6 Years of a Behavioral Emergency Response Team: Challenges, Lessons Learned & Team Development

Background: A Behavioral Emergency Response Team (BERT) is an evidence-based clinical code team that employs the crisis team leader model to rapidly de-escalate violent and / or disruptive behavior using the least restrictive means. BERT teams typically include mental-health professionals with secondary security support. Recent papers have argued that establishing BERT to respond to behavioral codes in the general medical hospital can help deliver better and more equitable care to patients.ⁱ

Methods: The BERT service at NYU Langone Medical Center (NYULMC) was established in 2017. At the medical center, any hospital staff member can activate BERT if concerned that an admitted patient’s behavior is imminently violent, dangerous, or disruptive to the environment. The BERT RN acts as the crisis team leader and directs appropriate interventions including de-escalation, environmental modifications, and utilization of restraints when necessary. Pharmacologic treatment recommendations are made by the BERT Psychiatrist in conjunction with the primary team. Afterwards, all staff involved participate in a debriefing and formal psychiatric consultation is offered when appropriate. In this study, we examined the first 6 years of BERT trends (n = 3,500 events) including: BERT activation patterns, interventions, and contributing factors.

Results: Annual number of BERT activations have steadily increased since inception, from 355 in 2017 to 827 in 2022. In the first three years (2017-2020), verbal de-escalation was the most frequent intervention utilized (46.5%), followed by IM/IV medications (39.2%). Restraints rarely occurred (3.2%). BERT interventions for 2020- 2022 will be analyzed and presented. In a 5-month sample of BERTs from 2022 (n=309), the most common precipitating factors for BERT included: Delirium (57%), Dementia (27%), Chronic Poor Coping (13%), Chronic Poor Impulse control (12%), Acute Substance Withdrawal (9%), Pre-existing Psychiatric Conditions (7%), Patient-Team Communication Problem (5%), Language Barrier (4%), Uncontrolled Pain (3%). A 3-month analysis of BERT activations relative to formal CL psychiatric consultation for a subset of patients in 2022 (n=115) showed 61% of patient with BERT activation had psychiatric consultation during their medical admission. For patients with at least 1 BERT who never receive formal psychiatric consultation, 82% do have a repeat BERT.
Discussion / Conclusions: Our data shows that BERT is an increasingly utilized hospital resource that most often employs verbal behavioral de-escalation techniques. Symptoms related to delirium and dementia, rather than pre-existing psychiatric conditions, are the most common factors identified as contributing to BERTs. Although less common, BERTs arising from poor patient-team communication, language barriers or inadequate pain control, represent nearly 10% of the identified precipitating factors for BERTs. These patterns are consistent with existing literature and represent a valuable opportunity for medical teams to enhance the delivery of patient-centered care. A prior study found that most behavioral emergencies stem from psychiatric emergencies (such as delirium) and that there are instances where patient psychosocial distress is exacerbated by clinicians’ behaviors. ⁱ

[i] Parker CB, Calhoun A, Wong AH, Davidson L, Dike C. A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings. AMA J Ethics. 2020;22(11):E956-64.