1. Behavior Response Team

2. At the core of Gundersen’s strategic plan is the ideal that we will enrich every life. The Behavior Response team is being initiated to increase the care and safety of our patients and our staff. Data collected by our security department has shown a steady increase in incidents involving agitated and aggressive patients. Staff feedback is that they are uncomfortable with their own skills and/or available resources for assistance in these situations.
Each situation involving an agitated patient will be unique based on the patient’s condition as well as the comfort level and experience of the staff involved. This course is designed to provide you with information about the team and how to call them for help when needed.
We also know that your perception of the experience is going to change each time you are involved in a crisis. It will take time and experience for you to become more comfortable with these types of events. We anticipate uneasiness, but we also hope that will decrease over time and with appropriate resources in place to assist you.

3. Objectives At the completion of the course staff will be able to:
Identify potential patient situations to call the team
State the process for calling the team
List which roles will respond to the call
Please take a moment to review the objectives listed.

4. What is it? Behavior Response Team to assist in CRISIS management
Patients ONLY at this time
The function of this team is to assist in a crisis event involving agitated or aggressive behaviors displayed by patients.
You may hear several different names for this team; behavior response team, B – R – T, or “bert”.
The team is currently designed to care only for patients in the inpatient setting. There are a few inpatient areas that are out of scope based on the patient care they provide and available resources already in place. These areas are: Emergency Services, the Operating room, Pediatrics, Pediatric Neonatal ICU, and Inpatient Behavioral Health. Outpatient areas, as well as family and other visitors are also out of scope but will be addressed in the future.
A new policy will outline the goals of the team, the process to activate the team, and the roles and responsibilities of the team members.

5. When do you call the BRT?
After the Primary Team has been notified and is unavailable
Immediate crisis/dangerous situation that requires more than security
Because each situation will be different, it is difficult to identify clear criteria for calling the crisis team.
Security staff are always available to assist with escalating patients and can be notified by phone or by pushing the duress button.
The times to call the behavior response team are when you feel you may need medical interventions. Most often this includes medications and/or restraints. The primary team should always be notified first if the situation allows. If the crisis happens without warning or if the primary team has been called and they are unable to respond themselves or do not feel they have the skill set to intervene, then the crisis team can and should be initiated.

6. Who should initiate the call?
RN assigned to patient
Charge RN
If any other staff member identifies a crisis or an escalation in behavior, the bedside RN or charge nurse should be notified
The decision to activate the behavior response team should be done by the bedside nurse or the charge nurse. Any staff member that identifies a crisis or a potential crisis should notified the bedside nurse or the charge nurse. They have knowledge regarding the patients specific situation and may be able to put other interventions into place to avoid the crisis.
The task of actually placing the call can be delegated to any staff member.

7. How do you call it? Press your duress button Dial 911
This notifies your coworkers that you have an escalating situation
Dial 911
Tell the operator:
Your location: building, floor, department , room number, closest elevator
Nature of the emergency (behavioral)
Your name
Your callback number.
Stay on the line
When faced with a crisis situation, staff should continue to push their duress button first. This notifies security, and also notifies the other staff on your unit. After pushing the duress, you should call As with other emergencies, tell the operator:
Your location, including the building, floor, department , room number, and the closest elevator
The nature of the emergency
Your name and
Your callback number
It is important to stay on the line until the operator tells you to hang up. This ensures that they have all needed information.

8. Who is on the team? Hospital Operations Manager Security Hospitalist
When the team is activated, expect to see the following staff respond:
Hospital operations managers or HOM. There role is to lead the team. They can call for additional resources as needed including but not limited to:
A Behavior Health Nurse
A Recreational Therapist
The Pharmacy
Spiritual Care
Social Workers
andSafety
Similar to codes and MRTs, HOMs are the primary role responsible for documentation of the crisis event. Details of documentation required will be discussed later in the course.
Security will respond to assist with any safety issues. They are trained in crisis prevention techniques and can assist with physical restraint of the patient.
The hospitalist will respond to assist with medical management of the patient and potential transfer to a more appropriate unit for continued management.

9. What do I do while waiting for the team?
Maintain safety for all
If too dangerous, stay out of patient’s room
Use the team if you need to interact, never 1:1
Get the BRT pack
After calling for the team, it is imperative to maintain safety for all involved. If the situation seems dangerous, you should wait for the team to respond before continuing any interaction with the patient. If any interaction is required, it should still be done as a team.
Someone from the unit should also retrieve the BRT pack.

10. BRT Pack Where is it? What is in it? Soft-restraints
4 point Restraints
Trauma scissors
Gauze
Spit Mask-3
Isolation Gowns-3
Nitrile Gloves-3 sets
Restraint Documentation Cheat Sheet
The BRT pack can be found wherever your unit’s crash cart is located.
Within the pack you will find the items listed above.
If the pack is used, Logistics should be called for a replacement.

11. Documentation for mechanical restraints
Resource for restraint documentation:
Violent Restraint documentation
Help…can’t link the documentation guide?
To assist staff in meeting all requirements for restraint documentation, simply enter “yes” in the restraint section of the Body System flow sheet. Remember that it is the intent of the restraint use that identifies if it is protective or violent. In the situation of the BRT, we would be using a violent restraint. The yes entered will then cascade all required rows for documentation into the flow sheet.

12. Here you can see the added sections and rows that need to be completed
Here you can see the added sections and rows that need to be completed. For further information, please reference the restraint policy and/or the restraint documentation guide attached to the policy.
The BRT pack will also contain a quick reference guide to assess with restraint documentation.

13. Chemical Restraint Defined as: Orders Documentation required
“A drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”
Orders
Medication
Chemical Restraint
Physical Hold Restraint order
Documentation required
In addition to mechanical restraints, the provider may order a medication to assist with managing the patients behavior. The majority of time, if a medication is given during a BRT assisted incident, it will meet CMS criteria to be a chemical restraint.
The definition of a chemical restraint is “a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition.”
When administering a chemical restraint, you will need to:
Have an order for the medication and the chemical restraint
Document assessments as indicated in the chemical restraint order

14. Chemical Restraint Orders
Monitoring/Assessments must be done:
every 15 minutes x4
every 30 minutes x2
every 60 minutes x1

15. Chemical Restraint Documentation
The intent of a chemical restraint is to control violent behavior.
Documentation is the same as a violent mechanical restraint

16. Additional Documentation
BRT form
Patient Related Event Note
This is a copy of the BRT form that should be completed during the crisis. These forms can be found within the BRT pack. This form will eventually be located within EPIC to chart to. After completing the paper form, it should be placed in the red patient folder. When the patient discharges, it will then be scanned into EPIC. In addition, after the crisis is over, bedside staff should complete a patient related event note.

17. At this time, the BRT should be identified in the “other” section of the patient related event note. Based on information gained during debriefing sessions, we can identify what additional information would be helpful within the patient related even note and make adjustments as needed to the template.

18. After the event Safety huddle (if needed)
RL6 for any patient injury sustained during event
Employee incident report for any employee injury sustained during event
Expect debrief with CNL or Clinical Manager
After the event, it is very important to make sure that all involved parties are cared for and feel back in control If needed, a safety huddle should be conducted.
Safety huddles help us look at system processes and patient specific information to make future changes. Any patient related injuries should have an RL6 event entered. Any staff injuries require an employee incident report to be completed. If needed, staff should follow up with Employee health as well.
Clinical nurse leaders and/or Clinical Managers will be debriefing with staff involved to help clarify the process and assess any changes that may be needed to improve the process. In addition, data will be collected to help us make future decisions related to the care and management of behavior escalations.

19. Safety is at the core of enriching every life, for both patients and staff. Thank you for completing this course. If you have further questions, please connect with your unit leadership. They can assist with finding the answers to your specific questions.