Predicting Agitation in the Emergency Department

The objective was to assess the ability of the Brief Rating of Aggression by Children and Adolescents (BRACHA) and its components to predict agitation requiring intervention in order to develop a tool for early risk stratification of youth presenting to the emergency department (ED) with mental and behavioral health (MBH) concerns.

This retrospective cohort analyzed patients aged 5 through 18 who were evaluated in the ED for MBH concerns from 2012 to 2020. Only records with a completed BRACHA assessment, a 14-item tool used to predict agitation on inpatient psychiatry units, were included. The primary outcome was "agitation requiring intervention," defined as episodes of agitation requiring physical or pharmacologic management. Predictive accuracy was measured by area under receiver operator characteristic curve (AUROC). The shortened tool (BRACHA-S) was developed using Least Absolute Shrinkage and Selection Operator regression. Performance characteristics for each BRACHA-S score were analyzed to create risk-stratified tiers.

Of the 32 906 ED MBH encounters, 3526 (10.7%) experienced agitation requiring intervention. The BRACHA had an AUROC of 0.81 (95% CI 0.79-0.82) in predicting agitation requiring intervention in the ED. The 5 items most predictive of agitation requiring intervention were used to create the BRACHA-S, AUROC 0.80 (95% CI 0.78-0.81). The "moderate-risk" (scores 2-3) and "high-risk" (scores 4-5) tiers had risk ratios for agitation requiring intervention of 6.0 and 14.0, respectively, compared with the "low-risk" group (scores 0-1).

Both the BRACHA and BRACHA-S tools accurately predict agitation requiring intervention in the ED and support effective risk stratification. Implementing these tools for early risk assessment may enhance patient safety and optimize resource allocation in emergency settings.