Violence against hospital staff has become more frequent and more severe across health care systems nationwide.
At Nemours Children’s Health, staff saw an opportunity to build a uniformed system to help staff respond to escalating patient behavioral situations across their two hospital campuses and more than 80 outpatient locations in six states.
“As we reviewed data and spoke with frontline staff about behavior escalations, it became clear that response varied widely both within and across our sites,” said Emily Fingado, MD, director of hospitalists at Nemours Children’s Hospital, Delaware.
In response, Nemours Children’s Health launched a systemwide improvement effort to redesign its escalation response framework for more consistency. The goal was not just to manage risk in the moment but to plan for it in advance — and make roles and expectations clearer across the organization.
“To best support our patients and associates, we had to eliminate variation and ensure that roles and expectations were clear and aligned across our enterprise,” Fingado said.
Meet ERNI and BERT
The project began with a continuous improvement initiative in early 2024, involving more than 100 employees from across departments and from Nemours’ two hospitals in Delaware and Florida. They included nurses, public safety officers, emergency department (ED) techs, social workers, child life staff, and physicians. From their input, the initiative created a tiered response model with three distinct levels of behavioral intervention:
- Initial de-escalation: Frontline caregivers try initial calming techniques such as distraction and calm, quiet voices.
- ERNI (Escalation Response Needed Immediately): Specially trained responders (including child life staff, social workers, ED nurses, and ED medics) step in when initial measures fall short. This alert is silent to prevent stimulation or further escalation.
- BERT (Behavioral Emergency Response Team): The highest level of response (including a physician leader, a nursing supervisor, public safety officers, and nurses) manage high-risk agitation or aggression.
“Though we already had an emergency response team, we made improvements that more clearly defined each person’s role during a response, and provided more evidence-based recommendations,” said Fingado. “Our goal is to create a safe environment for all, patients, their families, and our staff.”
Each level is supported by a clinical pathway, integrated Epic documentation tools, order sets, standard processes, and decision guidance. Fingado emphasized the importance of documenting interventions in the electronic medical record (EMR) so each provider can see what techniques have worked, and which have not, for a specific patient.
Through documentation, the goal is to ensure that in any behavioral escalation event, the providers interacting with the patient have all the information and guidance they need to make the right decision for the individual patient. “All of our pathways are recommendations, not requirements, and should be tailored to each child,” Fingado said.
The importance of preparation
Nemours also implemented a Daily Management System to anticipate and plan for behavioral health needs. This includes proactive huddles, early caregiver engagement, and dedicated planning time to develop individualized care strategies before the child arrives.
Fingado recalled a story of this in action: When a family called to schedule a visit, they shared concerns about their child’s complex medical and behavioral history. The provider reviewed the chart and saw a pattern of past escalations. They assembled a team — including psychiatry, psychology, child life, public safety, and the family — to plan ahead.
After discovering that busy hospital lobbies and transitions triggered this patient, they used car check-in, took the patient straight to a ready room, used distraction techniques, and brought staff into to the room instead of moving the child for specific tests. The visit went smoothly — no escalations, no disruptions — and the family left extremely grateful for the thoughtful care.
More structure, less violence
Since implementing the tiered model, Nemours has seen measurable improvements. Between November 2023 and September 2024, 82% of patients were successfully de-escalated by ERNI responders.
“This really affirmed the need for a tiered response,” Fingado said. “In a lot of cases, early interventions worked without needing the full emergency response team.”
Of the 148 BERT activations across both campuses, only 20 patients required restraint orders.
Just as important, the culture around safety has evolved.
“Before, there was a mindset that risk was just part of the job,” Fingado said. “Now, associates know that their safety matters, their concerns are valid, and they have resources available.”
Nemours has begun expanding the strategy beyond its hospital campuses, adapting the model to fit ambulatory and specialty care sites with varying resources. This includes site-specific improvement events, tailored staff training, and research-informed updates to clinical pathways.
“We continue to re-assess to align with the unique needs of the patients at each location. We make changes when needed and do so gradually,” Fingado said. “Doing so allows us to sustain this model and make a difference in the long-term.”
This article is based on a presentation at the Children’s Hospital Association’s Annual Leadership Conference.
