Results of a Multisite Transportability Trial of a Brief Emergency Department Intervention for Suicidal Adolescents and Their Families

Background: In emergency practice, usual care for suicidal adolescents is evaluation, with little or no treatment, and disposition, usually to an inpatient psychiatry unit. The Family Based Crisis Intervention (FBCI) for suicidal adolescents and their families is a single-session intervention designed to stabilize adolescents within a single ED visit and to provide training to empower the family to manage the adolescent safely at home. Results of a randomized clinical trial (RCT) of FBCI (Wharff et al. 2019) showed significant differences in hospitalization rates between FBCI and treatment as usual (TAU) patients and that FBCI caregivers experienced significantly larger gains in family empowerment (p=0.004) and client satisfaction (p=0.0005) than the TAU group. This paper reports results of a recently completed transportability trial conduced across 3 ED sites to assess clinician uptake of FBCI, patient disposition, and generalizability of the intervention.

Methods: The study sample was comprised of a convenience sample of sites that had expressed an interest in FBCI and were diverse in geographical location, size of the ED, and patient/clinician mix:  UNC-Chapel Hill (UNC) is a large ED with adult and adolescent patients; Children’s Hospital of Orange County (CHOC) is a small, pediatric ED; and Boston Children’s Hospital (BCH) is a large pediatric ED. All emergency mental health clinicians at these sites participated in a two day training of FBCI followed by weekly consultation calls.  During the study period, all clinicians were asked to complete a REDCap survey on each suicidal adolescent they saw. If they used FBCI, they were asked about patient/family demographics, use of the modules, clinician ratings of suicide risk, depression and anxiety, and disposition/follow-up services.  If they did not use FBCI, they were asked the reason. Both surveys included clinician demographics and qualitative questions about the clinician’s perception of the utility of FBCI.

Results: 240 patients received FBCI across the three sites (70%). Clinicians were multi-disciplinary. All five modules of FBCI were used and key components were discussed nearly 100% of the time. Reasons clinicians did not do FBCI were primarily no family member was present to participate or patient was intoxicated or cognitively delayed preventing discussion of FBCI. Overall rates of discharge home varied greatly: CHOC 89%, BCH 60%; UNC 45% overall; data showed that these proportions increased over time. Most clinicians responding felt FBCI was useful and could fit into their practice.

Discussion: Results of the transportability trial show that FBCI is both feasible and useful to a variety of mental health clinicians at diverse emergency departments. Facilitators to the use of FBCI were strong leadership to support change in practice, younger clinicians more open to practice innovation, availability of outpatient resources, smaller ED, universal health insurance. Barriers to use of FBCI were clinician resistance to change in practice, lack of outpatient resources, combined adult-pediatric ED, not having all child-trained clinicians, lack of systemic support. However, when used, FBCI was an intervention that clinicians felt was useful, fit into their practice, and that facilitated discharging patients home with their families.