O1026: Testing an Emergency Department Mental Health Care Bundle in Emergency Departments: An Implementation Study

Background: The emergency department (ED) is an important navigational hub and safety net for children experiencing mental and behavioral health crises. Using a quasi-experimental design (NCT04292379), we evaluated the impact of a novel mental health care bundle for children seeking ED care for these presentations.

Methods: The study took place in two pediatric EDs in Alberta, Canada. Children < 18 years with mental and behavioral health presentations were enrolled prior to bundle implementation (pre-implementation period: January 29, 2020-January 31, 2021), as the bundle was introduced to care (‘run-in’ period: February 1, 2021-June 30, 2021), and after full-scale bundle implementation (post-implementation period: July 1, 2021-June 30, 2022). The bundle involved early risk stratification, standardized mental health assessments, and provision of an urgent follow-up appointment after the visit.

The primary outcome was child well-being 30 days after the ED visit assessed using the Stirling Children’s Well-Being Scale (children aged < 13 years) or Warwick-Edinburgh Mental Wellbeing Scale (children aged 13- < 18 years). Change in well-being between the pre- and post-implementation periods was examined using an interrupted time-series (ITS) analysis and multivariable modelling. Health system changes (hospital admission, length of stay [LOS], revisits) and care satisfaction were also examined.

Results: We enrolled 715 and 697 patients in the pre- and post-implementation periods, respectively. The median age of patients was 13 years (IQR: 11, 15). The most common reasons for ED visits in both study periods were suicidal ideation, anxiety-related disorders, and mood disorders.

In the ITS analysis, there was no intervention effect on well-being. In the multivariable model, reduced well-being was associated with a mood disorder diagnosis (mean difference: -0.14; 95% CI: -0.26, -0.02) and non-binary gender identity (mean difference: -0.41; 95% CI: -0.62, -0.19).

The post-implementation period included a smaller proportion of visits resulting in hospitalization (difference: -6.91; 95% CI: -10.43, -3.38) and a longer LOS (difference: 89 minutes; 95% CI: 29, 133). Patient sociodemographics were not associated with LOS, but ED visit features (acuity, visits for suicidal ideation or mood disorder, visits that resulted in hospital admission) were. There were no differences after bundle implementation in unscheduled ED revisits within 72 hours or 30 days. Increased care satisfaction was associated with visits for suicidal ideation or mood disorder and that resulted in hospital admission; reduced satisfaction was associated with the post-implementation period, LOS, and visit acuity.

Conclusion: A novel care bundle for patients experiencing mental and behavioral health crises did not improve well-being after the ED visit. The bundle did reduce hospitalizations without evidence of undesirable impacts. Children with mood disorders and non-binary gender identity may have unique needs to improve well-being. Health system and satisfaction findings may have been affected by the occurrence of the COVID-19 pandemic during the study period.