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How to Implement a Behavioral Rapid Response Team for Inpatient Mental Health Emergencies

October 12, 2023

Just over 2 years after the American Academy of Pediatrics declared a mental health emergency among children and adolescents, many of us have tried to figure out ways to meet the enormous mental health need that exists for our patients. This is particularly important given the increased “boarding” of patients in other areas of the hospital as they await final disposition to a mental health facility. It is common for patients who are boarding and in an active mental health crisis to exhibit behaviors that may put them and others at risk. In a Quality Case Report being early released this month in Pediatrics, Statile et al (10.1542/peds.2022-059112) share with us their efforts to reduce violent behaviors that may occur a result of boarding a young patient with a mental health disorder in the emergency department or a general pediatric inpatient service

There were 2 goals for this quality improvement project:

  1. The primary aim was to increase the number of days between Occupational Safety and Health Administration (OSHA) reportable hospital staff injuries resulting from aggressive patient interactions over a one-year period (July 2019-June 2020)
  2. The secondary aim was to reduce the use of violent patient restraints over that same period.

Of note, the authors implemented this program in a quaternary care hospital that already had a mental health team that consulted on every patient who had or displayed behavioral challenges. This was because they were still observing aggressive patient interactions and staff injuries despite their being available. Statile et al utilized Plan, Do, Study, Act cycles to design and modify processes. Hospital staff then utilized a failure modes and effects analysis to improve their ability to anticipate and prevent patient interactions that could lead to staff injury.

Following this analysis, the authors created a behavior response team (BRT) made up of 3 staff members (nursing safety leader, protective services officer, and behavior safety service member) trained in therapeutic crisis intervention. The BRT was set up to respond to emergencies (e.g., similar to a code blue) and also had a proactive component whereby the team would meet to minimize a behavioral escalation. In addition to standing up that team, staff received expanded de-escalation training.

Although the authors did not observe any statistically significant change regarding their primary and secondary goals, the authors (and editors) should be commended for submitting and publishing this article. The authors speculate about why they were not able to find any significant difference. An additional observation is to what extent having a protective services officer (presumably a person with some training akin to a police officer) influences the secondary outcome of whether restraints are used.  Additionally, the last quarter of the reporting period coincided with the declaration of the COVID-19 pandemic which has been associated with an uptick in mental health crises. This uptick in such crises may have led to an increase in patients who exhibited behavior that put staff at risk thus reducing the number of days between OSHA-reportable hospital staff injuries which would be difficult to mitigate with this intervention.

This article contributes to the long-overdue discussion about how best to protect staff and still care for patients who are experiencing a mental health crisis. Healthcare staff injury from patient abuse has led to burnout and contributed to an exodus from the profession. In response, at least 32 states have gone so far as to make it a felony for patients to physically abuse hospital staff.

Given the decades of discussion about mental and physical health parity, perhaps all rapid response teams should have a behavioral specialist imbedded with them. This is akin to a number of police departments that have a mental health specialist available to answer calls for service that may have a mental health component.

Suffice it to say that implementing such a behavioral response team is a work in progress and is one that we, as a profession, should strive to improve and implement—patient care and our safety demands it.

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