Objective: Incidents of aggression and hostility towards staff in emergency departments (EDs) have escalated in frequency and severity, posing a serious threat to the well-being of patients and healthcare providers. Research on predictive tools for identifying individuals at risk of violent behavior in the ED remains scarce. The objective of this study was to assess the association between the Dynamic Appraisal of Situational Aggression (DASA) score assigned at triage and physical restraint or medications administered for safety during an ED encounter.

Methods: From January 11, 2023 to December 31, 2023, patients ≥ age 18 were assigned a DASA score during triage at five EDs. Subjects' triage DASA scores, demographic characteristics, and clinical outcomes were abstracted from the electronic health record. Subjects were risk-stratified into validated DASA risk categories for aggression (low, moderate, high, or imminent). Outcomes were measured by documented physical restraint or the administration of injected antipsychotic medication with or without a benzodiazepine. Modified Poisson regressions were used to calculate the crude and adjusted prevalence ratios (PRs) of any intervention (physical restraints and medication administration) by DASA score.

Results: 159,154 qualifying ED encounters were identified (mean age 51.5, 53.5% female). Increasing DASA score was associated with increasing PR of any behavioral intervention: physical restraint and/or safety medication administration. An imminent-risk DASA score was associated with an adjusted PR of 4.71 (CI 3.65-6.06, p < 0.001) for any intervention, 3.63 (CI 3.25-4.05, p < 0.001) for physical restraint, and 5.26 for any medication administration (CI 4.08-6.78, p < 0.001) compared to patients with a DASA score of 0.

Conclusions: Elevated DASA scores at ED triage were associated with an increased risk of patient restraint and safety medication administration during the ED encounter. Future research should assess how proactive interventions based on DASA scores influence violence risk and investigate the predictive value of consecutive DASA evaluations throughout ED encounters.