Written by Sindhu Sudanagunta
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A nurse-completed triage assessment can identify children with mental and behavioral health concerns who are at higher risk for agitation requiring intervention in a pediatric ED.
Triage nurses now doubling as fortune tellers for ED meltdowns
Nationally, mental and behavioral health (MBH) concerns are increasing and now account for ~13% of all pediatric ED encounters. Approximately 10% of these visits result in agitation requiring intervention (ARI), such as pharmacological or physical restraints. This prospective observational prognostic validation study enrolled 472 children aged 5–18 years presenting with MBH to two pediatric EDs. Nurses completed a 5-question Brief Rating of Aggression in Children and Adolescents – Short (BRACHA-S) assessment (see table). The summed assessment results were categorized into low (score 0–2), medium (score 3), and high (score 4–5) risk, and predicted ARI during the ED visit with moderate discrimination (AUROC 0.72). Relative risk for ARI rose ~2-fold (95%CI 1.1–4.3) from low to medium risk, and ~6-fold (95%CI 3.3–10.7) from low to high risk scores.
Importantly, this study evaluated the tool’s performance only and did not assess the downstream outcomes of early agitation risk identification. Also, it was conducted in 2 large children’s EDs with dedicated psychiatric intake services, which limits its generalizability to institutions with limited behavioral health resources.
How will this change my practice?
I currently assess agitation risk largely from history, behavior, and my own gestalt. While that works well enough, it does catch me flat-footed sometimes. This tool seems feasible (conducted within 17 minutes from arrival) and, in its current state, could create team awareness and a shared mental model of risk for agitation in children presenting with MBH.
I look forward to implementation studies of this tool and perhaps a BRACHA-S-guided care pathway for proactive safety planning.
Source
A Brief Tool to Predict Agitation in Pediatric Emergency Psychiatric Patients. Pediatrics. 2026 Aug 1;158(2):e2026076729. doi: 10.1542/peds.2026-076729. PMID: 42476577.
