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Outcomes Following a Mental Health Care Intervention for Children in the Emergency Department: A Nonrandomized
Amanda S Newton1, Jennifer Thull-Freedman2, Jianling Xie3
1Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Insights
A new mental health care bundle in pediatric emergency departments (EDs) did not improve child well-being. While hospitalizations decreased, emergency department length of stay did not, with findings potentially impacted by the COVID-19 pandemic.
Area of Science:
- Pediatric emergency medicine
- Child and adolescent mental health
- Healthcare quality improvement
Background:
- Emergency departments (EDs) are crucial for children's mental health crises.
- Families utilize EDs as a resource for mental health support.
- Novel interventions are needed to improve care for pediatric mental health emergencies.
Purpose of the Study:
- To evaluate a novel mental health care bundle's impact on child well-being.
- To assess the bundle's effect on patient satisfaction and health system metrics.
- To determine the effectiveness of integrated mental health care in pediatric EDs.
Main Methods:
- A nonrandomized trial was conducted in two Canadian pediatric EDs.
- Children under 18 with mental health presentations were enrolled pre- and post-bundle implementation.
- Child well-being was measured using validated scales; health system metrics (hospitalization, ED length of stay, revisits) and satisfaction were also analyzed.
Main Results:
- No significant difference in child well-being was observed between preimplementation and implementation periods.
- Reduced well-being z scores were associated with mood disorder diagnosis and nonbinary gender identity.
- Hospitalizations decreased, but emergency department length of stay increased during the implementation period. Care satisfaction remained unchanged.
Conclusions:
- The implemented care bundle did not improve child well-being 30 days post-ED visit.
- A decrease in hospitalizations was noted, but emergency department length of stay did not improve.
- Broader contextual factors, including the COVID-19 pandemic, may have influenced health system outcomes.
Importance:
The emergency department (ED) is an important safety net for children experiencing mental and behavioral health crises and can serve as a navigational hub for families seeking support for these concerns.
Objectives:
To evaluate the outcomes of a novel mental health care bundle on child well-being, satisfaction with care, and health system metrics.
Design, Setting, And Participants:
Nonrandomized trial of 2 pediatric EDs in Alberta, Canada. Children younger than 18 years with mental and behavioral health presentations were enrolled before implementation (preimplementation: January 2020 to January 2021), at implementation onset (run-in: February 2021 to June 2021), and during bundle delivery (implementation: July 2021 to June 2022).
Intervention:
The bundle involved risk stratification, standardized mental health assessments, and provision of an urgent follow-up appointment after the visit, if required.
Main Outcomes And Measures:
The primary outcome, child well-being 30 days after the ED visit, was assessed using the Stirling Children's Wellbeing Scale (children aged <14 years) or Warwick-Edinburgh Mental Wellbeing Scale (children aged 14-17 years). Change in well-being between the preimplementation and implementation periods was examined using interrupted time-series analysis and multivariable modeling. Changes in health system metrics (hospitalization, ED length of stay [LOS], and revisits) and care satisfaction were also examined.
Results:
A total of 1412 patients (median [IQR] age, 13 [11-15] years), with 715 enrolled preimplementation (390 [54.5%] female; 55 [7.7%] First Nations, Inuit, or Métis; 46 [6.4%] South, Southcentral, or Southeast Asian; and 501 [70.1%] White) and 697 enrolled at implementation (357 [51.2%] female; 51 [7.3%] First Nations, Inuit, or Métis; 39 [5.6%] South, Southcentral, or Southeast Asian; and 511 [73.3%] White) were included in the analysis. There were no differences between study periods in well-being. Reduced well-being z scores were associated with mood disorder diagnosis (standardized mean difference, -0.14; 95% CI, -0.26 to -0.02) and nonbinary gender identity (standardized mean difference, -0.41; 95% CI, -0.62 to -0.19). The implementation period involved fewer hospitalizations (difference in hospitalizations, -6.9; 95% CI, -10.4 to -3.4) and longer ED LOS (1.1 hours; 95% CI, 0.7 to 1.4 hours). There were no differences between study periods in ED revisits or care satisfaction.
Conclusions And Relevance:
In this study, the delivery of a care bundle was not associated with higher child well-being 30 days after an ED visit. Hospitalizations did decrease during bundle delivery, but ED LOS did not. These health system findings may have been affected by broader changes in patient volumes and flow processes that occurred during the COVID-19 pandemic, which took place as the study was conducted.
Trial Registration:
ClinicalTrials.gov Identifier: NCT04292379.
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