Triage Use of the Dynamic Appraisal of Situational Aggression Score in Pediatric Emergency Care

Abstract

Objective: Aggressive behavior by pediatric patients in emergency departments (EDs) threatens safety and care delivery, yet few studies have evaluated tools to identify children at risk. We examined the association between Dynamic Appraisal of Situational Aggression (DASA) scores and the use of safety medications or physical restraints during pediatric ED encounters.

Methods: In this cross-sectional study, patients aged 5 to 17 presenting to 5 EDs from January 11 to December 31, 2023, were assigned a DASA score at triage. Clinical information was abstracted from the electronic health record, and patients were stratified into low, moderate, high, or imminent aggression risk categories. The primary outcome was the use of a behavioral intervention (physical restraint or injected safety medications). Adjusted prevalence ratios (PRs) by risk category were estimated using modified Poisson regression.

Results: We identified 17,482 qualifying ED encounters [median age 12 (IQR: 8-15); 49.4% female]. Higher DASA scores were strongly associated with greater use of behavioral interventions. Compared with low-risk patients, those with imminent-risk scores had an adjusted prevalence ratio (PR) of 11.45 (95% CI: 8.16-16.06; P <0.001) for any intervention, 46.67 (95% CI: 31.53-60.61; P <0.001) for physical restraint, and 11.30 (95% CI: 7.99-15.98; P <0.001) for medication administration.

Conclusions: Elevated DASA scores at ED triage are associated with increased use of behavioral interventions in pediatric patients, representing the first aggression prediction tool with demonstrated value in both adult and pediatric populations. Future research should examine whether proactive, DASA-guided interventions can reduce aggression risk.

Keywords: aggression; dynamic appraisal of situational aggression; risk assessment; workplace violence.