Docs Seek Accountability for Violence Committed by Patients

Acts of violence targeting the professionals who staff America's emergency departments has gotten significantly worse since the COVID pandemic's onset — with serious implications for the future provision of emergency medicine. Those are among the conclusions from a new poll conducted for the American College of Emergency Physicians (ACEP) and reported September 22 in a virtual press briefing.

Among 2712 physicians responding to the ACEP poll conducted from July 25 to August 1, 45% said that violence in the ED has increased greatly and 40% said it has increased somewhat over the past 5 years, while 89% said they believe this violence has harmed patient care. And 55% reported that they personally had been assaulted in the ED — some of them on a weekly or more frequent basis.

That number is up from 49% in a similar poll conducted for ACEP in 2018. One third (33%) of respondents said they were injured on the job from a workplace assault, up from 27% in 2018. Reported incidents include verbal assaults with the threat of violence as well as being hit, slapped, spit on, punched, kicked, scratched or bit, sexual assaults and assaults with a weapon like a knife or gun.

Dr Alex Skog

Doctors often describe personal encounters that illustrate the survey results. Alex Skog, MD, an emergency physician in Oregon City, Oregon, and president-elect of ACEP's Oregon state chapter, said that when he was asked to speak at the press briefing, he started reviewing past violent incidents from his own career. But in the weeks leading up to the briefing, two more horrific incidents occurred, highlighting how dire the situation has become for emergency personnel.

"Few memories are more painful to me than an evening about a month ago when an intoxicated patient started roaming down the halls, out of sight of nursing staff due to overcrowding," Skog related at the press briefing. "I heard a scream. I was the second person into the room next door. I saw the male patient on the ground straddling a nurse I work with and repeatedly punching her in the head. I wrestled him off and was quickly joined by other staff," he said.

"I consider the staff I work with not just colleagues but close friends…Emergency medicine is hemorrhaging doctors, nurses, and techs who can no longer accept the violence they experience daily. I fear we will lose these frontline medical professionals unless action is taken to increase accountability and add protections for staff." Violent incidents like these contribute to increased rates of burnout, turnover, and mental health issues for emergency department professionals.

A Paralyzed ED

Skog described another very recent incident where an agitated patient, brought in by ambulance after an intervention involving multiple police and restraints to prevent him from attacking the paramedics transporting him, charged an emergency department technician, tearing his shirt and wrestling him to the ground.

While the physical trauma that results from events like this is unacceptable, other effects may be less obvious, Skog said. His department was essentially paralyzed by the turmoil in its ability to care for other emergency patients and had to go on ambulance diversion for several hours, causing delays in the treatment of other critically ill patients.

"The average emergency department clinician is well aware that violence today is completely different than it was 5 years ago, and this survey quantifies that," Skog said. Clinicians need to understand how important it is to share their stories and get the word out. ED professionals often fail to report violent incidents due to the belief that nothing will be done about it.

"But without us making it known to everyone, it will be harder to call stakeholders to account to address the problem." Those stakeholders include hospital administrators, law enforcement, and legislators, Skog added. "We need to find appropriate venues for holding the people who knowingly assault healthcare workers accountable."

Legislative Solutions Proposed

Two bills now in Congress are designed to address the problem of emergency department violence. While it is late in the legislative season of an election year, ACEP is encouraging legislators to include emergency department violence as a component of any larger conversation about mental health, patients, and physicians.

The Workplace Violence Prevention Act for Health Care and Social Service Workers, H.R. 1195, which passed the House in 2021 and was introduced in the Senate by Sen. Tammy Baldwin (D-WI), was highlighted in a press conference on the Senate lawn in May, cosponsored by ACEP and the Emergency Nurses Association (ED nurses may have even higher rates of violence on the job). It calls on the Occupational Safety and Health Administration (OSHA) to require employers in healthcare and social services to establish workplace violence prevention plans in accordance with OSHA's 2016 "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers."

This bill is supported by the American Public Health Association, although the American Hospital Association opposes it based on increased costs for hospitals. AHA has stated that hospitals already strive to prevent violence in the workplace, although ACEP's new study reinforces how this is not sufficient.

A recent article in Security suggests that hospitals could start implementing the features of H.R. 1195 even before it becomes law, given its important implications for hospital bottom lines, absenteeism, turnover, and morale.

A second bill, the Safety from Violence for Healthcare Employees (SAVE) Act, H.R. 7961, introduced in June by Reps. Madeleine Dean (D-PA) and Larry Bucshon, MD, (R-IN), would create federal penalties for violence against healthcare workers, similar to protections now in place for airport and airline personnel.

Violence's Vicious Cycle

"This type of legislation is urgently needed to ensure the safety of all health care providers," said Robert Glatter, MD, an emergency physician at Lenox Hill Hospital in New York City. "ED violence creates a vicious cycle affecting not only the long-term mental and physical health, but overall well-being and security of healthcare workers," Glatter told Medscape in a recent email.

"It ultimately impacts their ability to perform their jobs in a confident and competent manner. The bottom line is that much more needs to be done to ensure that every member of the team in the ED can make patient care a priority, as opposed to worry and concerns about their own safety."

The pandemic seriously eroded trust between patients and providers, Glatter said. This loss of trust is harmful not only to patient care, but to the long-term health and compliance of patients overall. It makes addressing the epidemic of ED violence crucial to all stakeholders, healthcare providers and patients alike."

Experienced clinicians have a sense of what triggers patients to an act of violence, although that understanding may not help in a fast-moving crisis, Skog said. In addition to the lack of trust between patients and clinicians, frustrations over delays in treatment, obvious agitation, intoxication, and drug-seeking behavior may be warning signs. "I can see patients' past violent behavior red-flagged in their chart, but they are still assaulting us."

What else could help? More use of metal detectors and the 24-hour presence of security personnel able to rapidly respond to escalating situations can be great tools in specific situations, he said. But emergency departments vary widely in size and setting. Another tool is an emergency device that can alert the entire department in a crisis.

But for Skog, one of the most important responses is to actually hold patients accountable for their acts of violence — to report them to the police and the criminal justice system. According to the new poll, hospital security departments pressed charges for such incidents a mere 2% of the time.

In Oregon, it now is merely a misdemeanor to assault a hospital worker, he said. A bill proposing to change that just died in the state legislature.

ACEP engaged Marketing General Incorporated (MGI) to replicate a brief polling survey originally conducted in 2018. Skog and Glatter have disclosed no relevant financial relationships.

American College of Emergency Physicians. ACEP Emergency Department Violence Poll Results. August 2022. Full report

Larry Beresford is an Oakland, California-based freelance medical journalist with a breadth of experience writing about the policy, financial, clinical, management, and human aspects of hospice, palliative care, end-of-life care, death, and dying.

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