Implementation of a Novel Agitated Behavior Score and Its Association with Code Violet Activation: A Case Series

Agitation in the emergency department (ED) poses a significant safety concern for staff and patients. Multidisciplinary responses, such as Code Violet activations, are common but resource-intensive. Early identification and intervention may reduce escalation, but ED-specific data are limited. The objective of the study was to evaluate the implementation of a novel agitated behavior score (ABS) and assess whether higher ABS scores are associated with increased risk of Code Violet activation.

This prospective observational study included adult patients admitted to a behavioral health unit in a community teaching hospital ED. Trained staff administered a novel 25-point ABS incorporating altered mentation, verbal agitation, and motor agitation. The primary outcome was Code Violet activation; secondary outcomes included pharmacologic interventions and substance use. Among 83 patients, 27 (33%) experienced ≥ 1 Code Violet activation. And those patients with Code Violet activation had higher initial ABS scores (mean 10.9 [6.35] versus 4.6 [4.43]; P <.001). Overall rates of psychotropic medication use were similar between groups; however, time to first medication was longer in the Code Violet group (4.0 versus 2.7 hours). Patients with Code Violet activations more frequently received parenteral medications, whereas those without the code activation more commonly received oral agents.

The agitated behavior score was associated with Code Violet activation and may help identify patients at greater risk of behavioral escalation. While it measures current agitation rather than predicting future agitation, its structured format may facilitate early recognition and management of agitation.