Pediatric Emergency Agitation Care Enhancement: Protocol for a Prospective Mixed Methods Study

Area of Science:

• Pediatric Emergency Medicine
• Child and Adolescent Psychiatry
• Healthcare Safety and Quality Improvement

Background:

• Agitation in pediatric mental and behavioral health (MBH) patients presenting to emergency departments (EDs) poses significant safety risks and strains resources.
• A lack of validated tools for agitation risk stratification in this population hinders evidence-based management.
• Developing effective strategies is crucial for reducing emergent interventions and enhancing patient and staff safety.

Purpose of the Study:

• To evaluate the predictive accuracy of the Brief Rating of Aggression by Children and Adolescents-Short Form (BRACHA-S) for agitation requiring intervention in pediatric ED patients.
• To codevelop a risk-based management plan bundle tailored for pediatric patients experiencing agitation or aggression in the ED.

Main Methods:

• A prospective, single-center, mixed-methods study involving children and adolescents (aged 5-18) presenting to the ED with MBH concerns.
• Nurses administered the BRACHA-S tool at triage; agitation requiring intervention was the primary outcome, defined by pharmacologic or physical/mechanical restraint use.
• Qualitative methods, including interviews and workshops with patients, families, and staff, were used to codevelop a tiered, risk-based management plan.

Main Results:

• Enrollment for Aim 1 (BRACHA-S validation) was completed with 472 participants; the study hypothesizes strong predictive validity (AUC >0.70).
• Data collection for Aim 2 (management plan development) is ongoing, involving key informant interviews, group assessments, and participatory design workshops.
• Anticipated results by June 2026 will include a stakeholder-informed, tiered management pathway aligned with BRACHA-S risk strata.

Conclusions:

• This study proposes a pragmatic approach to early agitation risk identification and management in pediatric EDs.
• Successful validation of BRACHA-S and implementation of a co-developed management pathway could significantly improve timely, least-restrictive interventions.
• The findings aim to enhance patient and staff safety by addressing critical gaps in validated tools and structured workflows for agitated pediatric MBH patients.