BERT Aims to Intervene Before a Code Violet Called

UH System Update | March 2025

A 24/7 Behavioral Emergency Response Team has become an invaluable support to caregivers at UH Cleveland Medical Center in responding to behavioral health crises.

At any time of the day or night, caregivers can reach an experienced behavioral health nurse on the Behavioral Emergency Response Team (BERT). Trained in de-escalation and crisis intervention, a BERT nurse can assist the team on the unit in mitigating challenging situations and reducing use of restraints.

Code Violets were called 27 times at CMC in January alone, and restraints were only used twice in those situations. Chief of Police James Kobak said the BERT team has been successfully managing Code Violet calls, so the UH Police Department is spending less time at those calls, allowing them to respond elsewhere.

“We’re here to keep patients and staff safe,” said Justin Phenney, MBA, BSN, RN, PMH-BC, who has a decade of inpatient psychiatric nursing experience from MetroHealth and Southwest General Health Center and was eager to help start UH’s BERT team. “There is a history of stigma with behavioral health that leads to patients not getting the care they need, especially in the homeless population. A program like this helps patients stay out of that predicament.

“We have helped stabilize patients from the mental health perspective and help discharge them home without them going to an inpatient mental health facility. If we can intervene early, it really can reduce the patient’s length of stay in the hospital. Our team is really focused on compassionate, dignified care. We want to create a healing environment.”

When called to intervene with a patient, a BERT nurse immediately assesses the safety of the environment, engages the patient verbally, delegates assistive tasks to the team, and works toward stabilizing the situation. They build a rapport during debriefing, make a plan to go forward and continue to round on the patient, typically following up multiple times a day for several days afterwards.

Chief Nursing Officer Melissa Hunt introduced the BERT concept at UH after seeing its success at VCU Health in Virginia, where she previously worked.

CMC’s Behavioral Emergency Response Team is staffed by experienced behavioral health nurses like Justin Phenney, MBA, BSN, RN, PMH-BC and Michaela Walker, BSN, RN.

“Our BERT nurses are forming relationships with caregivers very quickly and are viewed as successful at being able to deescalate people appropriately,” said Lisa Courtot, MSN, RN-BC, Director, Psychiatry Service Line & Nursing Practice, who manages the team. “And our patients understand the staff is communicating as a team.”

Delirium, substance abuse withdrawal or the desire to leave the hospital AMA (against medical advice) are among the reasons for calls to BERT, says Michaela Walker, BSN, RN, who joined the BERT team from Lakeside 40, a secured med/surg unit for patients with psychiatric co-morbidities.

When a patient displays signs and symptoms of a psychiatric/mental health crisis, a caregiver can reach the BERT nurse, who carries a rover phone at all times. The BERT nurse can focus on the patient’s mental health needs, giving them time and attention bedside staff may be unable to devote.

“Safety is our number one priority – we utilize least restrictive measures first such as redirection, distraction, decrease stimulation, and limit setting, which do go a long way,” Michaela said. “We are trained in a way that allows us to interact with this patient population in a specialized way. We are here to support nursing, and when they are so busy an extra pair of eyes can give them a sense of relief.

“We've heard nothing but great things about the BERT service. They are very grateful for us to come to their units.”

In cases of delirium, a state of confusion that affects one-third of patients over age 70, the BERT team is working with nurses to encourage a delirium protocol that clusters post-dinner care, facilitates rest in the evening and activity during the day, Justin said.

Before BERT came on the scene in the fall of 2024, caregivers were increasingly raising concerns about the escalating incidence of challenging patients, said Patient Experience Manager Mary K. Rodgers MHA, CPXP. The American Hospital Association noted that healthcare workers are five times more likely to experience workplace violence that those in other fields. The required Hospital Assault Response Prevention (HARP) training helps.

“They have been phenomenal – they are there at a moment’s notice to assess the situation as a neutral party and be the calming force to de-escalate the situation,” said Mary K. “Melissa was forward-thinking to bring this here.”

The Chief Nursing Officer is pleased with the highly talented team Lisa recruited for BERT.

“BERT has quickly become part of the CMC vocabulary,” Melissa said. “Every day when I am rounding, I hear from team members about the positive impact of BERT!”