Psychiatric and behavioral crises in medical/surgical and emergency care settings pose a major challenge to hospitals and clinicians. Patients experiencing behavioral crises require complex care and time- and resource-intensive intervention to manage concomitant psychiatric and medical problems. Some studies estimate that the prevalence of comorbid psychiatric disorders with acute physical conditions in hospitals is as high as 46%.1 For these patients, the risks of poor health and care quality outcomes are greatly increased. Psychiatric problems in medical patients are associated with longer length of stay, greater hospital cost, patient injuries, nosocomial infections, and increased restraint use.2,3
While all these outcomes have negative effects on patient health and well-being, restraint is particularly associated with psychiatric or behavioral crises in medical setting and additional harmful patient trajectories. Restraints can lead to further functional decline, poor circulation and cardiac stress, incontinence, muscle weakness, injuries, skin breakdown, and depression.4 While restraint use in hospitals has declined in recent years, management of psychiatric crises and restraint utilization remain significant challenges for clinicians working in nonpsychiatric hospital settings.5 There is also evidence that nurses, physicians, and other clinical staff may hold negative attitudes toward psychiatric patients and feel unprepared to manage behavioral events. Studies of clinician attitudes, knowledge, and skills for behavioral management suggest that nonpsychiatric staff may not be well prepared to intervene in cases of psychiatric comorbidity and may hold beliefs or attitudes that impede therapeutic relationship building and patient-centered care.6,7
In light of the challenges of managing patients with psychiatric problems in medical settings and promoting care quality, there is a need for interventions that target patient, provider, and system limitations that put these patients at greater risk of poor outcomes. In medical settings, rapid response teams (RRTs, also called emergency response teams) have emerged as a solution to acute medical crises, and this intervention concept has recently been considered for adaptation to psychiatric crises.8 Any staff member can activate medical RRTs when they feel a need for immediate bedside assistance for an emergent or acute medical crisis. RRTs have been effective at reducing cardiac arrests and arrest-related death, intensive care unit days, and inpatient mortality.9 Given the success of medical RRTs and their implementation for addressing acute medical crises in inpatient settings, the idea of a parallel psychiatric RRT for acute behavioral crises has recently emerged.10 Although psychiatric RRTs theoretically are promising for addressing behavioral crises in hospitals and reducing restraint utilization, psychiatric RRTs are a new intervention concept and as such have been primarily explored in a quality improvement context. There are not yet established structures, processes, and outcomes for implementing psychiatric RRTs, and best practices for implementation of psychiatric RRTs are not yet known. Given this gap, we sought to integrate the quality improvement and implementation science literature on psychiatric RRTs and identify structures, processes, outcomes, and characteristics of successful implementation associated with this intervention.
This systematic, integrative review searched for articles in nursing (CINAHL) and biomedical (PubMed) databases and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.11-13 Because the review was integrative, any study design including quality improvement and implementation science literature and nonempirical articles (reports, literature reviews, editorials) published in peer-reviewed journals were candidates for inclusion in the review. The review sought studies that implemented or evaluated an RRT specifically for psychiatric or behavioral events in nonpsychiatric hospitals. Psychiatric response teams for nonhospital community settings were also not considered to capture RRTs designed for hospital settings.
Articles were eligible for inclusion in the review if they involved reporting on the implementation or evaluation of a psychiatric or behavioral RRT, included at least 1 licensed health professional on the RRT, and were published in a peer-reviewed journal in English. There was no prespecified time frame for article publication to capture the broadest range of articles possible. There were also no limits on the type of article eligible for inclusion.
The literature review was conducted during January 2018 in CINAHL and PubMed. The CINAHL search terms were as follows: ([Behavior OR psychiatric] AND [Emergency response team OR rapid response team]). The PubMed search terms were as follows: ((“behavior”[MeSH Terms] OR “behavior”[All Fields] OR “behavioral”[All Fields]) OR (“psychiatry”[MeSH Terms] OR “psychiatry”[All Fields] OR “psychiatric”[All Fields])) AND (“emergency response team”[All Fields] OR “rapid response team”[All Fields]). No additional limits were placed on the search.
The search yielded 144 articles. The titles and abstracts of these articles were reviewed to select candidate articles for inclusion in the synthesis that related to the intervention of interest. We excluded articles about medical RRTs for psychiatric care settings, community psychiatric RRTs, psychiatric RRTs for outpatient psychiatric care settings, and studies not related to the topic. There were 7 remaining articles after applying these exclusion criteria and removing duplicate articles. The references of these articles were reviewed to identify additional articles for consideration. One article appeared to be a candidate for the review, but upon further exploration did not meet inclusion criteria; thus, in the end, 7 articles were included in the review. Six of the articles reported on a psychiatric RRT, and 1 article reported an interprofessional educational intervention for addressing behavioral crises in emergency departments. Although this article did not directly implement an RRT, the conceptualization and purpose of the educational intervention were very closely aligned with how actual RRTs were trained and implemented, so the educational intervention was included.
Data extracted from the studies included the design, sample, and setting; activation criteria for initiating an RRT response; team interventions; team members; factors associated with RRT implementation; outcome measures; process measures; balancing measures; lessons learned; and implementation challenges. The 3 types of measures, outcomes, processes, and balancing factors, were identified using definitions of quality improvement measures from the Institute for Healthcare Improvement (IHI).14 Outcome measures reflect how the system impacts the patients' health and well-being. Process measures reflect whether parts or steps in the system are performing as planned. Balancing measures capture whether changes designed to improve one part of the system are causing new problems in another part of the system.14 An evidence table was used to organize this information and compare findings and data across studies. The studies were rated on design strength (level of evidence) and evidence quality using the John Hopkins Nursing Evidence-Based Practice Model Evidence Rating Scales.15 The levels of evidence range from I (randomized controlled trials) to V (expert opinion). The evidence quality ratings range from A (high quality) to C (low quality or major flaws), determined by consistency of results, adequacy of control condition, sample size, ability to draw conclusions, and consistency of recommendations in light of the scientific literature.15 The data extraction was performed by 1 reviewer and is available as Supplemental Digital Content 1 (http://links.lww.com/NNA/A7).
The 7 psychiatric RRTs were implemented in hospital settings at large medical centers, small community hospitals, and a military hospital in the United States. All studies were quality improvement or implementation projects, and as such, all were level V evidence. The quality of evidence was A or B (high or good) for all reports. The literature on psychiatric RRTs is relatively recent; the studies were all published between 2010 and 2017. Most studies implemented the RRT on 1 or 2 units initially, modified, and then expanded to more units or the entire facility.
Psychiatric RRT Structure
Most psychiatric RRTs were led by a psychiatric RN.10,16-18 For these teams, the RN led an interdisciplinary team in conducting an assessment of the situation, selecting and tailoring interventions, developing a care plan, implementing interventions, and debriefing or follow-up education. At hospitals that did not have inpatient psychiatry and thus did not staff psychiatric RNs, the teams were led by trained RNs on the medical/surgical or emergency units who were designated RRT leaders during certain shifts.19,20 In addition to the RN, RRTs included other healthcare professionals and support staff including security staff, psychiatrists, the patient's primary provider, a pharmacist, a social worker or psychiatric social worker, the psychiatric clinical coordinator, nurse aides, hospital police officers, risk management staff, human resources staff, administrative staff, and nursing leadership. At minimum, the teams involved an RN and security staff member with a provider or pharmacist available by pager. One team automatically alerted a pharmacist when the RRT was activated for immediate review of patient medications for adverse reactions.19 Following the RRT intervention and resolution of the behavioral crisis, some RRTs offered debriefing, education, or a follow-up call for the patient's primary staff members who may have been less experienced with behavioral de-escalation.10,16,18
There were several ways the studies activated the RRT including assigning a psychiatric RN to staff the RRT and carry a team-specific pager,16 routing activation calls through a central behavioral health services department who notifies the team members,10 alerting the psychiatric unit charge RN,18 and using a violence risk assessment tool embedded in the nursing workflow.17 Activation criteria (psychiatric/behavioral, biomedical/pharmacological, and other) for the teams are summarized in Table 1.
The RRTs typically tailored and implemented interventions designed to de-escalate the behavioral crisis, starting with the least restrictive and most patient-centered interventions. Immediate interventions included verbal communication, calming techniques, and environmental/milieu changes.10,16-20 The team may have made recommendations for medication administration, medication changes if the event was precipitated by medication reactions or interactions, or individual assignment for the patient.16,17,19 Physical management (ie, physical hold, violent or nonviolent restraints, seclusion) or transfer to a psychiatric unit was considered only as a last resort if the patient was unresponsive to other interventions.16,17,19,20
Outcome Measures and Results
The studies examined the following outcome measures to assess the effect of the psychiatric RRTs: number of RRT calls, number of security calls; number of behavioral health crises, seclusion and restraint usage; behavioral health hours spent in restraints; staff injuries and assaults; staff knowledge and attitudes toward psychiatric patients and behavioral de-escalation; and staff confidence in their own skills for managing behavioral crises changes.10,16-20 Process measures were as follows: number of RRT calls and usages, response length of time, reason for call, interventions used, shift/location, and caller satisfaction (note: different studies conceptualized some of the same measures differently as process vs outcome). One study used a balancing measure of number of patients awaiting transfer to psychiatric units.19 The studies generally found that in the specific settings where they were implemented the psychiatric RRTs reduced utilization of security services, reduced restraint/seclusion use, and reduced staff injuries.16-20 There were small to moderate improvements around staff knowledge, attitudes, and self-efficacy related to managing psychiatric patients and behavioral de-escalation.10,17,18,21
Team Training and Implementation Preparation
To prepare the psychiatric RRT personnel for implementation of the intervention, several education and training programs were used. Projects that involved psychiatric staff who already were experienced with behavioral de-escalation tended to use less intensive trainings, such as online courses with in-person training, simulation scenarios, or a unit in-service.10,16-18 The trainings were more extensive for nonpsychiatric staff who would be responders.19-21 One interprofessional educational program designed to teach behavioral de-escalation skills used a simulation-based curriculum with standardized patients in scenarios that escalated to restraint application.21 Some or all of the training was also incorporated into preexisting annual staff educational programming times to make attendance less burdensome to clinicians.16-21
Implementation Challenges and Benefits
Several studies relied on the Iowa Model of Evidence-Based Practice for Implementation to frame the RRT implementation process with good success.10,18,22 There was also a pattern of piloting the intervention on 1 or 2 units, making intervention modifications based on strengths and limitations of the pilot and then implementing the RRT more broadly on additional units or the whole institution.10,18 The articles noted the importance of securing administrative/leadership support for the intervention and, if the RRT involved psychiatric nursing staff, securing support from psychiatric services.16,18,21 Having a provider on the team appeared to be key for making medication changes or other provider orders.17 Ongoing implementation challenges noted in the articles were how to ensure the availability of psychiatric RRT responders (particularly for hospitals without inpatient psychiatric staff), how to ensure consistent training for team members and general staff awareness of RRT resources with staff attrition and turnover, excessive resource drain, gaining staff and leadership buy-in, and staff waiting too long to all the psychiatric RRT or continuing to call security 1st. There were unexpected benefits to the psychiatric RRTs realized during the implementation processes. Two reports found that role modeling behavioral de-escalation, debriefing, and education for non-RRT staff on participating units was a critical component of intervention success and eventually reduced need for the psychiatric RRT altogether as staff improved their own behavioral de-escalation skills.10,16 Another study found that the psychiatric RRT led to greater awareness of assessing, diagnosing, and treating acute delirium and alcohol/nicotine withdrawal.16
This systematic, integrative literature review synthesized reports from nursing and biomedical literature on psychiatric RRTs and their implementation in hospital settings. This intervention appears to be relatively recent and has not yet been tested in a research context, but in quality improvement and implementation studies, psychiatric RRTs were successful at reducing utilization of security services, restraint/seclusion use, and staff injuries while moderately improving staff knowledge, attitudes, and self-efficacy related to managing psychiatric patients and behavioral de-escalation in the specific settings where they were implemented. The studies were evaluated using patient, staff, and process measures. Challenges reported in implementing the teams were related to resources, leadership support, appropriate team utilization, and consistency of training. Benefits of team implementation were reduced need for the psychiatric RRTs over time as nonpsychiatric staff saw role modeling of behavioral de-escalation and grew in their own skills and better identification of biomedical and pharmacological causes of behavioral crises. The findings around reduced need for the psychiatric RRTs over time due to role modeling and education are particularly promising, as well as the positive effects of psychiatric RRTs even for hospitals that do not have inpatient psychiatric staff. These findings suggest that the RRT staff training, debriefing, and educational follow-up are critical components of sustainability for seeing improvements in patient care quality around behavioral health.
To date, scholarly work on psychiatric RRTs has been limited to quality improvement and implementation projects, and as such, the findings from this review are not widely generalizable, and there is not yet a robust evidence based on the effectiveness of psychiatric RRTs for improving patient outcomes (ie, reduced restraint usage). However, the positive findings reported for the specific implementation settings in the studies reviewed provide preliminary support for considering psychiatric RRTs for hospitals implementing quality improvement around behavioral crises and testing psychiatric RRTs with more rigorous methodology in the future. There is a robust implementation science literature on how to successfully implement a medical RRT.8,14 The IHI recommends an implementation process involving: 1) engaging senior leadership; 2) identifying key staff for RRTs; 3) establishing alert criteria and a mechanism for calling the RRT; 4) educating staff about alert criteria and protocol; 5) using a structured documentation tool; 6) establishing feedback mechanisms; and 7) measuring effectiveness.14 Some psychiatric RRT interventions used elements of this implementation process, and future implementation studies should consider incorporating the full process. Additionally, future studies or implementation projects of psychiatric RRTs may benefit from measuring staff engagement in the implementation process or utilization of the intervention, including engagement in learning or educational components of the intervention as this aspect appears to be related to reduced RRT utilization and improved outcomes over time.
There are strengths and limitations to this review that should be noted. The evidence base for psychiatric RRTs is currently small and limited to quality improvement or implementation project with no established evidence for their efficacy from research. Without control conditions, baseline measure, and other methodological elements of research, it is impossible to determine the efficacy of the interventions at this time. It is possible that the intervention is in effect at other hospitals not included in our review but has not yet been evaluated or published. The specific search terms and inclusion criteria selected for the review may have limited articles using different definitions or terminology, and a single reviewer performed the data extraction. Despite these limitations, there are strengths to the review as well. Systematic search methods were used to identify articles from the nursing and biomedical literature, and we allowed for a broad range of project methodology and article types to synthesize as much existing evidence as possible. The review focused specifically on implementation factors associated with psychiatric RRTs, providing a roadmap for other hospitals that wish to consider a psychiatric RRT for quality improvement around quality of care for behavioral crises or for future research studies that may test the efficacy of psychiatric RRTs.
Psychiatric RRTs have demonstrated promise in quality improvement projects for reducing adverse patient outcomes related to behavioral health in hospitals. The synthesis of literature on this topic provides an implementation roadmap for other institutions seeking to improve patient care quality around behavioral health by identifying team structure, activation criteria, team interventions, team training, outcome and process measures, and implementations benefits and challenges. There is opportunity for hospitals to support nursing and other patient care staff by providing resources for patient behavioral events and equipping nonpsychiatric nurses with behavioral de-escalation techniques they can incorporate into their own practice.
The authors thank Cecelia Crawford for providing expertise in the construction of this manuscript.
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