1. Degree of agitation (how agitated is the patient?) 
  2. https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12138 (image below)

3. Assessment Scales

a. Positive and Negative Syndrome Scale (PANSS-EC)

  • Evaluates five items: excitement, tension, hostility, uncooperativeness, and poor impulse control
  • Score: Ranges from 5 to 35 
    • ≥ 20 clinically correspond to severe agitation

b. Altered Mental Status Scale (AMSS)

  • Scale ranges from unresponsive to combative

c. Behavioral Activity Rating Scale (BARS)

1. Difficult or unable to rouse
2. Asleep, but responds normally to verbal or physical contact 
3. Drowsy, appears sedated
4. Quiet and awake (normal level of activity)
5. Signs of overt (physical or verbal) activity, calms down with instructions
6. Extremely or continuously active, not requiring restraint
7. Violent, requires restraint