By Talar Baboudjian Stockton

No intervention seemed to be getting through. A patient was threatening to harm themselves on the neurosurgery unit, and Krystal Fox knew she had to act fast.

The nurse practitioner’s last resource would be calling a Code White, which involves security personnel. The experience could be distressing to the patient and staff. Instead, for the first time, Fox paged a service called BERT.

“It was surprisingly easy,” Fox says. “The lead, Jenna, came right away, and made a care plan to support the patient and the staff. It was very successful and we were able to avoid a Code White or having security involved in their care. It made a substantial difference in supporting the patient and staff.”

Jenna Richards is a clinical nurse specialist with the Consultation Liaison Psychiatry team at St. Michael’s Hospital, a site of Unity Health Toronto. Richards and her St. Joseph’s Health Centre counterpart, Glen D’Souza, make up Ontario’s first hospital mental health response team, formally called the Behavioural Escalation Response Team (BERT).

BERT responds to patients with escalating behaviours and intervenes before a Code White occurs. Their work follows the concept of a critical care response team, which is a team that responds to medical units to support patients who are medically decompensating prior to a Code Blue, when a patient experiences an urgent physical health event such as a cardiac arrest or losing consciousness.

The BERT service focuses on creating a safer environment for patients and staff, while improving patient outcomes.

When a patient begins to experience escalating behaviours, such as yelling, swearing, harming themselves or others, staff can page the BERT member at their acute care site, who will respond to help support the patient and staff.

“When you’re in a medical unit, you’ve got a lot of things on your mind, you’re really focused on your tasks at hand, and if a client is experiencing responsive behaviours, it’s really hard to take a step back,” says Richards.

“I try to figure out what’s the root of this issue, why are they experiencing responsive behaviours? I try to give another perspective to the situation on how we can address the unmet need and support the client while they’re here.”

Richards says the BERT service is an important way to acknowledge that the hospital can be an anxiety-provoking place, especially for patients who have experienced institutional and systemic oppression. There’s a misconception that people with responsive behaviours are dangerous, Richards says, but it is important to understand that they are often trying to communicate that they have an unmet need.

“The blame is not on the individual for their responsive behavior,” Richards says. “It’s really looking at what’s the big picture here, and what can we do better to support our clients while they’re in hospital.”

Stephanie Lucchese is the clinical nurse specialist for the Mental Health and Addictions Program at St. Michael’s Hospital. She also is behind the inception of BERT at Unity Health.

When she would respond to Code Whites at the hospital, she remembers staff would often have to use last-resort methods to de-escalate situations, with staff sometimes getting injured in the process. While debriefing with staff, Lucchese says they would always mention how the patient demonstrated warning signs before their behaviour escalated.

“That’s what got me thinking, how can we create a process that can begin right when the patient starts demonstrating these warning signs?”

Lucchese worked with her director, Janet Wilson, and the Mental Health Leadership team, to research possible solutions. The BERT model appeared in their review as an option that had been implemented at hospitals in the United States. Lucchese says research showed the best practice for preventing behavioral escalation is early intervention. Studies also suggested the model reduced restraint use and increased staff satisfaction.

The BERT service at the St. Joseph’s and St. Michael’s sites at Unity Health started in the spring, with two nurses, D’Souza and Richards, providing support during daytime hours during the weekdays.

Richards says she has received positive feedback from staff. They often are relieved when she responds to a BERT call, she says, and they appreciate the extra support.

Katie McTaggart is a charge nurse on the general internal medicine unit at St. Joseph’s. She says the BERT implementation has been helpful.

“It’s a much easier and more familiar point of contact as the charge nurse to help patients they can support with,” she says.

BERT has helped her come up with care plans for patients as well, and McTaggart remarks on how the team will even help out with patient discharge.

Lucchese says other hospitals are contacting her to learn from the BERT implementation.

“They’re interested in the BERT, and I think that shows how needed, how important this program is,” she says.

Back at the St. Michael’s neurosurgery unit, Fox says avoiding Code Whites can prevent patients from experiencing the trauma associated with them and build trust between patients and care providers.

“If we can prevent Code Whites, it will build better relationships with patients, increase their trust in health care, and allow for safer discharges.”

Talar Baboudjian Stockton is a communications intern at Unity Health Toronto.