February 27, 2023

HOMERuN Collaborative: Prevention and Management of Behavioral Escalation in Hospitalized Adult Patients Focus Groups

The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.

Moderators: Katie Raffel, Claire Westcott, Adam Starr, Courtney Enix   Background: Our group is working to build a system to help prevent and manage behavioral escalation in hospitalized adult patients. We aim to create a better approach to care for patients who demonstrate complex behaviors while creating infrastructure to better support staff, nursing, and providers involved in the care of these patients. We have summarized key themes that emerged regarding approaches and strategies mitigating complex or disruptive behaviors demonstrated by hospitalized adults.

Identification of Patients at Risk for Behavioral Escalation

Majority of participants had no standardized systems for identifying patients at risk for behavioral escalation at their respective institutions. Several institutions have "FYI" flags or behavioral notifications built into the EMR system after a patient has demonstrated complex, disruptive, or violent behaviors. However, there are no clear, uniform standards for which patients receive behavioral care notifications/plans. Participants across several focus groups expressed concern that behavioral "flags" within the chart may have unintentional consequences and potential harm, including introducing preemptive bias.

"We are often reacting as opposed to being proactive."

System-wide Approaches to Mitigation of Complex Behaviors and Management of Behavioral Emergencies

There is significant variability across institutions regarding the presence and make-up of dedicated behavioral health teams that can assist with de-escalation or mitigating complex behaviors. Providers frequently do not have any formal de-escalation training. Participants identified the need to strike a balance between having enough hands-on support during a behavioral emergency event to keep both the patient and staff safe while needing to limit individuals involved to prevent further patient distress and anxiety. After behavioral events occur, there is often no formal debriefing process and variability in establishing a formalized behavioral contract or care plan with the patient to prevent further events. **Institutions that have evaluated demographics of acute behavioral emergencies have identified racial inequities.

"I wish [providers, nurses] had more [training] in this area. And I wish they had more training in trauma-informed care because I think some of this comes from patients who have been traumatized either by a hospitalization or other kinds of trauma, and we trigger it."

Opportunities and Considerations

Consider introducing behavioral or safety risk stratification scores to proactively identify patients at risk for behavioral escalation. Few participants familiar with behavioral risk stratification systems (i.e., Broset score) did note that occasionally scoring systems may have been overly reactionary (i.e., trigging early, automatic Psychiatry consultation when may have not otherwise been indicated, etc.). Need for more formalized de-escalation and trauma-informed care training to better equip providers and staff to care for patients with complex behaviors safely. Introducing a structural checklist for providers, nursing, and staff at the bedside to identify factors that may be contributing to complex behaviors, including substance use or acute withdrawal, history of trauma, mental health conditions, racism, etc. Opportunity exists to learn from Pediatrics interventions designed to manage complex patient and family behaviors.

"Within Pediatrics, there has been a fair amount not only of behavioral emergency response teams but also other proactive solutions."

Key Takeaways: There are limited formal systems to adequately identify patients that may be at risk for behavioral escalation. Providers and staff frequently react to acute behavioral escalation events, rather than proactive identification or prevention. Formalized de-escalation and trauma-informed care training is necessary for providers and staff. Variability exists across institutions regarding the management of patients demonstrating complex behaviors and the presence of dedicated behavioral health specialty teams.

The Journal of Hospital Medicine is recruiting their 6th class of JHM Editorial and Digital Media Fellows. The programs are 1 year in duration (starting July 1) and can be done at each individual's respective institution. This is a great opportunity to gain insights into the editorial, reviewing, and academic publishing process. Perfect for junior faculty looking to engage on a national level, specifically those with an interest in research (though QI/PS and Medical Educators are very much welcome). The Digital Media Fellowship is a great chance for those interested in alternative means of engaging and creating content, as well. Please share widely with your colleagues and staff. Applications are due April 15, 2023.

HOMERuN-Affiliated Study Seeking Partners

Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE) Study

Purpose of RELIANCE: Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of these two FDA-approved medications. RELIANCE is intended to support hospital efforts to reduce the risk of all-cause hospitalization and premature deaths in individuals with COPD.  RELIANCE is Seeking Community-Based Hospitalists: Hospitalists are critical in the development of post-discharge care plans and medications used by people with COPD. We found from preliminary work that identification of people with COPD while they are hospitalized is an efficient recruitment method for RELIANCE. Benefits and Compensation: $500/year honorarium for being a community partner (paid after registration) plus $2,000 per patient enrolled. Option to participate in clinical roundtables with COPD thought leaders. Contribute topic ideas for future grant proposals or publications related to hospitalist care. Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication.  Please reach out to Tiffany.Lee@ucsf.edu if you are interested in participating and would like more information about RELIANCE.

Our next meeting will be on March 10, 2023.

Image Attributions: Vector images from vecteezy.com

Check out the HOMERuN website for more information. If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.