Journal Article Annotations
2022, 2nd Quarter

Emergency Psychiatry

Annotations by Scott A. Simpson, MD MPH
July, 2022

A Large Naturalistic Study on the BRACHA: Confirmation of the Predictive Validity.
Trauma-informed Care Interventions in Emergency Medicine: A Systematic Review.

PUBLICATION #1 — Emergency Psychiatry

A Large Naturalistic Study on the BRACHA: Confirmation of the Predictive Validity.

Drew Barzman, Rosalie Hemphill, Kacey Appel, Olivia Kerekes, Michael Sorter, Ashley-Marie Berry, Jennifer Combs, Alexander Osborn, P Daniel Lin

Abstract: Psychiatr Q. 2022 Jun 22. doi: 10.1007/s11126-022-09993-4. Online ahead of print.

Aggression is a major challenge on child/adolescent inpatient psychiatric units. A screening instrument to accurately identify risk is urgently needed. To determine the predictive validity of the Brief Rating of Aggression by Children and Adolescents (BRACHA). Prospective cohort study. BRACHA is administered by clinical staff in the emergency department (ED) prior to inpatient psychiatric admission. A consecutive sample of 10,054 admitted patients from 2010-2021. No patients refused screening nor were excluded. BRACHA administered to patients in the ED prior to admission at Cincinnati Children’s Hospital Medical Center (CCHMC). Patient behavioral outcomes measured by Overt Aggression Scale (OAS), categorizing aggression as verbal or physical, then as towards self, others, or objects. Female patients comprised 53.6% (n = 5,386) of the sample. Most patients were white (n = 6,556, 65.2%). Patients ranged in age from 4 to 18 years, with a mean age of 13.6 ± 3.1 years. A single biological parent (n = 5,317, 52.9%) was the predominant living arrangement among patients. The Area Under the Curve (AUC), as an assessment of predictive validity across all possible cut-offs of BRACHA scores ranged from 0.640 (aggression to self) to 0.758 (physical aggression towards others). Our findings support the BRACHA as a useful predictive instrument for aggression in inpatient psychiatric admissions from ED regardless of length of stay. Treating staff are then able to immediately classify risk level and inform care plans for all lengths of hospitalization. Applies to potential risk for aggression, except for self-aggression. Future data analyses will evaluate demographic factors to determine which improve predictive power of the BRACHA and can be used to create a BRACHA calculator. To our knowledge, this naturalistic outcomes study is one of the largest in psychiatry. The BRACHA will continue to be studied to evaluate risk for aggression on inpatient units and aim to assist in keeping unit staff and patients safe.

Annotation

The finding:
This retrospective study evaluated the performance of the 14-item Brief Rating of Aggression by Children and Adolescents (BRACHA) for predicting aggression during a child psychiatric admission. During the 11-year study period, the BRACHA was routinely administered by emergency department (ED) social workers for 10,054 psychiatric admissions at a children’s hospital. BRACHA scores were used to determine an appropriate level of care. In this study, BRACHA scores were correlated with subsequent aggression on an inpatient unit with an area under the receiver operating characteristic curve (AUC) of 0.71 for predicting any aggressive incident as defined by the Overt Aggression Scale, including self-aggression. At least one episode of verbal or physical aggression occurred in 33% of admissions. AUCs were better when predicting aggression towards others than when predicting self-aggression.

Strength and weaknesses:
Investigators took advantage of a large naturalistic database derived from usual practice. They excluded admissions to several high-risk units, including among children with neurodevelopmental disabilities. Each patient’s first admission was counted. While AUCs were reported, sensitivities and specificities were not. Several different outcomes were tested without controlling for multiple comparisons, and the cut-off points for the BRACHA are not well-described. The high rate of aggression may overstate the performance of the BRACHA. No multivariable analyses were performed, and it is unclear how interventions based on the BRACHA may have impacted outcomes. It is also unknown how gender, race/ethnicity, and other social factors impact instrument performance. Understanding whether the scale contributes to risk prediction during subsequent admissions would have been an invaluable inclusion, particularly as children with a history of violence are frequently denied admission to certain facilities based on that history.

Relevance:
Anticipating and communicating aggression risk is critical for emergency psychiatrists facilitating a safe disposition and helping receiving inpatient units

proactively reduce risk. The BRACHA has promise for assessing aggression risk among youth who are being psychiatrically hospitalized, although this study leaves some important questions unanswered. More generally, the use of standardized instruments to predict risk can improve safety and facilitate the expeditious transfer of patients from the ED to the appropriate next level of care. Finally, this study exemplifies the opportunities (and challenges) of using large datasets to validate risk assessment instruments in real-world clinical practice.

PUBLICATION #2 — Emergency Psychiatry

Trauma-informed Care Interventions in Emergency Medicine: A Systematic Review.

Taylor Brown, Henry Ashworth, Michelle Bass, Eve Rittenberg, Nomi Levy-Carrick, Samara Grossman, Annie Lewis-O’Connor, Hanni Stoklosa

Abstract: West J Emerg Med. 2022 Apr 13;23(3):334-344. doi: 10.5811/westjem.2022.1.53674.

Introduction:
Trauma exposure is a highly prevalent experience for patients and clinicians in emergency medicine (EM). Trauma-informed care (TIC) is an effective framework to mitigate the negative health impacts of trauma. This systematic review synthesizes the range of TIC interventions in EM, with a focus on patient and clinician outcomes, and identifies gaps in the current research on implementing TIC.

Methods:
The study was registered with PROSPERO (CRD42020205182). We systematically searched peer-reviewed journals and abstracts in the PubMed, EMBASE (Elsevier), PsycINFO (EBSCO), Social Services Abstract (ProQuest), and CINAHL (EBSCO) databases from 1990 onward on August 12, 2020. We analyzed studies describing explicit TIC interventions in the ED setting using inductive qualitative content analysis to identify recurrent themes and identify unique trauma-informed interventions in each study. Studies not explicitly citing TIC were excluded. Studies were assessed for bias using the Newcastle-Ottawa criteria and Critical Appraisal Skills Programme (CASP) Checklist.

Results:
We identified a total of 1,372 studies and abstracts, with 10 meeting inclusion criteria for final analysis. Themes within TIC interventions that emerged included educational interventions, collaborations with allied health professionals and community organizations, and patient and clinician safety interventions. Educational interventions included lectures, online modules, and standardized patient exercises. Collaborations with community organizations focused on addressing social determinants of health. All interventions suggested a positive impact from TIC on either clinicians or patients, but outcomes data remain limited.

Conclusion:
Trauma-informed care is a nascent field in EM with limited operationalization of TIC approaches. Future studies with patient and clinician outcomes analyzing universal TIC precautions and systems-level interventions are needed.

Annotation

The finding:
This systematic review describes the literature on trauma-informed care (TIC) in emergency departments (EDs). EDs are psychologically challenging and triggering environments for patients and staff alike. The authors identified ten peer-reviewed publications describing TIC in ED settings—five describing educational interventions and five reporting operationalization of TIC in the ED. Examples of TIC’s utility for emergency practice included improvement in staff comfort working with sexual assault survivors; decrease in use of restraint and seclusion; and greater staff confidence working with trauma survivors. The TIC framework can be leveraged to inform direct patient care, foster better community collaborations with emergency services, and foster resilience of ED staff.

Strength and weaknesses:
The authors sought to focus on a narrow definition of TIC for this literature review: only peer-reviewed manuscripts explicitly applying TIC were described, and grey literature was not included. The resulting literature is accordingly limited. Only a few studies were identified, and most of these were small and single – site. Prominent themes are described, but there is less discussion of the apparently limited quality of these articles.

Relevance:
Multiple organizations and regulatory bodies emphasize the use of TIC and care delivery, but this systematic review reveals the limited evidence base for these approaches. While greater innovation and more robust evaluation are needed, this review succinctly suggests how TIC can improve the humanity and psychological safety of emergency services for both patients and frontline staff. That TIC may produce such specific and profound benefits such as reducing restraint and seclusion ought to encourage more development and research of TIC-based interventions for patient-focused clinical outcomes. C-L and emergency psychiatrists are well-positioned to lead TIC efforts at their institutions.