This week we’ll be discussing an article published in the Colorado Journal of Psychiatry and Psychology by authors Nicoli, Carubia, and Penner. In this article, the authors discuss an innovative service called a Behavioral Assistance Response Team (BART), and the ways in which this service has been effective in integrating pediatric medical and mental health staff to better serve agitated patients in a pediatric setting.

What did they do?

Using electronic medical records from 2015-2017, the authors extracted information provided by a bedside nurse regarding the reason for the BART implementation, the interventions used, and the patient's response to the intervention. In this article, the authors describe the program in the pediatric setting, report data from the past 3 years of BART outcomes, and discuss future directions including possible replication in other medical centers. 

Why did they do it?

As we have discussed before, approximately 20% of youth aged 13-18 are experiencing some kind of mental health disorder at any given time. Medical staff often report difficulties managing individuals with complex psychiatric comorbidities, typically due to insufficient mental health training. As the authors of this article highlight, there are currently no “best practices” identified for managing agitated children in medical settings, and this often leads to staff feeling uncomfortable and under-trained when working with these patients. 

While the need to restrain an agitated patient in pediatric care facilities is rare, medical staff still require sufficient training to best manage these situations. In order to address this gap in practice, the BART was developed. BART consists of a multidisciplinary team of behavioral health and medical staff who intervene when there is potential of immediate harm due to a patient’s behavior. 

How did they do it?

Using electronic medical records, the authors extracted relevant data to BART implementation and used descriptive analytic techniques to identify trends across the data.

What did they find?

In this study, between 2015-2017, there were a total of 105 code BARTs, with an average of 1 BART code per 405 psychiatric admissions to the facility. The most common reason documented for calling a code BART was for an aggressive or agitated patient (61%), followed by danger-to-self (11.4%), other (9.5%), assaultive (8.6%), and out-of-control behavior (8.6%). Interventions deployed included mental health holds (3.8%), therapeutic holds (29.5%), pharmacological intervention (24.8%), and restraint (17.1%). Of those patients who required BART, 17% required multiple interventions. Forty-four patients (42%) did not require any intervention. 

Overall, the number of BARTs remained fairly stable throughout the years included in this study, but the number of patients who were successfully calmed after the interventions increased in the later years. 

What does it all mean (our take)?

The authors of this article discuss an important issue that comes up often in psychiatric care units - how can we most safely and effectively manage the highest severity patient behavior? The utilization of a BART team appears to present an opportunity for healthcare organizations to improve their ability to successfully manage highly challenging patient behavior, without placing this responsibility on under-trained staff. Oftentimes, deescalating such behavior is ultimately challenging and potentially dangerous, and we appreciate the authors putting this work together to demonstrate the potential effectiveness of implementing a BART team in healthcare facilities. We look forward to continuing to see more work published in this domain, as it remains an important issue facing psychiatric care providers.

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