Paradigm shift proposed away from containment-based mentality
A pregnant woman with an unknown medical, obstetrical, and psychiatric history presents to the perinatal triage center at 2am with a vague chief complaint of abdominal pain. The patient is responding to internal stimuli, inserting her hands into her rectum and vagina, shouting at staff, demanding pain medication, and refusing obstetrical evaluation.
The obstetricians notice that her hands appear bloody after inserting them into her genitalia, thereby raising concern for an acute pregnancy complication. However, they cannot perform an evaluation due to her combativeness. A hospital security code is called, in accordance with hospital protocol, to obtain assistance.
Security appears within moments. The obstetricians determine the need for an emergent psychiatry consult shortly after the arrival of security to help manage the patient’s psychosis. But there is no psychiatric care provider present in the hospital overnight and no inpatient psychiatry unit. The psychiatrist on home-based call recommends intramuscular haloperidol for sedation so that the obstetricians may proceed with their evaluation.
Intramuscular haloperidol is not readily available on the obstetrical unit and is delivered from the pharmacy after another delay. However, none of the obstetrical staff or security personnel feels sufficiently experienced to administer the injection without risking personal injury secondary to the patient’s agitation.
The nurse manager assumes the responsibility of administering the sedation but inadvertently moves within striking distance of the patient. Security intervene by physically restraining the patient though are consequently injured themselves.
A medical evaluation is performed by the obstetricians after a total delay of 30 minutes. Fetal monitoring reveals a distressed heart rate of unknown duration. The patient is taken for an emergent Caesarean delivery.
‘Disjointed, ineffective, unsafe’
“Containment-based responses without a clinical emphasis foster fragmented, delayed care,” says Carmen Black Parker, MD, Department of Psychiatry and Health Behavior, Augusta University, writing a perspective in the July/August issue of Psychosomatics.
Carmen Black Parker, MD
Many US academic and community hospitals do not have the funding or staffing for an overnight, in-house psychiatrist. Similarly, staff trained in providing safe clinical care to agitated patients may not be readily available to respond to a mental health emergency (MHE).
“The cumulative result [in the fictitious vignette above] was a disjointed, ineffective, and unsafe delivery of patient care as providers attempted to function outside their normal realm of expertise,” says Dr. Parker. “The resulting delays in care for this precipitous delivery could conceivably exacerbate clinical morbidity/mortality for the mother and baby with ensuing escalations of procedural requirements and hospital length of stay.”
Enactment of containment-based security codes in an MHE are insufficient to address comorbid medical and psychiatric needs, says Dr. Parker. Instead, she proposes a “paradigm shift from a containment-based mentality” to a model prioritizing treatment-based intervention.
“Containment-based responses without a clinical emphasis foster fragmented, delayed care.”
A psychiatric rapid response team, often referred to as a behavioral emergency response team (BERT), is designed to provide the physical safety of security codes while simultaneously advancing care by recognizing and treating the psychiatric origins of the disruptive behavior, so that primary teams are able to proceed with medical and surgical care.
“The BERT model is a particularly appealing construct for MHE intervention because its interdisciplinary, treatment-based paradigm offers a more comprehensive viewpoint,” says Dr. Parker. “A collaborative care design renders BERTs as viable for smaller, community-focused institutions, with little to no access to psychiatric practitioners or funding, as much as they are for major academic or metropolitan powerhouses, with vastly greater financial and staffing resources.”
Moreover, “hospitals are more inspired to support BERTs because any investment expenses are recognized to be offset and recouped by the cost savings potential of attenuating adverse MHE outcomes.”
Before an acute MHE ever occurs, a climate of preparedness encourages medical providers to monitor each inpatient admission for risk factors and early indicators of decreased verbal expressivity and impaired volitional behavioral control. This includes examining toxicology screens and past psychiatric diagnosis, assessing for signs of active delirium or disorientation, and remaining mindful of any past episodes of agitation.
Should preventive efforts prove insufficient, BERT codes function similarly to other medical emergency codes—by heralding the prompt arrival of the primary team’s clinicians with the notable addition of hospital security.
“The critical component of a BERT intervention is the around-the-clock coverage and attendance of a BERT nurse and/or technician who has been trained in crisis de-escalation techniques for both patients and providers, providing appropriate doses of chemical sedation when warranted, and [knowing] how to safely deliver care to behaviorally-distressed patients,” says Dr. Parker. “They need not be funded as full-time, mental health clinicians. Rather, true to the nature of collaborative care, they may be cross-trained members of existing general medical/surgical teams.
“The presence of a BERT nurse and/or technician helps rapidly address the comorbid MHE without demanding additional psychiatric resources by functioning as surrogates of C-L psychiatry; they provide direct clinical oversight to primary teams who would otherwise be unsupported in navigating clinical scenarios extending beyond their typical realm of training and experience.”
Benefits of BERTs
The Psychosomatics paper includes references to evidence that BERTs:
• Reduce the number of assaults.
• Decrease the use of physical restraints.
• Result in fewer security codes being implemented for active violence.
• Reduce the total number of combined security and BERT calls.
• Reduce length of stay.
• Medication initiation or adjustment is required to achieve psychiatry stability in only 36%-53% of BERT calls.
• BERTs have been successfully implemented without increasing direct financial expenditures and are shown to indirectly reduce financial losses by reducing the frequency and cost of patient/staff injuries.
• BERTs increase provider satisfaction and confidence in navigating MHEs in addition to positively impacting staff perception of MHEs.
“These gains may be achieved without increased dependence on C-L psychiatry,” says Dr. Parker. “Studies indicate that the C-L, or on-call psychiatrist, was involved during only 29%-36% of BERT calls, and one study found that new psychiatry consults resulted after just 8.3% of calls.
“Therefore, BERTs allow C-L psychiatrists to expand their sphere of influence, without necessitating their physical presence, by overseeing and empowering others to possess the skills needed to autonomously manage MHEs.”
“Psychiatric rapid response teams help rapidly address acute comorbid psychiatric needs, without demanding additional psychiatric resources, by functioning as trained surrogates of C-L psychiatry.”
Dr. Parker concludes: “Behavioral emergency response teams re-establish patient care within the intervention without omitting security containment.
“They help rapidly address acute comorbid psychiatric needs, without demanding additional psychiatric resources, by functioning as trained surrogates of C-L psychiatry, as they provide direct clinical oversight to primary teams who would otherwise be unsupported in navigating clinical scenarios extending beyond their typical range of expertise.”
She adds: “Countless opportunities to medically intervene upon MHEs are being overlooked due to a national tendency to misperceive these entities as security-based functions.
“These missed treatment opportunities may potentiate reduced quality in patient safety indicators, adverse outcomes manifested in avoidable morbidity/mortality for patients, increased incidents of workplace violence for health care providers, vast financial losses to insurance and hospital systems, and decreased patient and provider satisfaction.
“The ultimate goal is to create a standardized language of emergency codes, policies, and protocols that elevates psychiatric emergencies to equal footing as our medical counterparts. The safety of our patients and colleagues depends on this diligence.”
The full perspective, Psychiatric Emergencies in Nonpsychiatric Settings: Perception Precludes Preparedness, is here.