Planning for Behavioral Emergencies on Non-Psychiatric Units
This paper applies the FOCUS and PDCA quality improvement models to the problem of behavioral emergencies occurring on non-psychiatric hospital units, using an ICU scenario involving a patient exhibiting acute psychiatric distress. The paper identifies gaps in staff preparedness, outlines an interdisciplinary improvement team, and proposes a structured training program—ideally delivered by an external firm—to help ICU staff recognize and respond to behavioral and psychiatric crises. It also presents a five-step unit protocol for prescreening patients, maintaining response team visibility, and escalating care appropriately. Plan measurement and evaluation methods, including pre- and post-training assessments and incident report analysis, are discussed to ensure accountability and ongoing improvement.
- Possible Causes and the FOCUS Model: Applies FOCUS model to ICU behavioral emergency gaps
- Organizing the Improvement Team: Forming a cross-departmental hospital improvement team
- Understanding Root Causes: Cause-and-effect analysis of staff unpreparedness
- Improvement Plan and PDCA Framework: PDCA model applied to behavioral training plan
- Implementation and Training: ICU-specific training design and outside firm rationale
- Plan Measurement and Evaluation: Pre/post assessments and incident report review
- Five-Step Unit Protocol: Five actionable steps for behavioral emergency response
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What makes this paper effective
- Grounds every recommendation in a recognized quality improvement framework (FOCUS and PDCA), giving the argument a clear, professional structure that readers can follow step by step.
- Integrates peer-reviewed clinical sources (e.g., Tesar & Stern, 1986; Loucks et al., 2010) alongside institutional reports to balance practical guidance with evidence-based credibility.
- Closes with a concrete, numbered protocol that translates the abstract improvement model into actionable, unit-level steps—demonstrating applied rather than purely theoretical thinking.
Key academic technique demonstrated
The paper demonstrates applied problem-solving through a cause-and-effect analytical framework. Rather than simply describing a problem, the author uses each stage of the FOCUS model as a scaffold to diagnose system failures, identify responsible stakeholders, and propose targeted interventions. This structured diagnostic approach is characteristic of healthcare quality improvement writing at the graduate level.
Structure breakdown
The paper opens by identifying the triggering incident and the relevant FOCUS stages, then moves through team formation, root-cause analysis, and process selection. The second half shifts to the PDCA framework, covering plan design, ICU-specific implementation, measurement via pre/post assessments, outcome evaluation, and a final five-step protocol. References are formatted in APA style.
Possible Causes and the FOCUS Model
Hospital staff are trained to deal with minor behavioral problems because such problems often occur when a patient has experienced a traumatic injury or medical event. Patients confined to an ICU are particularly susceptible to adverse behavioral episodes. Tesar and Stern (1986) identify what should be examined as "(1) the presence of delirium or psychosis; (2) the type of ICU setting (e.g., coronary, surgical, respiratory, or medical); (3) a history of psychiatric disorder; (4) a history of central nervous system disorder; and (5) patients' personalities, which affect their reactions to illness and its treatment." There are many reasons why the ICU staff in this scenario was unprepared for the disruption caused by Mr. X, but by using the FOCUS model — Find a process to improve, Organize a team that knows the process, Clarify current knowledge, Understand causes of process variation, and Select the process improvement — it becomes clear exactly what needs to be done to ensure that the next time such an incident occurs, staff can handle it with greater knowledge and available resources.
The first part of the FOCUS plan is identifying the process to improve, which is evident from the scenario: the ICU staff's ability to deal with patients who have unknown behavioral issues. It can be assumed that the patient has a psychiatric diagnosis that was not apparent to the staff, but that assumption cannot be made initially. The evidence states that Mr. X began the disruption by yelling while on his bed on all fours. His yelling appeared nonsensical — he called out "Help, help" when there was no apparent reason for distress, and said "I don't know" when no question had been posed. Psychiatric staff may have recognized that the patient was disoriented and appeared to be speaking to someone other than the staff, suggesting a possible psychological cause for the outburst. Therefore, to make the process as straightforward as possible initially, the staff needs to understand the signs of a possible psychiatric disorder and how to respond effectively — even if that means calling a rapid response team trained to deal with such emergencies (Loucks et al., 2010). The identified process, then, is that all hospital staff need to recognize a psychiatric emergency and either have sufficient training to respond or have access to a qualified team who can.
It is well established that hospitals will treat individuals in their emergency rooms who have psychiatric disorders (American Hospital Association, 2007b), so a plan must be in place when this occurs. In the case of Mr. X, he was in the ICU and had not been identified from his prior history as having a behavioral disorder, but that did not mean the disorder was absent. To ensure that staff have a recourse when an emergency such as this occurs again — as it most likely will — the hospital must develop a systematic process improvement plan.
Organizing the Improvement Team
A team needs to assess the needs of the hospital. The investigation team must include a leader who coordinates meetings, staff members from various departments, a member from hospital security to provide recommendations, and representatives from the hospital's legal and financial departments. The leader should be someone from hospital management who is also familiar with behavioral health issues — making the director of the behavioral health division the ideal candidate for this position. Since a behavioral emergency can happen anywhere in the hospital, it makes sense to include at least one senior staff member from every department. A representative physician from behavioral health should be included, as should physicians responsible for specialties that can carry a behavioral component, such as the cardiac ICU (American Hospital Association, 2007a). The legal representative can inform staff of the legal ramifications of their actions, while the financial staff member can outline the potential costs to the hospital.
The first issue the team must address is what happened and why the incident occurred. From the scenario, the staff was not prepared for such a patient reaction and was not sensitive to the patient's concerns. At no point during the incident did any staff member call for a member of the psychiatric team. This suggests either complete unpreparedness or unawareness of the resources available within the hospital. This lack of preparedness and inability to understand the incident helped escalate the patient's distress. The staff's uncertainty also made them reluctant to assist the patient the following day.
Understanding Root Causes
Understanding the possible causes of the incident is the next step in the FOCUS model. Now that the primary causes have been identified — unpreparedness and inaction — it is necessary to examine the antecedents of the incident more deeply. By using a cause-and-effect diagram, the root problems become visible. The first issue was that the patient was not identified in the chart as having a behavioral diagnosis. This can be inferred from the fact that the physician had the patient's chart and was asking nurses questions about the patient, yet both parties appeared confused about why Mr. X was acting the way he was. It is possible that Mr. X had no psychiatric history, or that the relevant records had not yet been received from his psychiatrist.
Using a cause-and-effect framework, the core problem is that hospital staff did not know how to respond to a behavioral health emergency. Those affected include all staff with direct patient care responsibilities and, ultimately, the patients themselves. The problem arises whenever a patient with a behavioral health issue has not been recognized as such, and it can occur anywhere in the hospital because it is difficult to predict when a person will experience an acute psychiatric episode.
The final piece of the FOCUS model is selecting a process improvement. For the purposes of this paper, the improvement is kept focused: the hospital's training program is clearly lacking. The entire staff needs to be made aware of how different psychiatric and behavioral disorders present and how each can be addressed. The training program should be conducted by the behavioral health staff and designed specifically to the individual needs of each hospital department (DMHRM, 1997). The program must be intensive enough to reinforce prior training while also incorporating department-specific scenarios that reflect the types of situations staff may actually encounter.
References
American Hospital Association. (2007a). Case examples. Behavioral health challenges in the general hospital.
American Hospital Association. (2007b). Recommendations. Behavioral health challenges in the general hospital.
Cooke, M. (2010). The safe management of behavioral health patients in non-behavioral health settings. Alabama Safe Management.
DMHRM. (1997). Management of aggressive behavior. Women and Children's Hospital, Adelaide.
Elson, W. (2006). Restraints and seclusion. Sarasota Memorial Hospital Policy.
Loucks, J., Rutledge, D. N., Hatch, B., & Morrison, V. (2010). Rapid response team for behavioral emergencies. Journal of the American Psychiatric Nurses Association, 16(2), 93–100.
Tesar, G. E., & Stern, T. A. (1986). Evaluation and treatment of agitation in the intensive care unit. Journal of Intensive Care Medicine, 1(3), 137–148.
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