Presenters: Rachel Peterson, MD, and Edward Kim, MD
Recently, concern has been growing about hospital patient-to-worker harm events and the increase in patients with mental health disorders admitted to hospitals. Also troublesome are how concerns are escalated, the words used to describe problems, and the way teams that respond can significantly affect the situation. Due to these issues, Behavioral Emergency Response Teams (BERT) were created to respond quickly and appropriately to behavioral events. BERTs were modeled after rapid-response teams to provide early, directed patient interventions and support clinical staff.
In many places, behavioral concerns are met with security. The presence of any law enforcement can interfere with medical care and create an unwelcome environment based on the individual’s past experiences. BERTs differ because they do not primarily rely on security restraint but instead create patient-centered treatment space. BERT is a multidisciplinary response that starts with a trained mental health clinician entering the room first. After arrival, there is an assessment, intervention, and a debrief of the event. Data has shown that with the initiation of BERTs, there is improved collaboration, decreased harm events, and reduced restraint and security use.
To create an optimal BERT team, there are hospital structures that facilitate its success. First, a psychiatric-trained clinician is available to respond to events. Workers and staff receive training in de-escalation, straightforward language, and centering of the patient and family. There must be clear conversations and decisions on who constitutes the hospital security staff. Lastly, the team needs clear input from families whose voices are often not heard, people who experience psychiatric-related conditions, and who have different, often negative, interactions with security and hospital systems.
The PHM 2023 presenters implemented a BERT program at their institution. The BERT calls were reviewed and compared to the data of the general population. The results showed that BERT alerts were rare (less than 1% of all admissions), more likely to occur in patients with Medicare or Medicaid, more likely to occur in teenage patients, and more likely to occur in Black patients. All specific data is to be published in the future by the presenters.
System improvements can result in better responses to behavioral events. Clear communication, training, and language use by all staff can create standard processes. Implementing behavioral health plans, involving child life, and using specially trained behavioral health clinicians on rounds can prevent events. Involving families, lifting often unheard voices, and transparent monitoring of current and new systems through a chief health equity officer can be a first step to improved equity.
- Initiation of BERTs improves collaboration, decreases harm events, and decreases restraint and security use.
- BERT use is more likely in teen patients, patients with a public payer source, and Black patients.
- A solution to these issues is difficult, to say the least. True change starts with culture and often the first step is identifying the disparity and where the issues are.
Dr. Edwards is a pediatric hospitalist working in Omaha, Neb. with an interest in quality improvement and system changes. His focus includes how hospital systems directly and indirectly affect patient care, reducing harm from preventable events, and disclosures.