Regulating the System: Development and Early Implementation of a Behavioral Escalation Response Team in Pediatric Primary Care

Objective: Behavioral escalation in pediatric primary care destabilizes the healthcare system and ultimately impedes medical care. There is currently no standard to address behavioral escalation in this primary care setting. This gap in care disproportionately impacts patients who are most at risk. This article describes the implementation of a novel Behavioral Escalation Response Team (BERT) in a pediatric primary care setting and illustrates how a quality improvement approach can be used to develop a trauma-informed response to behavioral escalations. Method: BERT was developed in a pediatric primary care clinic serving patients with complex needs. A conceptual model for BERT was developed through the engagement of stakeholders and the completion of needs assessments. A quality improvement approach was used to iteratively construct and refine the BERT protocol. The BERT protocol was created to improve identification, assessment, and implementation of evidence-based de-escalation and intervention strategies in primary care. Behavioral escalation was categorized based on the severity of risk, and relevant interventions were implemented to de-escalate patients and families. Results: The BERT protocol was activated for 48 individual patient encounters throughout the first year of trial and implementation. Most BERT encounters engaged patients and families who were at risk due to developmental delay and/or history of trauma. BERT was most often implemented during well-child visits and in conjunction with in-office procedures. Conclusions: This study provides preliminary evidence of BERT’s value as a safe and effective strategy to identify and de-escalate patients and families through the implementation of a structured and predictable therapeutic response.

Implications for Impact Statement

This study proposes a novel, highly structured intervention to help manage behavioral crises that occur in pediatric primary care clinical settings. The Behavioral Escalation Response Team intervention was created through collaboration among psychologists, physicians, and allied health care providers. This trauma-informed framework guides the implementation of evidence-based therapeutic strategies to help regulate patients, families, and the health care team during moments of significant mental health or behavioral concerns.