2023 14th Annual NUBE Conference

With behavioral health diagnoses accounting for an increasing number of Emergency Department (ED) visits - over 2 million in 2021 in California alone (1) - our California-based, academic ED has continued to experience a growing number of behavioral emergencies. Although our team developed a semi-structured approach to these acute events several years ago, over the past year it became clear that we needed to refine our process and more clearly-define roles to keep our staff and patients safe. The academic ED environment, with its regularly rotating groups of trainees, can complicate this process by making consistency difficult to achieve. To address the complex problem of managing behavioral emergencies in a coordinated, compassionate way in an academic ED environment, we engaged a multidisciplinary team of emergency physicians and trainees, psychiatry APPs and staff, emergency nurses and technicians, security, and department leadership. By utilizing the design-thinking process, which began with asking stakeholders probing questions about the current process and their needs, we were able to better understand and define the problems surrounding our existing response to behavioral emergencies (2). After refining our understanding, we ideated around potential solutions, which ultimately led to the creation of a two-tiered process for behavioral emergencies: Code 100 for immediate threats that are unresponsive to verbal de-escalation and tension reduction strategies, and Code 99 for escalating situations that have not yet become immediate threats. Based on stakeholder interviews, our team also developed a “post-code huddle” process and checklist to ensure each team member is on the same page following a behavioral emergency event.Given the relatively transient nature of many stakeholders due to our academic setting, our team opted for a multi-pronged implementation strategy. We began with in-person presentations at meetings and educational conferences, which included de-escalation training in many cases. In addition, we used technology to our advantage by creating streamlined workflow flyers that we uploaded on our ED’s online information hub, as well as email communication, printed flyers, and on-shift education at huddles. Due to the constant rotation of trainees in our academic environment, we have implemented regular “pulses” of re-education to improve awareness, while also relying more heavily on nurses and attending physicians who are more longitudinal team members in our ED structure. Since implementing this two-tiered behavioral emergency response process and post-event huddle earlier this year, we have experienced significantly reduced chaos and confusion surrounding many of our behavioral emergencies. While the academic ED environment brings unique challenges, particularly for implementing long-term, sustainable change for critical situations such as behavioral emergencies, it also provides an opportunity to implement innovative approaches - such as design-thinking in this case - and test creative culture-change strategies.

Learning Objectives:

1. Articulate the ways in which a design-thinking approach can be utilized to address structural and workflow challenges for patients with behavioral emergencies in the ED.
2. Summarize the unique challenges of addressing behavioral emergencies in academic EDs, with regularly-rotating groups of trainees.
3. Demonstrate the potential value of a post-emergency behavioral event huddle in improving teamwork and patient safety.