How DART Helps Physicians De-escalate Situations



Although few are formally trained in how to handle it, healthcare professionals can encounter a violent patient or their family member and find themselves instantly in a tense and sometimes dangerous situation.  This worst-case scenario, however, can be dealt with in many cases before things take a turn for the worse.  That’s where the DART program comes in.

DART (Distress Activation Response Team) is essentially a team de-escalation program that also sets a behavioral agreement with the patient or their family member.  First, someone (a doctor, nurse, or other healthcare professional) begins to notice a challenge with a patient or family member’s behavior. They call DART and inform the nurse or unit clerk.  That person then pages the DART team and the group – which usually includes security, a social worker, the primary physician for the patient, and the bedside or nurse charge – assembles quickly.

If the situation is immediately dangerous, security will  intervene right away.  If not, the team first huddles outside the room of the incident to figure out what information they’d like to convey and how they want to approach the situation.  Then, ready with a plan, they go into the room and discuss the problem with the patient, the provider, and their entire team.

The goal, as Neera Ahuja, MD, chief of the division of hospital medicine and co-founder of DART  explains, is to address the issue directly, saying, “Here is what we perceive as the problem, this is the undesirable consequence, how can we work together to make this better?"  The DART team gets input from the patient and family member “but also sets some reasonable   guidelines and guardrails embedded in compassion and professionalism” so that the problematic behavior doesn't continue.  Sometimes, Ahuja remarks, the presence of a security officer alone is enough to change the tenor of the incident.

After that discussion’s over, the team debriefs again outside the patient’s room, documents the incident, and flags the patient’s chart to make other care members aware of  the  issues and the behavioral compact.  Ideally, DART has just prevented what could have been a major incident from ever even happening.

The Beginning of DART

Ahuja, who’s also medical director for the general medicine wards, says DART came about because of concerns from many of her providers.  “I recall in 2018 I was on service, and an intern said they dreaded going into a certain patient's room because of how rude a certain family member or patient could be, and other members of the care team would approach me about how to handle the patient/family member who repeatedly sabotages the care plan,” Ahuja remembers.  She also regularly heard about problems from both colleagues overseeing their own residents and the nursing staff, who are the most common recipients of this type of behavior because they spend so much time at the bedside.

Ahuja did some research, spoke with colleagues at SHC, and ended up collaborating with them on DART, which was piloted for a year and then successfully expanded housewide.  DART is part of a larger Violence in the Workplace Taskforce, which has 4 sections: training and education, early reporting, post incident support, and incident response, containment, and recovery.

DART’s role is primarily in the first two sections, ideally to intervene so the other two aren’t needed.  Ahuja and her team of colleagues (including Daniel Ramberger, Hirut Truneh, Lisa Shieh, Nidhi Rohatgi, Jeff Chi, John Kugler, Jason Hom, Charles Liao, Tom Russin, Anthony Alabastro, Joe Daley, and many others) have trained all the hospital MDs, nurses, security staff, social workers, patient managers and case managers in the DART procedures, including de-escalation training.   DART has now been implemented hospital-wide.

DART Team Members

DART as a Resource

Ahuja herself took part in the trainings, and found them very valuable. “The crisis de-escalation training led by Anthony Alabastro from security was invaluable,” she says.  “He said: if you're in a patient's room and after an attempt to de-escalate you notice that the patient's pupils dilate and they're clenching their fists or their face goes white, you should step back because they are about to assault you.” She and other physicians found these clues illuminating because they’re so often thinking about patient’s medical problems and emotional distress that they wouldn’t think to look for these warning signs.

Ahuja adds that every physician or healthcare worker has probably dealt with an aggressive patient or family member “at least once” in their career.  There are regular instances of DARTs being called at the hospital.  Although, as Ahuja points out, this is a good thing, because it means that physicians and providers are reaching out for help before things escalate.

More good news?  DART is effective.  “I've seen it work really nicely,” she explains.  A patient’s family member was behaving aggressively, a DART was called, and “on a subsequent hospitalization, that particular patient's family member was so much more pleasant and cooperative.”

Expanding DART

For the future, DART hopes to expand.  It’s largely inpatient right now and working to move to ValleyCare and other Stanford affiliated sites; but Ahuja says colleagues from outpatient clinics like radiology, dermatology, and urology, for example, also see aggressive patients and would like DART implemented in these clinic settings.

In the end, DART is all about the balance of patient care and provider safety: “We want to be compassionate when we care for patients and their family members,  but we have to be protective too,” Ahuja explains.  “We call it creating a culture of civility; it’s been a productive  and collaborative journey.”