An Integrative Literature Review of Psychiatric Rapid Response Teams and Their Implementation for De-escalating Behavioral Crises in Nonpsychiatric Hospital Settings

Abstract

OBJECTIVE To synthesize articles exploring the implementation of psychiatric rapid response teams (RRTs) for behavioral crises in hospital settings. BACKGROUND Psychiatric/behavioral crises in nonpsychiatric hospital settings can lead to restraint use, staff injuries, and poor patient outcomes. Psychiatric RRTs may provide a solution, but they are a new, understudied intervention, and their implementation varies across institutions. METHODS A systematic, integrative literature review of nursing and biomedical literature yielded 7 articles about psychiatric RRTs. Data were extracted on RRT structure, processes, outcomes, and implementation. RESULTS Psychiatric RRTs were structured as a nurse-led, interdisciplinary intervention. When implemented using evidence-based models, they reduced security calls, restraint use, and staff injuries while moderately improving staff knowledge and self-efficacy. RRTs that included education, debriefing, and role modeling appeared to increase staff behavioral management skills and eventually reduced the need for RRTs. CONCLUSIONS Psychiatric RRTs have demonstrated promise in quality improvement projects for reducing adverse outcomes related to behavioral health in hospitals.

A Call for Behavioral Emergency Response Teams in Inpatient Hospital Settings

“…6 Some US hospitals have independently pioneered behavioral intervention teams, often called behavioral emergency response teams (BERTs). 2,4,7 BERTs are a heterogenous mixture of interdisciplinary, psychiatrically trained team members who deploy to behavioral emergencies across the hospital, similar to the way that medical RRTs respond to medical crises. But BERTs are by no means the only solution to the problem of providing more ethical interventions for behavioral emergencies.…”

“…Here, we briefly summarize 2 recent literature reviews that extensively analyze and report promising data about BERTs' team composition, risk management strategy, and activation criteria, as well as financial considerations and clinical and workplace safety outcomes. 2,7 At a minimum, all BERTs include a primary, psychiatrically trained clinician and some form of secondary security assistance. The primary BERT clinician might be a psychiatrist, a mid-level practitioner, or a floor nurse, for example.…”

“…When patient-clinician relationships become fraught, interdisciplinary BERT members are all trained to preserve patient-centeredness through de-escalation and problem solving while simultaneously reprioritizing proactive clinical investigation and treatment as indicated. 2,7 Security staff are available but frequently are not involved or even seen by patients in these cases. Thus, a BERT is ideally activated before a patient demonstrates an outward act of internal distress akin to a behavioral emergency.…”

“…As primary teams witness BERTs de-escalate and favorably interact with patients, however, fewer BERT calls are required, as staff members become more skilled themselves in responding to behavioral crises. 7 Ethics of Behavioral Emergency Responses Using evidence-based practices for acute behavioral crises should not be a voluntary, optional undertaking. Just as the 100,000 Lives Campaign pushed proactive care through RRTs, so must BERTs or clinically equivalent interventions become standard of care for acute behavioral emergencies.…”

“…However, these efforts do not provide security backup and lack the fail-safe reliability, efficiency, and robustness of other medical emergency protocols like BERTs. 2,7 Furthermore, the presence of a lone psychiatrist is insufficient to safeguard against the multifactorial inputs that contribute to poor medical and safety outcomes or iatrogenic discrimination. 2 Beneficence also requires removing financial barriers to patient care.…”