.

Prenatal screening for substance use and violence: findings from physician focus groups.

OBJECTIVE: To guide quality improvement activities, the study sought to identify effective strategies for influencing and improving physician screening and referral of pregnant women for violence and substance abuse (alcohol, drugs and tobacco). METHODS: This qualitative study conducted in Washington State consisted of interviews with eight physicians and focus groups with twenty-eight physicians who practice obstetric care. Physicians, selected using systematic sampling, were asked about perceptions on the importance of screening and barriers to effective screening, awareness of information and resources from the state Department of Health, and the effectiveness of various provider training strategies for improving prenatal screening. RESULTS: Physicians were most interested in practical, concise information for themselves and office staff. Referral information and patient handouts were identified as important tools to increase the efficacy of screening and intervention. Physicians supported in-person programs in offices or in hospitals but rejected use of audio conferences and direct mailings. CONCLUSIONS: This study provided insight about the way we deliver best practice information to physicians. Collecting qualitative data from physicians is important prior to developing statewide quality improvement activities aimed at this group.