Predictive Validity of DASA for Emergency Department Restraint in Behavioral vs Nonbehavioral Health Patients

Violence in the emergency department (ED) is increasing, threatening patient and clinician safety. Prior work shows the Dynamic Appraisal of Situation Aggression (DASA) score can be feasibly implemented at ED triage and is associated with subsequent behavioral interventions. This study evaluates the sensitivity and specificity of DASA for predicting safety interventions among patients who did and did not require behavioral health (BH) consultation.

At five affiliated EDs, nurses assigned DASA scores at triage for all adult patients, categorizing risk as low (0), moderate (1–3), high (4–5), or imminent (>5). Triage scores, demographics, BH consultation status, and use of physical or chemical safety interventions were extracted from the electronic health record. We calculated sensitivity, specificity, PPV, and NPV for BH and non–BH patients and assessed overall discriminative performance using ROC curves and AUC.

Over 34 months, 480,917 adult ED encounters were recorded (mean age 51.8, 53.2% female), including 21,170 (4.4%) requiring BH consultation. There were 7,861 physical restraints and 22,914 medication interventions. Sensitivity increased with higher DASA risk categories (5–46% overall), while specificity remained high (>94%) and PPV low (3–9%), with high NPV across groups (97–100%). BH-consulted patients showed higher sensitivity and PPV but lower specificity than non-consulted patients. AUC was 0.567 for all patients, 0.543 for non-consulted patients, and 0.718 for BH-consulted patients.

Low DASA scores were highly specific but not sensitive, effectively ruling out restraint needs. Higher scores increased sensitivity but had low positive predictive value, especially in non-BH patients due to rare safety events. DASA is most useful for identifying low-risk patients and predicting restraint in BH patients. In the ED, low scores can help staff allocate resources efficiently, while higher scores may prompt earlier interventions to manage aggression and improve safety.