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• W4386585441 abstract "Figure: violence, hospital violence, emergency medicine, triage, assault, pandemic, protocol, policyThe most recent violent attack in the emergency department where Alexander Skog, MD, works happened on Nov. 30. Or at least it was the most recent one when he spoke to EMN; there have probably been more in the time it's taken for this issue to go to press. “A patient checked in, and during triage, he told the nurse that he was homicidal, and he wanted to kill anyone who disrespected him,” recalled Dr. Skog, an emergency physician at Providence Willamette Falls Medical Center in Oregon City and the president of the Oregon chapter of the American College of Emergency Physicians. “The nurse asked the next in her set of triage questions, and he said that he felt terribly disrespected by her and started throwing chairs around the waiting room and breaking things. Fortunately, the triage room is close to security, and she was able to run out of there and get security and the police, but what's particularly frustrating and emblematic of this problem is the fact that the same person had been at a different ED the day prior, and had a not-quite-as-bad incident of verbally assaulting health care workers.” Such incidents were relatively rare when Dr. Skog began his emergency medicine residency at Oregon Health & Science University in 2015. “You'd maybe hear the big story people had about being assaulted by a patient or family member once in that year,” he said. “Now, assaults in the ED seem to be, unfortunately, a weekly, if not daily, occurrence.” Rising ED Violence An August survey from ACEP found that two-thirds of doctors working in emergency departments reported being assaulted in the past year alone, with more than a third saying they had been assaulted more than once during that time. (https://bit.ly/3G1xzLZ.) That survey also noted a 45 percent spike in violent incidents in emergency departments over the past five years. “Violence in the emergency department continues to threaten and harm emergency physicians and patients,” said Chris Kang, MD, the president-elect of ACEP. “Over the past five years, emergency physicians have witnessed and experienced a steady increase in assaults made worse by the pandemic. This report underscores how attacks on emergency physicians, care teams, and staff are rampant and must be addressed.” “The emergency department is the one place in society where we are legally bound to provide care regardless of what you did before or what's happening now,” said Dr. Skog. “There's almost no other place in our society with that requirement. And a small subset of the community has realized that they can walk into the ED and receive excellent care no matter what, with no consequences for their violent or abusive behavior. So, this will happen again and again.” Violence against emergency physicians, nurses, and other emergency department personnel was not uncommon before the pandemic, but it's clear there has been a dramatic spike in violence in recent years. A 2018 ACEP survey found 47 percent of emergency personnel reporting having been assaulted. (https://bit.ly/3CtSx5B.) “I see this increase anecdotally in my emergency medicine practice, and it's confirmed by a survey which found there has been a 200 to 300 percent increase in assaults on hospital staff by patients or their family members since the pandemic began,” said Jennifer Casaletto, MD, the president of the North Carolina College of Emergency Physicians. Breakdown of Trust That may be because of a breakdown of trust between provider and patient over the past three years, Dr. Skog said. “Before the pandemic, in most circles of our society, medical professionals were understood to be doing their best to help people in society live longer and happier lives, and to be motivated by that goal to follow objective evidence,” he said. “Then several months into the pandemic, there began to be louder and louder voices questioning our intentions. I appreciate when patients have questions about why I make certain recommendations or order certain tests, but before the pandemic, I never felt nearly as frequently that patients were questioning my motives for doing things. No longer is there this understanding that the people who work in a hospital are there for their patients' and the community's good.” Two-thirds (66%) of respondents to the 2022 ACEP poll agreed COVID-19 has heightened violence in the ED, and 69 percent said COVID-19 has decreased the level of trust between patients and physicians or ED staff. (https://bit.ly/3G1xzLZ.) “The rising violence, in combination with the stress of the pandemic, is decimating the emergency department workforce that forms our nation's health care safety net and leading to very long waits to be seen in EDs all over the nation,” Dr. Casaletto said. And it's turning into a vicious cycle: The health care system is stressed, and doctors, nurses, and allied health professionals are leaving the field at unprecedented rates. More than 230,000 health care providers left the profession in 2021, according to a report from Definitive Healthcare, with emergency medicine among the top 10 specialties that lost physicians (internal medicine was first). (https://bit.ly/3I3fRdX.) This means people have less access to outpatient providers, and they feel even more that the medical establishment is failing them, said Dr. Skog. “I can't tell you how often I walk through the halls of my ED and the walls are lined with patients who've been there for days, anxious and sick and in pain. All those things increase the stress on providers and patients alike, and that type of environment leads toward more reactivity, more frustration, more anger and discontent,” he said. “Almost weekly, I hear nursing colleagues, physician colleagues, and others say, ‘I'm done. I'm not going to do this anymore. Not going to come to work and risk my own safety when it feels like no one else cares. I risked my own safety coming to work through the pandemic; I'm not going to keep doing it when I'm getting threatened every day by my own patients.’” No Repercussions There are no simple solutions to violence against EPs, and many security interventions have unclear benefits. “While we know that the presence of metal detectors finds more weapons, there is no study that shows that the presence of metal detectors decreases violent incidents or keeps either patients or ED staff safer,” Dr. Casaletto said. One of the biggest problems is that often no charges are filed against individuals who assault ED staff. “The ACEP survey notes that only two percent of respondents who had been physically assaulted said their hospital pressed charges,” she said. “Despite assault on a health care provider being a felony in North Carolina, we have great difficulty getting charges filed and even more difficulty getting these cases prosecuted. It seems here in Charlotte that pulling a knife on a grocery store or department store worker is prosecuted, while law enforcement sees it as acceptable behavior in the emergency department.” Hospital culture and law enforcement too often see workplace violence in health care as part of the job, she said. “We need hospitals to support their staff safety by supporting and encouraging reporting and developing effective relationships with law enforcement to ensure this happens.” Dr. Skog agreed. “I do greatly appreciate the work law enforcement does and understand the restrictions that they have,” he said. “But in previous times when I've been assaulted, the police have come and offered to escort the person off the property or maybe given them a ticket for trespassing, not necessarily arrested them or even given them a ticket for assault. My understanding is that it's unlikely these people will be prosecuted in the end, and that fact contributes to underreporting of violence. People think, ‘What's the point of me putting in the effort to report this when it's not going to change anything?’” Taking Meaningful Action Some hospitals have begun taking a harder line on violent and abusive behavior. Mass General Brigham released a new patient code of conduct in early November outlining a list of behaviors toward staff members that will no longer be tolerated. “We recognize the threat of disrespectful, racist or discriminatory words and actions on members of our community,” said a hospital statement. “Just as we have policies for our employees and clinicians to treat each other and every patient and visitor with courtesy and respect, this policy helps to define appropriate behaviors for patients, family members, visitors and research participants.” (https://bit.ly/3hWQxLW.) No longer tolerated at the hospital are physical and verbal threats, offensive comments about race, accent, religion, and gender or sexual orientation, and refusal to see clinicians or staff members based on these personal traits. (https://bit.ly/3WNt3HX.) “If we believe you have violated the Code with unwelcome words or actions, you will be given the chance to explain your point of view,” the policy states. “Some violations of this Code may lead to patients being asked to make other plans for their care.” ACEP and the Emergency Nurses Association launched the No Silence on ED Violence campaign in 2019 to bring attention to violence in the ED, provide resources to effect safety improvements, and seek state and federal policy solutions. The campaign has called for national standards on workplace violence in health care, and ACEP has been a driving force in supporting the Workplace Violence Prevention for Health Care and Social Service Workers Act, introduced by Rep. Joseph Courtney (D-CT). The legislation passed the House in April, and was introduced in the Senate by Sen. Tammy Baldwin (D-WI) in May. “Meaningful progress is urgent and requires a collaborative effort—we've taken a lot of steps in the right direction and our work continues,” said an ACEP spokesperson. “Policies that address ED violence were a key part of ACEP's annual Leadership and Advocacy Conference, where hundreds of meetings on this issue were facilitated between emergency physicians and elected officials. More recently, we collaborated with Reps. Madeleine Dean (D-VT) and Larry Bucshon (R-IN) to help draft and introduce the SAVE Act (H.R. 7961), which establishes federal criminal penalties for violence against emergency physicians and other health care workers, just as there are for airline or airport workers and others.” The emergency medicine community is a resilient group, Dr. Skog said, but resilience only goes so far. “After three years of worsening conditions, deteriorating appreciation for the work we do, more assaults, and more negative aspects of our jobs without a light at the end of the tunnel, we have to find a way to reinstate the mutual respect, passion, and care between the community and emergency medicine professionals.” Hospitals' Responsibilities to Protect ED Personnel ACEP's current recommendations on Protection from Violence and the Threat of Violence in the Emergency Department (June 2022; https://bit.ly/3C8ObjM) state that hospitals and administrators have these responsibilities, to name a few: Provide an ED security system that may include signage, security personnel, personnel training, physical barriers, and surveillance equipment. Develop written ED protocols with input from staff and the community which are reserved for violent situations occurring in the ED to ensure the safety of patients, visitors, and health care workers. Develop and enforce a mandatory reporting policy that requires employees to report any verbal assault or physical battery. Such policies should clearly state that reporting will not result in any adverse action by the hospital, such as termination, suspension, or retaliation, that discriminates against an employee who reports. Adopt a zero-tolerance policy for employees, patients, families, and visitors that states that any violence in the ED is not acceptable. Provide post-incident support for employees involved in violent events, including prompt medical treatment, debriefing, counseling, and employee assistance. Pursue maximum criminal prosecution, when deemed appropriate, against those individuals who threaten and commit violent acts against health care workers. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com. Follow her on Twitter@writergina." @default.
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