When presenting to an ED with suicide, self-harm or other mental health crises, youth may also experience "boarding", which is defined by the Joint Commission as "the practice of holding patients in the ED or another temporary location after the decision to admit or transfer has been made." A recent national survey of 88 US acute care hospitals conducted by our research team found that 98.9% of hospitals were boarding youth awaiting psychiatric hospitalization, for an average of 2-3 days. However, as illustrated in a systemic review, little research has focused on developing interventions to support youth during this highly vulnerable time. 3

I-CARE is a modular, blended digital health intervention facilitated by individuals who are not mental health clinical staff to teach youth evidence-based psychosocial skills during the boarding period. This study will evaluate I-CARE's efficacy using a patient-level randomized clinical trial (RCT), randomizing youth to receive standard safety supervision or I-CARE in addition to standard safety supervision. If found to the efficacious, I-CARE could be scaled-up in new settings with limited resources and has the potential to significantly improve the quality of care received by youth experiencing boarding.

Suicide is the second leading cause of death among adolescents; from 2007 to 2017 suicide deaths tripled in youth 10 to 14 years. Emergency departments (EDs) at acute care hospitals increasingly serve as portals of care for youth with suicidal ideation or attempt. When these youth are deemed to require psychiatric hospitalization, the demand for beds often exceeds supply, leading to psychiatric boarding. To address this gap, a multidisciplinary team including pediatricians, psychologists and patient partners developed a modular digital intervention and associated training materials to deliver evidence-based psychosocial skills to youth during boarding. This program, entitled I-CARE (Improving Care, Accelerating Recovery & Education), consists of 7 web-based animated videos and workbook exercises, facilitated by licensed nursing assistants who provide 1-on-1 safety supervision during boarding. Given that 1-on-1 safety supervision is the current standard of care at most hospitals, I-CARE requires minimal additional resources beyond those already available in these settings. The psychosocial skills included in I-CARE are grounded in cognitive behavioral therapy and were prioritized through a rigorous Delphi process evaluating their importance and feasibility to deliver during psychiatric boarding.

Inclusion Criteria:

• Adolescents of any sex and gender, aged 12-17 years at ED visit or hospital encounter
• Presenting with suicide attempt or ideation, or self-harm
• Medically stable
• English-speaking
• Awaiting transfer for inpatient psychiatric care or disposition.

Exclusion Criteria:

• Cognitive or developmental delays precluding participation (intellectual functioning <12 years of age)
• Behavioral limitations that preclude program participation
• Active psychosis
• Legal parent/caregiver unable to speak English or unavailable to provide consent (e.g. Wards of the State)

Data will be uploaded into the NIMH Data Archive (NDA).

Data will be collected from approximately 173 adolescents 12-17 years of age. Measures include:

1. Depression, Anxiety, and Stress Scale - Youth version (DASS-Y)
2. Harkavy-Asnis Suicide Scale (HASS) - Suicide Attempt module
3. Concise-Health Risk Tracking-Self Report (CHRT)
4. Revised Children's Anxiety and Depression Scale-25 (RCADS-25)

All data will be deposited to NDA starting 12 months after the award begins and will be deposited every six months thereafter following the usual NDA data submission dates.

All those with access to the NDA will have access to our data.