Rapid Response, Reliable Change

Transcript of the Video

**0:08**
Good morning. Welcome all to the sunrise session sponsored by Vistelar.

**0:09**
My name is Dr. Julibeth Lauren. I'm currently serving as the chief clinical officer for Vistelar, and I'm here to present today for you, um, a presentation on- Rapid Response, Reliable Change: A BERT Program's Replicable Model, and, the One-Year Results that were done by Children's of Nebraska. Your speaker today is Dalton Meister.

Dalton serves as the chief safety and wellbeing program' manager at Children's of Nebraska, and he leads the behavioral emergency response team.
He was trained at the University of Michigan, and he's a clinician researcher.

**0:47**
One- of the things that, uh, we wanted to, uh, bring to you today about the behavioral emergency response team is everybody remembers back in about two thousand and four when the Ten Thousand Lives campaign for IHI came into play with the rapid response teams and the wild success that realized. And since then, we've recognized that the behavioral emergencies weren't receiving that level of attention.

**1:07**
They were treated more as a security event rather than a clinical event.

**1:17**
And we know that our regulatory agencies tell us that they are, in fact, a clinical event, and they are our patients in our care, and they are in our charge as clinicians.

**1:24**
Um, so one of the things that we've seen happen recently in the literature is an expansion of the behavioral emergency response teams, not just to put them in place for emergencies, but to put them in place for proactive and preventative measures, and that's what Vistelar is all about.

**1:44**
So with further ado, I'm gonna turn it over to Dalton Meister, and I will be running around with the mic for questions as we go.

**1:50**
Welcome, Dalton, please.

**1:53**
Wonderful. Can everyone hear me all right? Fantastic.

**2:03**
Well, good morning, everyone.

**2:04**
How's it going? Good. Rock and roll. Okay.

**2:07**
My name is Dalton Meister. I'm with Children's Nebraska, as Dr. Lauren had mentioned, and I'm excited to share a little bit about how we built and sustained a behavioral escalation response team at Children's Nebraska, not only to create a program, but also to be part of a broader prevention and response service to moments of crisis for children' in our care.

**2:25**
We were really focused on helping to identify earlier opportunities to meet children' at moments of dysregulation, to, support in a response that was coordinated, evidence-based, and trauma-informed. And we wanted to make sure that we could tell our story as how you can turn moments of urgency into moments of structure, how you can help turn that structure into practice, and then how you can turn that practice into meaningful results and change for the children in your care.

**2:50**
So before we begin, just wanted to note that this presentation is primarily for educational purposes. It reflects my perspective as a presenter and does not necessarily constitute medical advice or official organizational policy of Children's Nebraska or Vistelar. Additionally, we have also disclosed our organization's relationship with Vistelar, um, in this presentation.

**3:10**
Um, they are not paying me to be here. They're not providing me benefits.

**3:15**
They did sponsor me coming to the conference. I wanna be ethical in any of those disclosures. Um, but otherwise, the views represented within my portion of the presentation just constitute how we prepared a BERT team with support from Vistelar's program, um, in our context. So what are we going to cover today? We're going to do three things together.

**3:34**
First, we're going to examine the pressures that are pushing nursing leaders to strengthen behavioral escalation response. Second, we are going to evaluate how leadership and operational structures made an enterprise BERT implementation possible.

**3:43**
And third, we're going to identify practical strategies that you can take back to scale, sustain, or adapt this work in your own setting.

**3:55**
Our goal is not just a reflection on our work, but how it can translate into actions that may provide support to you and your efforts in your context.

**4:02**
So before we begin and talk about the design of our BERT program, I wanna first ground you in who we are as an organization, because this work is inseparable from how we care for children at Children's Nebraska.

**4:15**
Our approach is rooted in a trauma-informed philosophy that centers safety, that focuses on dignity, connection, and the recognition that behavioral escalation is often a child's way of expressing distress, unmet needs, or feeling that they are not in control in a particularly hard moment.

**4:31**
Has anybody ever witnessed a kiddo feeling scared or out of control during a hospitalization? Just a raise of hands.

**4:36**
Right. It's normal. Hospitalization is hard, and this is something we wanna make sure that we can have as a responsive service to those really hard moments when the feelings come up really fast.

**4:46**
So Children's Nebraska is Nebraska's only dedicated children's hospital, and that gives our work a very clear leadership imperative. From Omaha, we serve childrens and families across our state, across the region, and from forty-five states represented in our care.

**5:00**
We're a two hundred thirty-one bed level I pediatric trauma center with more than fifty subspecialties in pediatrics, thirteen outreach clinics, and a dedicated behavioral health and wellness center that came this year, which has been a really exciting adjustment and change. In addition, um, we are a large, complex pediatric system with both extraordinary reach but also extraordinary responsibility to our community.So what is our commitment to our community? When we talk about this responsibility, what do we say we're going to do, and how are we going to tie BERT back to this? Because it can't be separate from that commitment. How can you integrate these types of programs? So to the point previously that Dr.

**5:33**
Lauren mentioned, it's not a response, but it's truly integrated into the very care that you're providing to children and families at every level.

**5:43**
At Children's Nebraska, our mission is to improve the life of every child, and our vision is to lead in children's health.

**5:48**
That means that we are trying to build systems that really focus on helping children, families, and care teams move through moments of distress with safety, dignity, and connection. We're gonna connect that back today through the way we structured our BERT, and hopefully that can be helpful in kind of tying to your mission and values as an organization as you build out or continue to build your BERTs.

**6:07**
Um, from there, our values are not just words on a slide. They are operationalized in this work through how we innovate to develop new iterations of the BERT program, how we collaborate to co-design it across professions, how we focus on accountability through reflective practice and the insights that we get from our debriefs to help us build stronger BERT processes, and also how we develop respect not only for our patients and families, but for our team members.

**6:32**
How do we show up in these hard moments and normalize that it's okay to call for additional support, it's okay to need additional support with case conceptualization, it's okay for certain situations to exceed what's available in the resources of a unit, and that we can bring those resources to you to help support you in hard moments, similar to medical RRTs? And finally, excellence.

**6:50**
How can we provide the very best care possible, grounded in all the values, philosophy, and beliefs we're talking about to make sure that it's not only extraordinary for patients and families, but also helps our team to achieve well-being? And so what I'm hoping you'll hear today is how BERT has become a practical way of realizing and operationalizing these values and this commitment in the work that we do. We grounded it first in a philosophy. So our focus is, as a BERT team, how do we integrate our larger approach to care and create it within a larger umbrella? Our approach to behavioral health practice as Children's is not really around crisis, but it's built on a full continuum of prevention, early intervention, response, and continuous improvement, and BERT can't be separated from this.

**7:33**
We have really focused on making sure that at the very center of the work that we do, in and alongside the child, is a trauma-informed, whole-person-centered model that prioritizes the safety, dignity, equity, and people-first culture for children, families, and our team members.

**7:48**
And BERT lives within that larger system and is one expression of how we do that work day in and day out, help to continue to care for patients and families, and also make sure that we are taking care of children across our organization. So what was our approach? We're kind of getting down to the operational level, and then we're going to get really deep into the BERT.

**8:09**
Think of BERT as nested within this operational structure. At Children's Nebraska, it is not just our philosophy, but how we turn that conceptualization into operational practice. We have developed a larger safety and well-being approach, that's the program I help to support at Children's, that really focuses on making sure that we are aligned, integrated, and accountable to the philosophy we've discussed.

**8:30**
The Safety and Well-Being Council is at the top of that structure. They help to define strategic priorities, to create the philosophy itself, to create empowerment principles that we focus on engaging every work group and team in. From there, we have integration leads.

**8:43**
How do we take that philosophy and move that into practice? What are the key areas our patients, our families, our teams are identifying as areas of distress within the context of care? How can those relate to behavioral determinants? How can those relate to medical determinants of care? What's the intersection between those two, and how can we care for folks in those hard moments? We then develop committees.

**9:03**
Think of those as smaller buckets within the larger bucket that focus on specific things. Workplace violence prevention, clinical effectiveness, building safer infrastructure and environments in our care, and then also data and metrics.

**9:14**
How can we, across those committees, track some of the key measures, metrics, but also key APIs that we are working on within committees to help have a larger effect? And then reporting up to each of those committees is a large group of work groups, with BERT being one of those work groups.

**9:30**
We have a cascade of work groups that go across the committees and really focus on key specific projects.

**9:35**
Those projects could be in a specific department. They could be in an environment. They could be across the enterprise. As I mentioned before, we're a large organization that has primary care, specialty care, home health, an acute hospital, and a behavioral health and wellness center, and sometimes we're spanning that whole scope with projects.

**9:50**
Sometimes it's contained to the medical center, which is the BERT team we'll talk about today.

**9:58**
And so what happened? How did we do what we did, and what did this bring us in terms of insight, and how did we get to you today? We wanna talk about the organizational realities we had, but we also wanna talk about how this work was changing the care that we provide and the environments in which we reach children.

**10:13**
We are really focusing on developing our care environment and talking about how a behavioral response team became essential, and so we're gonna kinda take you through that story as we go along.

**10:25**
So first, what happened? The need became clear that we needed a behavioral escalation response team when we started to see national trends showing up in very local ways.

**10:36**
We were seeing the effects of the pediatric mental health crisis that has been impacting our nation.

**10:41**
And just to pause there briefly, how many others have seen the impacts of this crisis since announced in the pandemic? Right.

**10:49**
It's had a pervasive impact on our children, on their communities, on the way we provide, but also the way others receive care.

**10:55**
There have been longer waits. There have been complex needs in terms of utilization and enhancement of acuity.

**11:00**
Because kiddos have had to wait longer, there may be less access to resources, and that led to kiddos showing up at our hospitals, um, coming for care, really needing to be with us, present in a space that could help them in a moment of crisis. But also, um, raise of hands, whose hospitals were initially built to manage that type of crisis?Right.

**11:13**
Did you feel the pressure of that raise of hands as that crisis began to come into effect? Right. We wanna be present to be there for kiddos and families in these complex moments, but were our structures initially designed for that? Maybe not.

**11:30**
And so our focus as we began to develop it was we needed to ensure that not only did it meet the multiplicity of needs we identified, but that it was also fully aligned with our commitments and philosophy.

**11:40**
How can we make sure that our approach would be guided by the program that I talked about previously, integrate prevention, intervention, crisis response, and continuous improvement, be trauma-informed, evidence-based, but also contribute directly to care while advancing prevention? How in the future when we've learned something from a kiddo who's communicating to us through behavior in a moment of distress, can we prepare for the future? And we'll talk a little bit about that as well today.

**12:06**
Again, we also wanted to monitor outcomes. We wanted to embed quality improvement, and we wanted to make sure that we could strengthen our resilience as an organization. And this helped us to create a culture that will support wellbeing, safety, and equity for our patients, families, and team members. That's a big ask. Does anybody agree? Right. We're gonna talk about that today.

**12:26**
So what did we do? We then developed our BERT program through an interprofessional steering committee.

**12:32**
We took a discipline design-oriented approach that really focused on using literature review, peer benchmarking, and project management methodology to focus on answers to key questions to determine whether a program like this could con-- succeed in our context.

**12:45**
And we wanted to focus on things such as what is the scope of our team? Where are they going to cover? What are they going to do? What are we trying to impact? From there, also, we wanted to ask when and how should it respond? Is this gonna be a twenty-four-hour service? Who is going to respond? How are we going to make sure that they can be there? And then who needs to be involved to make sure that can happen? Another big piece that I haven't seen as much in the literature, but that we talked about very extensively is also what roles need to be present.

**13:12**
Not just positions, not just specific designations, but also functional rapid response roles that our team can utilize in these moments to make sure that our response is effective. And then finally, um, what's the way that we can make it sustainable? Because not only for our patients and families do we want a response, but we want a response that is sustainable for our team, that they feel supported in, that they have education, appropriate staffing, care, support.

**13:35**
And then from there, we recognized early that education would be critical, not only for the team, but for the clinical enzo-environments where the resource would go live, because this wasn't only a team-based response, but also a culture shift in how we approach these moments.

**13:48**
And we wanted the team to trust those responses.

**13:50**
And finally, once that design work was complete, we implemented BERT in phases through house-wide education. We focused on responder training, intentional unit-by-unit scaling, and a quality-focused infrastructure. That allowed us to build not only a response, but a program with reliability and durability that we needed for it to grow over time.

**14:08**
And so where are we today? Since launching our BERT program in July of twenty twenty-four, we have moved from concept to enterprise scalability. What began as a targeted pilot has now expanded across three service lines, um, that being our consult, huddle, and stat structures, which we'll talk about in a little bit. We have been able to go into four key care environments, our medical surgical areas, our cardiac care areas, our intensive care areas, and our emergency department. And that matters because that tells us this model is not confined to one setting, but it's functioning across very different operational and clinical realities.

**14:41**
Um, raise of hands, how many people's EDs are the same as their med surg? Right. Yeah. Certain pieces, right? But then how do we continue to talk about how dynamically different that care can be, the staffing ratios can be, the way that we approach things? And that was something we wanted to, in this team, develop so it could support similarly in those areas and return to clinical management by those teams because they're going to be the subject matter experts, one, on their relationship to patient and family.

**15:09**
We're gonna be meeting them very, um, briefly in the care period.

**15:12**
But also, they're going to be the experts on the type of medical care the child needs, and we are there to help stabilize and support through a moment of distress, provide recommendations, develop an individualized plan, and then to integrate alongside them as they continue with care. And then as we continue, we have invested in workforce capacity.

**15:27**
We have trained a hundred and seventy-three responders and developed nine key core instructors, helping to create the infrastructure needed not just to launch our program, but to sustain it and spread it. And across that first phase of implementation, we have supported a response to, in only a year and a half, three hundred and seventy-four behavioral escalations with acute agitation present in each and every one of them.

**15:50**
But we were able to meet those kiddos in moments of crisis in ways that I think you'll find pretty incredible throughout the course of this presentation. Finally, for those in our audience, this is the key takeaway.

**15:59**
These numbers are more than growth.

**16:01**
We have really tried to reflect how we have operationalized the BERT. Not only did we build it, but it was used, and we were able to find effect in some of the outcomes we'll talk about in a little bit. It want-- I want to show you that through leadership support, governance, training, and our clinical philosophy, when we combine all of these things together, they can create something really beautiful.

**16:16**
It can create a response system that's scalable, durable, and increasingly embedded in everyday practice and o-can also meet kiddos in some of the hardest moments that they experience.

**16:27**
And so next, and probably on top of mind, is how did we design our clinical team and who is on it? Um, we wanna make sure that we can talk a little bit about this together today.

**16:38**
And so I wanna provide you some priority considerations. This is really some of the key questions that we asked ourselves when we were composing our team, and this came to be very effective for us.

**16:47**
Um, we wanted to make sure that we are first, um, defining who provides clinical direction during an event and which disciplines are essential to deliver safe and coordinated intervention.

**16:55**
Second, we really wanted to focus on establishing the team's scope of coverage, hours of operations, and a standardized pathway for off-hours escalation.

**17:07**
These were really important for making sure that we weren't asking our teams to respond in ways that were unsustainable for their hours of work or for who would be present within the facility. Third, we wanted to create a staffing model that was operationally sustainable.

**17:16**
So we wanted to have clear plans of activation, how roles would be covered when certain folks were off, and also how we would respond to concurrent events. Um, does anybody have a BERT team here at the facility?Okay.

**17:28**
Has anybody ever had two BERTs at one time? Yeah.

**17:35**
And we have to have plans for those because similar, if you had two RRTs called at once, how can both on-call folks respond? And we created parameters for that as well.

**17:45**
That was very important for us.

**17:48**
And finally, responsibilities that we, um, created during the response must explicitly be delineated for who deescalates, who medically manage, who focuses on safety, who's there to support and be present with the family or siblings, and also how can we make sure that documentation occurs after the event? Is that the responsibility of the unit or the responsibility of the BERT team? Through that, we developed some training and competency work that really created expectations to extend beyond BERT responser-- responders and also out to the different teams where BERT was live. And we tried to create frontline team responsibility for early recognition and continuity of care so that we wouldn't be taking care from the bedside, but really be coming to support the bedside in those hard moments.

**18:29**
And then finally, um, we wanted to consider how all of these align with our organization. How are we gonna do these in ways that are consistent with our philosophy? There's a lot of different ways to reach these ends, but then how do we make sure that this is consistent with who we wanna be as an organization and how we wanna show up for children and their families? So from there, I wanna talk a little bit about how this whole thing works.

**18:50**
Um, first, I'm gonna talk a little bit about first and core piece of the puzzle, the bedside team.

**18:54**
That absolutely cannot happen without the bedside team. So I just wanna give our bedside teams a huge shout-out. Um, the first is that we have our bedside nurse.

**19:04**
At Children's Nebraska, the bedside nurse is often the first to recognize that a child is beginning to become dysregulated.

**19:09**
That nurse is typically the one who activates our BERT. They help to notify our provider, and they begin an immediate nursing assessment.

**19:15**
They also continue to provide essential cares in line with the plan of care for the child until the point where the BERT team can respond. When they're responding, they're assessing safety, they're implementing a plan of care.

**19:23**
They may administer any medications that have already been previously ordered for PRN or to help support the child in that moment.

**19:29**
They're trying to assess, are there any basic needs that the child may need met that as a result of complex staffing or complex other determinants on the unit may have been harder to reach the child until that moment of distress. And then from there, they're providing an SBAR to the team on arrival. Who's my patient? A little bit about what's going on and who they are and why they're here with me. My assessment of what happened and what I knew about why the feelings became big.

**19:52**
And then from there, what do I need from the BERT team? Sometimes it's I need help while the provider and I are making a medical plan in terms of medications.

**20:01**
Sometimes it's I really need help deescalating this patient. I've been working with them throughout the day, and I've been really struggling to connect with them.

**20:06**
Can someone help me in this moment? And sometimes it can be more acute, right? We can have situations where someone's acutely or imminently hurting themselves or others, and that person really needs help to safely and supportively guide that person through that moment of distress.

**20:20**
Then there's our provider.

**20:22**
They bring medical and clinical decision-making framework to the response. They are able to evaluate for medical contributors to the agitation.

**20:28**
They're able to determine broader clinical plan for the patient and then place orders needed to support safe care.

**20:34**
This can involve medication, precautions, consultation, or when absolutely necessary and as a last resort, restrictive interventions. They also complete the provider level documentation associated with the event, and put simply, they help to ensure that behavioral escalation is addressed in a way that is a clinical presentation and in response and alignment to the patient's clinical needs.

**20:51**
We wanna make sure that we're not differentiating behavior from the clinical presentation of the ca-- patient, but that it's a broader part of their plan of care and integrated into the way we're supporting medication management or medical management more broadly if we're in a medical context. Example given, if we've got a kiddo who has, I don't know, cue one vitals or cue however frequent procedures, and that procedure is the source of distress, how can we work through in that moment and help them adapt to that procedure? Um, provide support in a-addressing it and making sure that they can feel supported in it or provide some type of alternative intervention to make sure that we're not repeating the cycle every frequent order-based hour, but also that they get the necessary care that they need.

**21:33**
And then the charge nurse or designee serves as the bedside operational leader during the event.

**21:37**
This role is absolutely essential. And so I wanna note this, that over time, we integrated the charge more specifically on the unit, and they are the person that helps to organize the response when the BERT team arrives.

**21:47**
I think of them kind of the funnel through which the bedside team goes and the BERT team comes to.

**21:51**
They are the person who helps to delegate responsibilities, manage resource deployment on the unit, and maintain oversight of the event.

**21:59**
They are there to make sure that the right people are doing the right tasks and that additional support is pulled from the unit only when it's needed, but they primarily work with the bedside nurse and the BERT team.

**22:08**
They can also work with other team members to cover the bedside assignments of the bedside nurse who had a BERT activated on their patient so that they're not feeling stressed trying to cover potentially in a med surge environment three, four, maybe more patients at the same time that they're caring for a patient who is in an acute need and in distress.

**22:25**
And then from there, there are our supporting team members. We can't do it without the other team members on the unit.

**22:29**
They can potentially help to grab the BERT bag, help to grab supplies, co-check medications, support with documentation checks, whatever may be in alignment with your organization policy or miscellaneous tasks during the BERT that can help us operationally. The charge nurse is usually the one to delegate to those other team members who might be needed and where we could mobilize them in a moment of crisis.

**22:49**
From there, we have the BERT team itself.

**22:53**
And so I kinda wanna talk about the BERT responder team. Who is coming to the bedside? Um, one of the most important leadership decisions in building this model was defining what additional capacity should arrive, what disciplines contribute, and how to ensure the response was standardized but also right-sized so that we weren't over-responding.The core concept was this, BERT responders don't replace the bedside team, as I've mentioned before.

**23:11**
They augment it.

**23:17**
They bring in additional capacity for stabilization, de-escalation, and coordination. Our primary BERT responders include our medical surgical charge nurses.

**23:23**
Um, three of them are trained to come to these events.

**23:29**
We have our security and our house supervisors, as well as our emergency department charge.

**23:32**
And we are also working on continuing to make sure that these team members are trained in support through verbal de-escalation, and when clinically indicated and consistent with policy, to assist in physical hold and mechanical restraint application, but as an absolute last resort.

**23:47**
And then from there, they provide operational support to the bedside nurse, helping to create just enough structure, coverage, and support so that the team can continue to respond safely and in alignment with the clinical plan.

**23:52**
They have also made sure that, um, our security supervisors are rounding in our huddle activations, which we'll talk about in a little bit.

**24:05**
So our whole BERT responder team doesn't come to every tier of BERT activation.

**24:10**
And Child Life also responds. They bring a different but equally essential skill set. Their role is to support de-escalation in developmentally appropriate ways for the child.

**24:17**
Our Child Life s- pa-- specialists can help to reduce stimulation, build structured coping exercises for the child, support, um, when indicated, and contribute to, um, what we call PATCH plan assessments.

**24:31**
Has anybody heard of the PATCH program at Children's? It's essentially an adaptive care plan for neurodiverse youth that focuses on kiddos who may not communicate verbally, um, or focuses on kiddos who may have additional functional or cognitive needs to make sure they have adaptive sensory plans in their care, um, so that we can make sure to support them, and those are driven by our Child Life specialists.

**24:51**
We also have social work. They are essential to the responses. All of our social workers are co-trained mental health practitioners, and so they can provide clinical assessment at the bedside and do a focused clinical assessment, help to build our BERT plan or an elopement prevention plan if it's needed, and really make sure that after the event, we can help to debrief with the team and process through the event and its impact on the safety and well-being of our team members. Spiritual care, um, is consultative, so they respond in moments when our team is needing additional support after the event, but they don't necessarily respond to it. And psychiatry is made available on call to be supportive and assistive with medical management consultation.

**25:31**
Um, we use a platform called QGenda, um, to help call our on-call docs, and our providers can call to the psychiatrist through that platform if they need additional support.

**25:39**
The psychiatrist will already be aware that the BERT has happened as it's pushed to their phone in an activation, as it is with all others during an event.

**25:45**
And then they will know that they may potentially be called for medication management consultation at the bedside.

**25:52**
Additionally, I'd like to note three specific groups, um, that are pretty essential to our work.

**25:57**
Our BERT instructors, we have nine of them in total.

**26:01**
They have trained every single one of our responders and our absolutely incredible unit embedded team members. Um, the program manager is me, and then we have a specific program social worker who can help with high acuity cases that may have higher utilization of the BERT team, may have higher utilization of hospital services, or may have persistent and more intractable barriers to safe discharge or safe care during time at Children's so that we can focus even in a more honed, individualized way on kiddos who are really in distress.

**26:27**
So from there, we've talked a little bit about the team.

**26:31**
I kinda wanna move to clinical process and how we designed it.

**26:34**
From there, we have really developed and focused on a high reliability BERT protocol that is really focusing across five clinical and operational domains.

**26:44**
First, we have to define our activation thresholds, methods, and expectations for early recognition of behavioral risk.

**26:51**
There are a lot of variable ways that we can identify that a kiddo may be in distress. Defining for yourselves how you'll approach that as a team so you can standardize that education, look for observable markers that someone may be becoming dysregulated, and be objective in that so that we can have more equitable and consistent care across children is so important.

**27:05**
And we wanna make sure that you're being intentional when you're developing your BERT team.

**27:10**
We know we had to be very intentional about this, as without this, it can become more subjective and potentially inconsistent in how we're responding to different children at either different times of day based on different considerations, and we know we want to avoid, um, more subjective or inobjective care.

**27:28**
From there, we also focus on making sure we can stratify our response pathways to be responsive to different identifications or indications of distress.

**27:35**
Um, different indications of distress may have different levels of acuity.

**27:41**
And so we built an acuity-based stratification framework, which we're gonna talk about on the next slide. We developed an operational reliability focus that was measured through our response times, how we have mobilized the team, and how we have covered moments when folks have maybe had multiple activations at one time.

**27:57**
Um, we made sure that our bedside model, um, was focused on making sure that they knew how to assess, de-escalate, and make decisions from a pharmacologic standpoint.

**28:06**
So we created pathways or clinical pathways that allow us to support with medication management at the bedside while the BERT team is stabilizing.

**28:13**
And then we have also tried to use least restrictive interventions and really created explicit criteria for the use of restraint, um, beyond what's considered an accreditation policy to make sure that not only is it a last resort, um, but that there is no other option, and that the beneficence of that stabilization outweighs the potential risks, both not only from a safety standpoint, but also from a therapeutic standpoint for children. Um, and then from the last standpoint, we wanna make sure that we had governance structures. How are we going to manage the BERT team? And we wanted to make sure that we had clear identification of who makes decisions about changes in BERT.

**28:49**
How do we document, how do we debrief, and how do we integrate across environments and make sure that we have representatives from all the different areas that are involved in the BERT program?From there, we began to develop how we respond and what our services are.

**29:05**
So we're now getting into kind of the meat and potatoes of what happens when the BERT team is being called upon. Um, to guide which BERT service to activate, we developed this risk stratification framework. It focuses on agitation across a continuum, and it starts with calm, progressing through mild, moderate, and severe. And each level builds in the intensity of behavior and the potential impact on care and safety for everyone involved. We wanted to help standardize language across teams and ensure we aligned the intervention to the actual risk.

**29:32**
Um, from a BERT consultation perspective, we use this for mild agitation, and it typically involves a social work consult as a preventative step, and it does not include a full activation of the BERT team.

**29:40**
For the BERT huddles, this is moderate agitation, and it focuses on a formal BERT activation.

**29:45**
The bedside team, as well as social work, child life, and a security supervisor come to this event, and they are able to help support in creating a plan for the patient while also supporting them in moderate moments of distress.

**29:56**
And then the status for severe activation, which involves a full activation of the entire BERT team I talked about before, the entire bedside team, and available team members as needed.

**30:07**
From there, I'm gonna talk about each of these a little more in depth.

**30:14**
So before I describe our huddle and STAT, I kinda wanna start at the earliest point of our continuum, the BERT consult.

**30:18**
This is the most preventative form of direct patient care in our model, and in many ways it reflects the philosophy underneath everything we've built.

**30:23**
The consult is designed to meet those earlier in the moments of distress and to be there and present with the child even when they're calm or if they're mildly distressed.

**30:34**
The team is really beginning to notice signs that distress could build if we do not respond thoughtfully, early, and in a coordinated way.

**30:39**
We try to make sure that that starting point matters because trauma-informed behavioral health practices are not only about what you do in crisis, it's about what you do before the crisis to make sure that when there's still time to understand the child, partner with caregivers, and build conditions that reduce the likelihood of behavioral escalation before it occurs, we should do that in the first place.

**30:58**
And I think many of us could agree with that.

**31:01**
At Children's Nebraska, BERT consults are typically initiated by a nurse or providers through social work.

**31:07**
The social worker then leads that focused clinical assessment I discussed before and makes sure that we can identify their known stressors, um, different things that lead to changes in their regulation, previous efforts that have been successful or une- unsuccessful for the team, and really focus on some of the different environmental, physical, or psychological factors that may contribute to the distress in the medical environment.

**31:26**
Our goal is not to reduce the child to a behavior problem, but to make sure that we can understand the child may be communicating what supports are most likely to help them in hard moments.

**31:35**
Additionally, we want the consult to become a prevention-focused planning process.

**31:40**
So social work will use that assessment to develop recommendations individualized to the child that are communicated back to the team through the EMR. And when needed, additional specialties are then brought in, so the plan reflects the behavioral, medical, and psychosocial needs that the patient may have together.

**31:54**
The consult concludes with a struc- structured documentation of the plan in the EMR, so it's clear and broader, um, use is available to the team across shifts.

**32:04**
And the larger message for our team is that our model begins with prevention. We start by recognizing distress early, making sure that we can coordinate around a child and family, and from there, if distress intensifies, the continuum moves into the BERT huddle, and then if necessary, the BERT STAT. You're going to see a growth in the amount of team members that come here in the BERT huddle.

**32:23**
Um, each of these boxes represents a different team member who responds to the event itself. So now I'm gonna talk about the BERT huddle.

**32:33**
If the consults are most preventative intervention, the huddle is where we often provide additional resources when concerns begin to arise.

**32:38**
Um, this service is activated when moderate agitation is present, when a child's behavior is beginning to impact care delivery, but there's still an opportunity to intervene early, make sure that the team is all aligned, and reduce the possibility of further escalation through intentional presence and patient-centered care. We're making sure that the huddle is where our trauma-informed practice can become the most visible because the goal is not simply to manage the behavior, but to understand what the child's communicating and respond in a coordinated, individualized way to the patient.

**33:07**
Once activated through our communication system, the huddle is expected to convene within fifteen minutes.

**33:14**
At the bedside, the nurse provides a structured SBAR handoff, so the team has a shared understanding of the child's medical status, any of their behavioral presentations, and what's already been attempted and what may be contributing to their distress on the floor.

**33:27**
From there, we try to make sure that we have a minimum of four trained responders present because effective early intervention still depends on enough capacity for role clarity, caregiver support, and coordinated planning, but also safe response if we do need to move towards a more restrictive intervention.

**33:38**
Additionally, if the child remains dysregulated when the team arrives, roles are assigned more immediately, and someone will begin to lead de-escalation, and the team will focus on stabilization.

**33:48**
Once that's achieved, the planning will re-resume, but we'll always attempt to triage what the most acute behavioral concern is for the child in that moment, so we can be present and attempt to potentially diffuse or work through that moment together, reduce stimulation, potentially use a trusted caregiver or connected support in the room with the child in and alongside our de-escalators to make sure that it's also a familiar presence, something that feels safe for the child, something that will help to reaffirm the different things that they may need in that moment.

**34:19**
And then we conclude with our documentation, plan visibility, and clear follow-through for the team.

**34:24**
And that matters because continuity is everything in this structure. Um, question, raise of hands, how effective would this BERT team d- be if we just called the team to the bedside and then left but didn't tell the bedside team anything we did? Right.

**34:38**
It needs to be something that integrates into the broader environment of care. Similar to our rapid response teams, similar to our medical alerts, this is a clinical intervention.

**34:45**
And so we're saying there to help debrief with the team, help them process through emotionally, but also professionally how they can continue to care for the child in these hard moments.

**34:56**
And that doesn't mean they did something necessarily wrong, but it is an opportunity to better understand that child in their care.And finally, is our BERT STAT.

**35:06**
So let me walk you through our highest acuity service, the BERT STAT.

**35:09**
This is the most intensive direct care response to our model, reserved for moments when a child's behavior signals imminent risk of harm to self or others.

**35:16**
In those moments, our aim is not simply to rapidly respond to the situation, it's to restore safety in a way that's clinically led, trauma-informed, and least restrictive as possible.

**35:26**
We are trying to recognize that escalation is often a child's expression of overwhelming distress, fear, unmet needs, or a feeling of a loss of control, as we discussed at the beginning. When a STAT's activated through our hospital communication system, responders move immediately to the bedside rather than in fifteen minutes. This pulls the whole team together, and we really try to make sure that children in crisis have enough of a coordinated team and response to support them in those hard moments because they deserve that care, right? We're trying to meet them in some of the hardest moments they have.

**35:53**
We do the same medically.

**35:56**
We can do the same medically behaviorally. And so we're making sure that on arrival, we still get that SBAR.

**36:01**
It's very similar to the huddle in terms of progression. We focus on care planning when possible or triage to stabilization if there's a need to more immediately respond.

**36:07**
But you'll note that within our BERT continuum, the indication for further stabilization or restrictive intervention is always team-based assessment on site.

**36:18**
The STAT does not correspond to a translation for restraint. We want to make sure that on the ground, our teams are individually assessing whether they're responding immediately, in fifteen minutes, coming for a consult to see where the child is in that moment, because the moment of distress that led to us being called could be different a moment later, and we really need to understand what's happening with the child and ask how can we help rather than how can we respond and intervene. So from there, what helped us build a durable and sustainable program once we built that structure? I kind of want to talk a little bit about that because it's one thing to get a BERT off the ground.

**36:50**
It's another thing to keep it rolling down the road. So when we think about BERT leadership, the central question is not just who leads the program. It's whether the leadership structure is strong enough to govern, grow, and protect its integrity over time.

**37:05**
BERT is not just me.

**37:06**
BERT is not just any one of our team members. It's an interprofessional response that we've collaboratively built together over time and through an interprofessional governance structure.

**37:11**
We have really focused on being explicit about our executive sponsorship, day-to-day operational oversight on each unit, and accountability to our clinical practice standards that we design as a program.

**37:25**
We have ensured that the right disciplines are at the table. We have co-representation from nursing, psychiatry, psychology, social work, security, quality, frontline operations, our providers, some of our technicians, some of our different leaders in our areas of legal and safety. And we wanted to make sure that across these different domains, we had co-representation from everyone who could be involved in these structures.

**37:45**
And we also try to gather feedback from the patients and families as the events go along to make sure that they can provide us insight into different ways that we can care for them in the future or different stressors that were created for them within the context of the care they're receiving.

**37:54**
And we reflect those in the BERT plan so we can meet them in hard moments with more patient-centered strategies. To structure that sustainability, we really tried to create a larger governance structure.

**38:10**
First, we created the BERT work group.

**38:12**
That provides the operational oversight and strategic home for the program, brings together the disciplines, aligns priorities, and helps to ensure accountability for any of our clinical direction, resources, or program standards.

**38:23**
Our review committee was structured to serve as the formal event review body, reviewing every STAT activation and debrief that occurred after it to make sure that we could learn process improvement insights from the forms we created.

**38:34**
We developed a process improvement group to translate those findings into action. And finally, we developed a BERT instructor group to sustain the clinical model at the frontline by supporting education, role clarity, and reliability in practice.

**38:46**
And so why does our BERT work? We've talked through the structure of the program, and the next question is why this model works.

**38:53**
And to answer that, we're going to shift from describing the components of the BERT to looking at the logic underneath it, its mechanisms, relationship, and design, and then we'll talk about outcomes. So this is a little bit of our logic model.

**39:06**
If all the things I've told you are true, if the context, if the situation, if the assumptions about the care we need to provide to children are accurate, and if we input resources, these could be people, these could be education, this could be a focused response program like what was provided through Vistelar.

**39:19**
This could be different structures that we need to develop within our organization, and we develop those into activities, a structure that works for our space, our context, our community.

**39:24**
Then from there, that should lead to outputs.

**39:30**
We'll start to see people use the BERT, which I've described previously. We'll start to see people's confidence improve in the BERT.

**39:35**
We'll start to see outcomes such as reductions in restraint duration, frequency, improvement in perception of safety for our team members, decreases in the amount of alternative events that are being called through security as a standalone, making sure that we're beginning to see those impacts on our community. In the intermediate term, that'll lead to the realization of what we've talked about in our broader program philosophy. And in the long term, that will lead to the way we say we care for our community being true and reflected in the way that we practice.

**40:03**
And so over time, this should all flow. And if there are breakdowns within that logic, you can begin to look at where that breakdown occurred and how you can continue to improve the program over time because it won't be perfect.

**40:13**
We had multiple iterations of BERT as we began to develop it. This is a more finished product that you're seeing today, but it was many months of continued collaboration, process improvement, and reflection.

**40:21**
And I just kind of want to note that as you go along.

**40:26**
It's always okay to come back to what have you put in and what do you want to get out of it and where in that line and continuation do you see things that can become hard and how can we resolve those questions together with our community.

**40:38**
And so finally, I kind of want to end with what our outcomes are.

**40:43**
I want to talk a little bit about what we saw with BERT in the first few years.

**40:48**
So what we saw in the first phase of implementation was both growth and utilization and an encouraging shift in how the service was being used.

**40:55**
We saw our BERT activations increase, which showed it was being used, rising from ninety to one hundred and sixty-seven from the first to second year with a particularly strong increase in huddles.

**41:03**
And that shows us that we're using more proactive and preventative engagement with children and families, meeting them earlier, meeting them before the distress has reached the highest level of acuity.

**41:14**
We've also been able to see STATs proportionately decrease, meaning that there are less STATs occurring and that we are having teams reach out for support earlier.Next, I wanna talk about violent restraints. This has some pretty incredible outcomes. We have been monitoring this very closely, and what we saw is not only did we see that our event frequency decreased, but also that duration dropped substantially from nearly two hours in twenty twenty-four to just forty-four minutes in twenty twenty-five. We also saw the restraint profile begin to shift with fewer mechanical restraints occurring and we having a greater reliance on physical holds when the restraints occur.

**41:53**
That means, like, proportionally, we're using less restrictive interventions when we're using them, and we're also using less restraint interventions over time.

**42:00**
We also saw a similar signal in BERT reported, um, high-risk events.

**42:04**
So during phased implementation, BERT was involved in a substantial share of violent restraint episodes for restraint use, and we also don't use violent restraint very often during BERT activations, which are only the huddle and stat considerations.

**42:16**
It went from twenty-two percent in twenty twenty-four to fifteen point six percent in twenty twenty-five. And for comparison, in a lot of the literature I'm seeing, usually that number for peer hospitals is between forty and sixty percent of BERT activations involving restraint.

**42:29**
And so we've had pretty incredible outcomes with keeping that at a very low number.

**42:34**
Um, and then for us, these were early indicators that our model was not just being activated, but beginning to move intervention earlier and support safer, more trauma-informed care.

**42:44**
We began to see decreases in our elopement, um, terms of attempts. Um, we also saw our fidelity increase with screening.

**42:50**
Our positive screens increased, meaning we were identifying it better and earlier, and also our high-risk identification increasing. We saw significant reductions in the amount of disturbance calls or standalone security calls to patient bedside, um, within our facility at about a ninety-three percent rate.

**43:10**
And we saw significant between twenty and sixty-four percent reductions in assaults and human bites across areas where BERT is live.

**43:20**
You will see a specific box here marked in red. That is the one environment where BERT has not gone live yet, and you see a pretty massive increase that could be an outlier.

**43:25**
So I wanna be conscious that that is one year of data, um, but have noted that all other areas where BERT is live saw significant downturns.

**43:32**
And if you go previous years back, there's been a steady uptick in the amount of workplace assaults and workplace violence in different areas within the facility.

**43:44**
Um, and we have seen sustained decrease since BERT was implemented.

**43:47**
We also saw significant increases in perceptions of employee safety, that employees felt safety was important to the organization and that providers felt the same.

**43:57**
And so where are we going from here? Next, we're moving to scalability and sustainment.

**44:02**
Our next phase is really focused on making sure that we can be sustainable but also disciplined.

**44:10**
In the inpatient setting, we are refining the model through a process improvement, which will actually go live on tomorrow, I believe, um, to help further enhance our roles.

**44:19**
And we are also looking at ambulatory scalability in twenty twenty-seven to make sure that we can look at what, um, rapid response can look like in ambulatory clinic environments that may be more isolated.

**44:26**
It may not look like a rapid response team coming from a location, but may look like more localized subject matter expertise embedded in the team members with algorithmic response, empowering folks to hard pause or hard stop specific procedures or appointments if specific behavioral indication is present, huddle with the team that they have in that area, use those local resources to support the patient, and then either return to care if de-escalation occurs or pause the visit and reschedule with a huddle to occur before the next visit.

**44:58**
And this is kind of what we're looking at in the future.

**45:00**
So some key takeaways. Uh, behavior is communication, and our response must be clinical and child-centered.

**45:05**
Sustainable response requires leadership to invest in infrastructure to support the bedside in crisis moments, and prevention, early intervention, and continuity are what make safer outcomes possible.

**45:16**
And then I'm going to pass it back in just a moment to Dr. Lauren for some closing remarks, and then I'll be here for questions.

**45:21**
But I just wanted to thank all of you for your attentiveness, especially over the breakfast hour, and it was a pleasure to meet you all. Thank you, Dalton.

**45:34**
As I think, uh, you can all agree, these are pretty some phenomenal results. This exemplar, um, is translatable to the adult environment as well.

**45:41**
There's a lot in the literature. Um, if you are interested, um, Vistelar does have training programs for, uh, hospitals in both preventative, which we call non-escalation and de-escalation, personal protection, and safety.

**45:51**
There are some flyers on your tables.

**46:00**
There's-- be some more on the way out the door. On the backside of that is a QR code where you can take a lesson for free online. In addition to that, I'd invite you to, um, scan this QR code.

**46:07**
This is to Dalton's webinar presentation that he did for us this past fall.

**46:15**
So with that, uh, thank you all for your attention today. Greatly appreciate your time and interest in this topic.

**46:21**
It's, it's very important that we really start making headway with the violence in workplaces and get to the preventative side of, uh, workplace violence. So thank you for your time.

**46:33**
And if you are interested in questions with Dalton, he'll be here for a few minutes.

**46:38**
But please follow up. He'll be down at booth one-- ten seventy-two in the exhi-exhibit hall, um, where he can meet with you there.

**46:43**
So thank you all for your time. Have a wonderful day.

**46:48**
Perfect. Questions? Does anybody have any questions? I have a question.

**47:00**
In our, um, facility, we currently just have one process and all it can fall under. So whether it's a behavioral health patient, an escalated parent, do you have two separate processes or, um, how did you incorporate this into your system? Yeah.

**47:16**
Did everybody hear that okay? So we do bisect it by patient and caregivers. Um, really the main demarcation is not necessarily that the patient has to be a child, but that they have to be an admitted patient, right? Because then we can take it as a clinical rapid response.

**47:31**
We are also developing a more restorative, relationally focused caregiver engagement and escalation stratification that'll operate across the entire enterprise, that'll focus on our relationship to the family, collaborative care planning, how we can approach in moments of distress at the bedside or in the clinic, um, with unit leadership, with a social worker safety and wellbeing response team, and then finally with administration, trying to create multiple tiers of relational repair and restorative focus, um, for those relationships.

**48:02**
But we tried to bisect it as the rapid response possibly being contained to both can sometimes create, um, decision confusion or decis-decision ambiguity and delay as we're trying to identify whether someone is a patient. And so we've requested that it only be called on patients, not on siblings, not on other children, not on patients who are not yet admitted, just to make sure that the team is clinically protected, but also that we have differentiated responses based on populations in our care, um, as there's different responses that we can use for those populations. Yeah. Okay. Let me get a chair without somebody behind me. Um, I-- This was a wonderful presentation and so thoughtful.

**48:42**
I've been researching this for our organization, so thank you so much.

**48:50**
Sure. This is wonderful. Um, does the-- My question is, does your huddle team provide the care considerations and structure for the bedside staff? Meaning, like, do you utilize FYI and I don't know if you use Epic or Serna- Yeah.

**49:00**
But do they develop, like, a nice care plan for the bedside staff just so they know, "Okay, this is what we're doing next time," 'cause usually there's a next time.

**49:12**
Yeah. Yeah. So that EMR integrated plan from social work-- So social work will do a focused clinical assessment with the patient that's both a combination of, like, behavioral analysis, but also, um, like a therapeutic note that can be made sensitive, put in the chart. From there, they'll take key elements of that and put it into an EMR related flow sheet for Epic, where that then populates into a care plan that is, um, FYI activated.

**49:36**
So we can deactivate the FYI if we don't wanna see it anymore, or we can set it to time limited for when we want it to be reassessed.

**49:47**
But then when you pop into the chart, it'll say, "Child has a BERT plan that's located in the Calm tool," and Calm tool banners will pop up right on the first pages that nurses open.

**49:53**
They can click into it, and that has their BERT plan, elopement plans if they have it, or a patch plan, as I talked about before. But great question. Yes. Do you use the BroSET tool? Um, in terms of the BroSET violence screening tool? Yes.

**50:14**
We are looking at a more standardized, like, violence or agitation screening. At the time, we had concerns that existing tools were more adult oriented or didn't necessarily, um, align with our philosophy as a children's hospital, and so we built an individualized, um, stratification from calm to severe. But it functions very similarly to a screening tool like the BroSET or like the VAT or, um, some of the other ones that exist out there.

**50:38**
At this time, we haven't implemented one. We're looking at potential modification of an Australian tool, um, for implementation in the U.S., but that would be long way down. Take one more.

**50:51**
So when you started this work, my question is around staff resistance to it.

**50:56**
So I am from Oschner Children's. We're building out a children's hospital, but right now our pediatric units are very much embedded in an adult setting. So I'm trying to help my adult colleagues that have been leading this group for years and years and years understand this and this patient population.

**51:15**
Our nursing team has had so much trauma from really mismanagement of this patient population that while I'm trying to start a task force to have this conversation, I have crickets.

**51:26**
No one wants to, to be involved 'cause no one wants to take care of the patients. And I'm just curious, when you started the work, did you have any resistance in how you would advise leaders to help overcome it? A hundred percent.

**51:44**
And I think that'll be present in any context, right? I think that we are in many ways trying to focus on, like, ways to protect ourselves from change management that may not necessarily sustain at different times.

**51:56**
How can we communicate the beneficence of this to our patients, to our teams, um, the importance of this specific type of philosophy and care? We started with the council and focused on really senior and executive leadership getting engagement, buy-in, support, then building in integrated, um, team-based representation within that council to empower area champions, our emergency department fellowship director, our focus on having several medical surgical hospitalists and our intensivists at the table, and then beginning to implement and integrate into, we've built this philosophy and this understanding of where we wanna go as an organization. It's built together by and for our teams. And then from there, we also had nursing representation, legal, security, all of these other folks on the council, then began to ask, "Okay, what does it look like to operationalize this, and where can we begin piloting?" We started with a small pilot in medical surgical.

**52:51**
Um, it was specifically, I believe, on med-surg six is where we started, and then we expanded more broadly.

**52:56**
But they were a very interested team in developing that project out.

**53:00**
From there, when the other teams began to see the impact of that initial implementation, its decrease of incidents of violence, some of the feedback from their peers and colleagues, then it kind of began to cascade this change relating to it can dually be possible for us to recognize and realize this philosophy and to be cared for at the same time.

**53:21**
And I think sometimes those pieces can be put into opposition, and with the wrong structures can be functionally created to be oppositional to one another.

**53:28**
You may hear sometimes things are too focused on patient care, things are too focused on the team, but we're all coexisting in these spaces at the same time, and building that integrated approach to one another, I think, is w-- an orientation and philosophy is really what empowered us to mutually see and be empathetic for and connect to one another.

**53:46**
And we kind of built that further out with trauma-informed care training to further move up the stream from reaction to response to prevention over time. And I'd be happy to talk more about that if you'd like to.

**54:01**
Wonderful. Thank you, Dalton. Thank you all. Have a wonderful day. And if you want to come down and ask Dalton additional questions, come to ten seventy-two in the exhibit hall.

**54:10**
Thank you.