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A Brief Tool to Predict Agitation in Pediatric Emergency Psychiatric Patients
Lynn Babcock1,2, Lily Klein1, Yin Zhang1
1Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Insights
The Brief Rating of Aggression in Children and Adolescents-Short (BRACHA-S) tool effectively predicts agitation requiring intervention in pediatric emergency departments. This validated scale aids nurses in early safety planning for mental and behavioral health encounters.
Area of Science:
- Pediatric Emergency Medicine
- Child and Adolescent Psychiatry
- Clinical Nursing Research
Background:
- Emergency departments (EDs) frequently encounter pediatric patients with mental and behavioral health (MBH) concerns.
- Accurate and timely identification of agitation is crucial for patient and staff safety.
- Existing tools may not be optimized for rapid triage assessment by nurses.
Purpose of the Study:
- To validate the 5-item Brief Rating of Aggression in Children and Adolescents-Short (BRACHA-S) scale.
- To assess the BRACHA-S's ability to predict agitation requiring intervention (ARI) in pediatric ED MBH encounters.
- To evaluate the BRACHA-S's utility for triage by emergency department nurses.
Main Methods:
- Prospective observational prognostic validation study conducted in two pediatric EDs.
- Included children aged 5-18 years presenting with MBH concerns.
- Nurses completed the BRACHA-S (0-5 score) upon ED arrival; ARI defined as pharmacologic treatment or restraint.
Main Results:
- The BRACHA-S demonstrated moderate discrimination for ARI (AUROC=0.72).
- ARI incidence significantly increased with higher BRACHA-S scores (e.g., RR 5.9 for scores 4-5 vs. 0-2).
- High scores (4-5) showed high specificity (>89%) and positive predictive value (>33%); low scores (0-1) had high negative predictive value (96.7%).
Conclusions:
- The nurse-completed BRACHA-S at triage shows moderate predictive ability for ARI in pediatric ED MBH cases.
- The scale identifies clinically meaningful risk gradients for agitation.
- Findings support the BRACHA-S's use for early safety planning in pediatric EDs.
Objectives:
To validate the 5-item Brief Rating of Aggression in Children and Adolescents-Short (BRACHA-S) completed by emergency department (ED) nurses at triage for predicting agitation requiring intervention (ARI) among pediatric ED psychiatric or mental and behavioral health (MBH) encounters.
Methods:
We conducted a prospective observational prognostic validation study (October 2024-November 2025) at 2 pediatric EDs. Eligible encounters included children aged 5 to 18 years presenting with MBH concerns. After ED arrival, nurses completed the 5 BRACHA-S items assessing aggression-related history and current agitation (total score, 0-5). ARI was defined as pharmacologic treatment of agitation/aggression and/or physical or mechanical restraint use. Discrimination was assessed with area under the receiver operating characteristic curve (AUROC). Performance characteristics were estimated for a 3-tier model (scores 0-2, 3, and 4-5).
Results:
Among 472 encounters, 55 (11.7%) had ARI. BRACHA-S scores were associated with ARI (AUROC, 0.72; 95% CI, 0.64-0.79). ARI incidence increased with score: 0, 3.3% (2/60); 1, 6.3% (6/96); 2, 6.4% (7/110); 3, 12.4% (17/137); 4, 31.8% (14/44); and 5, 36.0% (9/25). Scores 0 to 1 had a negative predictive value of 96.7% but a specificity of 13.9%. Scores 4 to 5 had a specificity of at least 89% and a positive predictive value of greater than 33%. Compared with scores 0 to 2, relative risk of ARI was 2.2 (95% CI, 1.1-4.3) for score 3 and 5.9 (95% CI, 3.3-10.7) for scores 4 to 5.
Conclusions:
In pediatric ED MBH encounters, the nurse-completed triage BRACHA-S demonstrated moderate discrimination and identified clinically meaningful risk gradients for ARI that may support early safety planning.
