Utilizing Age-Friendly Innovations to Decrease Incidence of Behavioral Emergencies in the Acute Medical Setting: A Quality Improvement Study

Abstract:

Background: Behavioral emergencies in the acute medical setting often require consultation-liaison (C-L) psychiatry resources and are associated with negative clinical, safety, and quality outcomes (Parker, 2019). While many hospitals utilize a multidisciplinary behavioral emergency response team (BERT) for these incidents, it is common for nonpsychiatric clinicians to lack confidence in safe crisis de-escalation (Parker, 2019). Though BERT utilization often involves elderly patients with dementia and delirium (Tommasini, 2022), literature is lacking in how to best apply geriatric psychiatry interventions in the medical setting to prevent and manage these behavioral emergencies.

Methods: The VA Boston Healthcare System (VABHS) utilizes a BERT composed of the C-L team, Patient Care Coordinator (PCC), nursing, and VA police. Tracking of VABHS behavioral emergencies in July 2022 showed that incidents involved predominantly elderly patients with neurocognitive disorders, similar to prior literature. With aim to decrease the number of behavioral emergencies and their associated negative outcomes, a team of nurses, psychologists, physical therapists, geriatricians, and C-L psychiatrists implemented multiple Age-Friendly innovations in the acute medical setting starting in April 2023. Guided by the 4Ms of the Age-Friendly Health Systems initiative (Mentation, Mobility, Medication, and What Matters), these innovations included an Age-Friendly Toolkit, implementing the Staff Training in Assisted Living Residences (STAR-VA) evidence-based program in the acute medical care setting, dementia training, and the assiSTed eaRly mobility for hospitalizeD older vEterans (STRIDE) program. Initiatives were implemented in specific hospital units, and data regarding behavioral emergencies and nursing staff burnout on these units were compared pre- and post-intervention. Staff burnout was assessed by measuring exhaustion, emotional hardening, and sense of accomplishment. The study was determined exempt from review by the VABHS Institutional Review Board.

Results: Preliminary results showed up to a 55% decrease in the number of behavioral emergencies in the units in which these innovations were fully implemented. For parameters of burnout, there was a 17% decrease in exhaustion, 16% decrease in emotional hardening, and a 28% increase in staff’s sense of achievement. Further results will be gathered in summer 2024 once the innovations have been implemented on additional units, with data ready for the November conference.

Discussion: Our study demonstrates how collaborative, multi-disciplinary implementation of Age-Friendly innovations decreased the number of behavioral emergencies in a VA hospital. Despite adding additional tasks associated with these innovations, nursing burnout decreased following implementation. Future directions include expanding the initiative to other hospital units and systems and determining how to further hone the initiative to enhance safety and decrease hospital costs.

Conclusion/Implications: As the population continues to age, implementing Age-Friendly innovations in other acute medical settings can help decrease behavioral emergencies associated with delirium and/or dementia and decrease staff burnout. Further study of effects on patient safety and medical costs are needed.

1. Parker CM. Psychiatric Emergencies in Nonpsychiatric Settings: Perception Precludes Preparedness. Psychosomatics 2019; 60(4): 352-360.

< !2. Tommasini NR, Iennaco JD. A Model Program to Manage Behavioral Emergencies and Support Nurses in the Medical Setting. Nurs Adm Q. 2022 Jan-Mar 01;46(1):37-44.

Presentation Eligibility: Some of this work was presented at the 2024 annual meeting of the American Association for Geriatric Psychiatry, which focused on the Implementation and description of the Age-Friendly innovations themselves. This presentation will focus and significantly expand on the behavioral emergencies data pre and post implementation of these innovations.

Diversity, Equity, and Inclusion: This submission focuses on innovation to improve care of older Veterans with neurocognitive disorders, many who suffer from stigma and limited resources.