Prioritization of Randomized Clinical Trial Questions for Children Hospitalized With Common Conditions: A Consensus Statement.

Importance: There is a lack of randomized clinical trial (RCT) data to guide many routine decisions in the care of children hospitalized for common conditions. A first step in addressing the shortage of RCTs for this population is to identify the most pressing RCT questions for children hospitalized with common conditions. Objective: To identify the most important and feasible RCT questions for children hospitalized with common conditions. Design, Setting, and Participants: For this consensus statement, a 3-stage modified Delphi process was used in a virtual conference series spanning January 1 to September 29, 2022. Forty-six individuals from 30 different institutions participated in the process. Stage 1 involved construction of RCT questions for the 10 most common pediatric conditions leading to hospitalization. Participants used condition-specific guidelines and reviews from a structured literature search to inform their development of RCT questions. During stage 2, RCT questions were refined and scored according to importance. Stage 3 incorporated public comment and feasibility with the prioritization of RCT questions. Main Outcomes and Measures: The main outcome was RCT questions framed in a PICO (population, intervention, control, and outcome) format and ranked according to importance and feasibility; score choices ranged from 1 to 9, with higher scores indicating greater importance and feasibility. Results: Forty-six individuals (38 who shared demographic data; 24 women [63%]) from 30 different institutions participated in our modified Delphi process. Participants included children's hospital (n = 14) and community hospital (n = 13) pediatricians, parents of hospitalized children (n = 4), other clinicians (n = 2), biostatisticians (n = 2), and other researchers (n = 11). The process yielded 62 unique RCT questions, most of which are pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Overall scores for importance and feasibility of the RCT questions ranged from 1 to 9, with a median of 5 (IQR, 4-7). Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis). Conclusions and Relevance: This consensus statementhas identified the most important and feasible RCT questions for children hospitalized with common conditions. This list of RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for hospitalized children.

Human-Centered Design to Improve Care for Youths Experiencing Psychiatric Boarding.

The number of children and adolescents presenting to hospitals with mental health conditions has increased markedly over the past decade. A dearth of pediatric mental health resources prevents delivering definitive psychiatric care to this population at many hospitals; thus, children and adolescents must wait at a medical facility until appropriate psychiatric care becomes available (an experience described as psychiatric "boarding"). Clinicians caring for youth experiencing psychiatric boarding report inadequate training and resources to provide high-quality care to this population, and patients and caregivers describe significant frustration with the current standard of care. Recognizing these issues and the unique emotional components associated with psychiatric boarding, we employed human-centered design (HCD) to improve our hospital's approach to caring for youth during this period. HCD is an approach that specifically prioritizes the assessment and integration of human needs, including emotional needs, as a means to inform change. We used an HCD framework encompassing 5 stages: (1) empathize with those affected by the issue at hand, (2) define the problem, (3) ideate potential solutions, (4) prototype potential solutions, and (5) test potential solutions. Through these stages, we elicited broad stakeholder engagement to develop and implement 2 primary interventions: A modular digital health curriculum to teach psychosocial skills to youth experiencing boarding and a comprehensive clinical practice guideline to optimize and standardize care across clinical environments at our hospital. This manuscript describes our experience applying HCD principles to this complex health care challenge.

Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems.

OBJECTIVES: Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians. METHODS: As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites. RESULTS: Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system. CONCLUSIONS: The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

Rural-urban disparities in health care delivery for children with medical complexity and moderating effects of payer, disability, and community poverty.

PURPOSE: Children with medical complexity (CMC) may be at increased risk of rural-urban disparities in health care delivery given their multifaceted health care needs, but these disparities are poorly understood. This study evaluated rural-urban disparities in health care delivery to CMC and determined whether Medicaid coverage, co-occurring disability, and community poverty modified the effects of rurality on care delivery. METHODS: This retrospective cohort study of 2012-2017 all-payer claims data from Colorado, Massachusetts, and New Hampshire included CMC <18 years. Health care delivery measures (ambulatory clinic visits, emergency department visits, acute care hospitalizations, total hospital days, and receipt of post-acute care) were compared for rural- versus urban-residing CMC in multivariable regression models, following established methods to evaluate effect modification. FINDINGS: Of 112,475 CMC, 7307 (6.5%) were rural residing and 105,168 (93.5%) were urban residing. A total of 68.9% had Medicaid coverage, 33.9% had a disability, and 39.7% lived in communities with >20% child poverty. In adjusted analyses, rural-residing CMC received significantly fewer ambulatory visits (risk ratio [RR] = 0.95, 95% confidence interval [CI]: 0.94-0.96), more emergency visits (RR = 1.12, 95% CI: 1.08-1.16), and fewer hospitalization days (RR = 0.90, 95% CI = 0.85-0.96). The estimated modification effects of rural residence by Medicaid coverage, disability, and community poverty were each statistically significant. Differences in the odds of having a hospitalization and receiving post-acute care did not persist after incorporating sociodemographic and clinical characteristics and interaction effects. CONCLUSIONS: Rural- and urban-residing CMC differed in their receipt of health care, and Medicaid coverage, co-occurring disabilities, and community poverty modified several of these effects. These modifying effects should be considered in clinical and policy initiatives to ensure that such initiatives do not widen rural-urban disparities.

Hospital-Level NICU Capacity, Utilization, and 30-Day Outcomes in Texas.

Importance: Risk-adjusted neonatal intensive care unit (NICU) utilization and outcomes vary markedly across regions and hospitals. The causes of this variation are poorly understood. Objective: To assess the association of hospital-level NICU bed capacity with utilization and outcomes in newborn cohorts with differing levels of health risk. Design, Setting, and Participants: This population-based retrospective cohort study included all Medicaid-insured live births in Texas from 2010 to 2014 using linked vital records and maternal and newborn claims data. Participants were Medicaid-insured singleton live births (LBs) with birth weights of at least 400 g and gestational ages between 22 and 44 weeks. Newborns were grouped into 3 cohorts: very low birth weight (VLBW; <1500 g), late preterm (LPT; 34-36 weeks' gestation), and nonpreterm newborns (NPT; ≥37 weeks' gestation). Data analysis was conducted from January 2022 to October 2023. Exposure: Hospital NICU capacity measured as reported NICU beds/100 LBs, adjusted (ie, allocated) for transfers. Main Outcomes and Measures: NICU admissions and special care days; inpatient mortality and 30-day postdischarge adverse events (ie, mortality, emergency department visit, admission, observation stay). Results: The overall cohort of 874 280 single LBs included 9938 VLBW (5054 [50.9%] female; mean [SD] birth weight, 1028.9 [289.6] g; mean [SD] gestational age, 27.6 [2.6] wk), 63 160 LPT (33 684 [53.3%] female; mean [SD] birth weight, 2664.0 [409.4] g; mean [SD] gestational age, 35.4 [0.8] wk), and 801 182 NPT (407 977 [50.9%] female; mean [SD] birth weight, 3318.7 [383.4] g; mean [SD] gestational age, 38.9 [1.0] wk) LBs. Median (IQR) NICU capacity was 0.84 (0.57-1.30) allocated beds/100 LB/year. For VLBW newborns, NICU capacity was not associated with the risk of NICU admission or number of special care days. For LPT newborns, birth in hospitals with the highest compared with the lowest category of capacity was associated with a 17% higher risk of NICU admission (adjusted risk ratio [aRR], 1.17; 95% CI, 1.01-1.33). For NPT newborns, risk of NICU admission was 55% higher (aRR, 1.55; 95% CI, 1.22-1.97) in the highest- vs the lowest-capacity hospitals. The number of special care days for LPT and NPT newborns was 21% (aRR, 1.21; 95% CI,1.08-1.36) and 37% (aRR, 1.37; 95% CI, 1.08-1.74) higher in the highest vs lowest capacity hospitals, respectively. Among LPT and NPT newborns, NICU capacity was associated with higher inpatient mortality and 30-day postdischarge adverse events. Conclusions and Relevance: In this cohort study of Medicaid-insured newborns in Texas, greater hospital NICU bed supply was associated with increased NICU utilization in newborns born LPT and NPT. Higher capacity was not associated with lower risk of adverse events. These findings raise important questions about how the NICU is used for newborns with lower risk.

Clinician-Spoken Plain Language in Health Care Encounters: A Qualitative Analysis to Assess Measurable Elements.

PURPOSE: Good communication and use of plain language in health care encounters improves outcomes, including emotional health, symptom resolution, and functional status. Yet there is limited research on how to measure and report spoken plain language, which is the use of familiar, clear language. The authors aimed to describe key, measurable elements of spoken plain language that can be assessed and reported back to clinicians for self-reflection. METHOD: The authors conducted secondary analysis of transcripts from recorded encounters between breast cancer surgeons and patients with early-stage breast cancer. Two coders used a hybrid qualitative analysis with a framework based on US Federal Plain Language Guidelines. To develop major themes, they examined (1) alignment with the Guidelines and (2) code frequencies within and across transcripts. They also noted minor themes. RESULTS: From 74 transcripts featuring 13 surgeons, the authors identified two major themes representing measurable elements of spoken plain language: (1) clinicians had a propensity to use both explained and unexplained medical terms, and (2) clinicians delivered information using either short turns (one unit of someone speaking) with one topic or long turns with multiple topics. There were three minor themes that were not indicative of whether or not clinicians used spoken plain language. First, clinicians regularly used absolute risk communication techniques. Second, question-asking techniques varied and included open-ended, close-ended, and comprehension checks. Third, some clinicians used imagery to describe complex topics. CONCLUSIONS: Clinicians' propensity to use medical terms with and without explanation and parse encounters into shorter or longer turns are measurable elements of spoken plain language. These findings will support further research on the development of a tool that can be used in medical education and other settings. This tool could provide direct and specific feedback to improve the plain language practices of clinicians in training and beyond.

Child Health Needs and the Pediatric Hospital Medicine Workforce: 2020-2040.

Pediatric hospital medicine (PHM) established a new model of care for hospitalized children in the United States nearly 3 decades ago. In that time, the field experienced rapid growth while distinguishing itself through contributions to medical education, quality improvement, clinical and health services research, patient safety, and health system leadership. Hospital systems have also invested in using in-house pediatricians to manage various inpatient care settings as patient acuity has accelerated. National PHM leaders advocated for board certification in 2014, and the first certification examination was administered by the American Board of Pediatrics in 2019. In this article, we describe the development of the subspecialty, including evolving definitions and responsibilities of pediatric hospitalists. Although PHM was not included in the model forecasting future pediatric subspecialties through 2040 in this supplement because of limited historical data, in this article, we consider the current and future states of the workforce in relation to children's health needs. Expected challenges include potential alterations to residency curriculum, changes in the number of fellowship positions, expanding professional roles, concerns related to job sustainability and burnout, and closures of pediatric inpatient units in community hospitals. We simultaneously forecast growing demand in the PHM workforce arising from the increasing prevalence of children with medical complexity and increasing comanagement of hospitalized children between pediatric hospitalists and other subspecialists. As such, our forecast incorporates a degree of uncertainty and points to the need for ongoing investments in future research to monitor and evaluate the size, scope, and needs of pediatric hospitalists and the PHM workforce.

Pediatric Hospitalization Trends at Children's and General Hospitals, 2000-2019.

This study examines whether pediatric inpatient care has been redistributed from general hospitals into children's hospitals.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States: 2019 update.

BACKGROUND: General hospitals (GH) provide inpatient care for the majority of hospitalized children in the United States, yet the majority of hospital pediatrics research is conducted at freestanding children's hospitals. OBJECTIVE: Updating a prior 2012 analysis, this study used 2019 data to describe characteristics of pediatric hospitalizations at general and freestanding hospitals in the United States and identify the most common and costly reasons for hospitalization in these settings. DESIGNS, SETTING, AND PARTICIPANTS: This study examined hospitalizations in children <18 years using the Healthcare Cost and Utilization Project's 2019 Kids' Inpatient Database, stratifying neonatal and nonneonatal hospital stays. INTERVENTION: Not applicable. MAIN OUTCOME AND MEASURES: Sociodemographic and clinical differences between hospitalizations at general and freestanding children's hospitals were examined, applying survey weights to generate national estimates. RESULTS: There were an estimated 5,263,218 pediatric hospitalizations in 2019, including 3,757,601 neonatal and 1,505,617 nonneonatal hospital stays. Overall, 88.6% (n = 4,661,288) of hospitalizations occurred at GH, including 97.6% of neonatal hospitalizations and 65.9% of nonneonatal hospitalizations. 11.4% (n = 601,930) of hospitalizations occurred at freestanding children's hospitals, including 2.4% (n = 88,313) of neonatal hospitalizations and 34.1% (n = 513,616) of nonneonatal hospitalizations. In total, 98.9% of complicated birth hospitalizations and 66.0% of neonatal nonbirth hospitalizations occurred at GH. Among nonneonatal stays, 85.2% of mental health hospitalizations, 63.5% of medical hospitalizations, and 61.3% of surgical hospitalizations occurred at GH.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019.

Importance: National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. Objective: To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. Design, Setting, and Participants: This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Exposures: Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. Main Outcomes and Measures: The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. Results: The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Conclusions and Relevance: Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure.

BACKGROUND: Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience. METHODS: Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated. RESULTS: The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery. CONCLUSIONS: A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.

Association Between Educational Resources and Pediatric Fellows' Mental Health Attitudes and Self-Reported Competence.

BACKGROUND/OBJECTIVES: Children with chronic medical conditions (CCMC) have high rates of mental health (MH) conditions. This study examines associations between MH educational resources during fellowship and 3 dependent variables: fellows' interest, perceived responsibility, and self-reported competence in assessing MH concerns of CCMC. METHODS: Subspecialty fellows taking the American Board of Pediatrics in-training examinations in February 2020 were invited to participate in a survey inquiring about MH educational resources. Logistic regression examined associations between MH educational resources and the 3 dependent variables, adjusting for demographics and program-level characteristics. RESULTS: Of the 97.7% (4216) fellows who responded, 3870 were included in analyses. About 37.5% reported formal MH teaching sessions; 36.7% reported on-site MH professionals engaged in teaching; 41.6% reported co-assessing patients with MH specialists; and 28.3% reported performance evaluation of their MH skills. All 4 resources were significantly and positively associated with self-reported competence in adjusted analyses, with odds ratios (OR) ranging from 1.28 (95% confidence interval (95% CI): 1.03-1.58) for formal teaching sessions to 2.14 (95% CI: 1.73-2.65) for performance evaluation. Resources were positively associated with the dependent variables in a "dose-response" pattern. Respondents who reported having all 4 educational resources compared to zero resources had an OR of 2.20 (95% CI: 1.74-2.78) for high MH interest, 3.18 (95% CI: 2.45-4.12) for high perceived responsibility, and 4.38 (95% CI: 3.43-5.60) for high self-reported competence CONCLUSIONS: Access to mental health educational resources was associated with higher interest, perceived responsibility, and self-reported competence; investing in these resources may improve fellows' skills in addressing the emotional needs of CCMC.

Specialties Providing Ambulatory Care and Associated Health Care Utilization and Quality for Children With Medical Complexity.

OBJECTIVE: Although children with medical complexity (CMC) have substantial health care needs, the extent to which they receive ambulatory care from primary care versus specialist clinicians is unknown. We aimed to determine the predominant specialty providing ambulatory care to CMC (primary care or specialty discipline), the extent to which specialists deliver well-child care, and associations between having a specialty predominant provider and health care utilization and quality. METHODS: In a retrospective cohort analysis of 2012-17 all-payer claims data from Colorado, New Hampshire, and Massachusetts, we identified the predominant specialty providing ambulatory care for CMC <18 years. Propensity score weighting was used to create a balanced sample of CMC and assess differences in outcomes, including adequate well-child care, continuity of care, emergency visits, and hospitalizations, between CMC with a primary care versus specialty predominant provider. RESULTS: Among 67,218 CMC, 75.3% (n = 50,584) received the plurality of care from a primary care discipline. Body system involvement, age > 2 years, urban residence, and cooccurring disabilities were associated with predominantly receiving care from specialists. After propensity score weighting, there were no significant differences between CMC with a primary care or specialist "predominant specialty seen" (PSS) in ambulatory visit counts, adequate well-child care, hospitalizations, or overall continuity of care. Specialists were the sole providers of well-child care and vaccines for 49.9% and 53.1% of CMC with a specialist PSS. CONCLUSIONS: Most CMC received the plurality of care from primary care disciplines, and there were no substantial differences in overall utilization or quality based on the PSS.

Characterization of Birth Hospitalizations in the United States.

OBJECTIVES: A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations. METHODS: We conducted a cross-sectional analysis of the 2019 Kids' Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator "in-hospital birth" and any categorized by the Pediatric Clinical Classification System as "liveborn" were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression). RESULTS: In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million). CONCLUSIONS: Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications.

I-CARE: Feasibility, Acceptability, and Appropriateness of a Digital Health Intervention for Youth Experiencing Mental Health Boarding.

PURPOSE: Youth with suicidality requiring psychiatric hospitalization may first experience boarding at acute care hospitals. Given infrequent provision of therapy during this period, we developed a modular digital intervention (I-CARE; Improving Care, Accelerating Recovery and Education) to facilitate delivery of evidence-based psychosocial skills by non-mental health clinicians. This pilot study describes changes in emotional distress, severity of illness, and readiness for engagement following I-CARE participation, and evaluates the feasibility, acceptability, and appropriateness of I-CARE. METHODS: A mixed-methods approach was used to evaluate I-CARE, offered to youth 12-17 years from 11/21 to 06/22. Changes in emotional distress, severity of illness, and engagement readiness were evaluated using paired t-tests. Semistructured interviews with youth, caregivers, and clinicians were conducted concurrently with collection of validated implementation outcome measures. Quantitative measure results were linked to interview transcripts, which were analyzed thematically. RESULTS: Twenty-four adolescents participated in I-CARE; median length of stay was 8 days (IQR:5-12 days). Emotional distress decreased significantly by 6.3 points (63-point scale) following participation (p = .02). The increase in engagement readiness and decrease in youth-reported illness severity were not statistically significant. Among 40 youth, caregivers, and clinicians who participated in the mixed-methods evaluation, 39 (97.5%) rated I-CARE as feasible, 36 (90.0%) as acceptable, and 31 (77.5%) as appropriate. Adolescents' prior knowledge of psychosocial skills and clinicians' competing demands were reported barriers. DISCUSSION: I-CARE was feasible to implement and youth reported reduced levels of distress following participation. I-CARE has the potential to teach evidence-based psychosocial skills during boarding, which may provide a head-start on recovery before psychiatric hospitalization.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019.

Importance: Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking. Objectives: To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals. Design, Setting, and Participants: Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age. Exposures: Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types. Main Outcomes and Measures: Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals. Results: Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations. Conclusions and Relevance: Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.

Direct Admission to Hospital for Children in the United States.

One in four unscheduled hospital admissions for children and adolescents in the United States occurs via direct admission, defined as hospital admission without first receiving care in the hospital's emergency department. The purpose of this policy statement is to present recommendations to optimize the quality and safety of this hospital admission approach for children. Recommendations included in this policy statement provide guidance related to: (i) direct admission written guidelines, (ii) clear systems of communication between members of the health care team and with families of children requiring admission, (iii) triage systems to identify patient acuity and disease severity, (iv) identification of hospital resources needed to support direct admission systems of care, (v) consideration of patient populations that may be at increased risk of adverse outcomes during the hospital admission process, (vi) addressing the relevance of local factors and resources, and (vii) ongoing evaluation of direct admission processes and outcomes. The recommendations included in this policy statement are intended to support the implementation of safe direct admission processes and to foster awareness of outcomes associated with this common portal of hospital admission.