Preventing and managing behavioral escalation in the acute care setting: an interdisciplinary approach to internal medicine curriculum development.

Abstract: Background

• 90% of internal medicine residents report experiencing verbal or physical violence while in training.


• There is currently no standard of practice regarding appropriate management of behavioral events (BEs) in the hospital.


• To our knowledge, there are no other residency programs that have developed curriculum related to an interprofessional to prevent and manage behavioral escalation.


• We developed a curriculum to teach IM residents how to prevent and manage behavioral escalations in the hospital.

Methods

A team of faculty from the internal medicine and psychiatry departments partnered to design and deliver the curriculum. The curriculum consists of two separate 90-minute presentations to the PGY-1 and PGY2/3 groups as part of the general internal medicine residency educational series. To assess the curriculum, the team asked the residents to fill out pre and post anonymous electronic surveys and collected quantitative and qualitative data.

Results

111 internal medicine residents participated in our sessions and completed the pre-survey.

• Residents were called to behavioral events (BEs) 4.6 times per year.


• 71.2% said they had no prior training in handling BEs.


• 30.6% felt they were unprepared to attend most BEs.

72 residents completed the post-survey.

• 94.4% said the session demonstrated effective de-escalation techniques that could be applied to real-life de-escalation situations.


• 88.9% said they agree or strongly agree that they felt better prepared to attend to behavioral escalation situations in the hospital after this sessions.

61 residents completed both the pre- and the post-surveys for our session, and pre-post comparison data are reported here.

• 49.1% more residents had a framework to approach an agitated patient.


• 45.9% more residents said they could demonstrate the 10 domains for proper de-escalation.


• 49.2% more residents had read the Epic agitation pathway.


• 42.6% more residents felt their role as an MD or APP during BEs was more clear.

Qualitatively, residents reported they enjoyed the collaboration between hospital medicine and psychiatry faculty and requested additional time and integration of nursing and other behavioral health colleagues.

Discussion

Our interdisciplinary curriculum was feasible, valued by the residents, and increased confidence in all domains assessed in the survey. Residents appreciated both evidence-based and specialist approaches to behavioral emergencies. Next steps include creation of specific PGY-2/3 curriculum that will primarily be made up of case-based learning and small group discussions. We will continue to measure the effectiveness of our curriculum and the hope is that it can be used by training programs within CU and at other institutions across the U.S.