A resident’s experience
Dr. Vidor E. Friedman
Those are key findings from an email-based survey administered to ACEP members in August of 2018.
“The results are quite troubling,” Vidor E. Friedman, MD, FACEP, president of ACEP, said during a press briefing at the group’s annual meeting. “Emergency physicians are reporting that violence in emergency departments is increasing and that it’s harming not only physicians and nurses, but also patients and the care that’s being provided to them.”
Dr. Friedman, who practices emergency medicine in Maitland, Fla., recalled one afternoon shift when police brought in a drunk man they had cited for vagrancy after finding him in a ditch by the roadside. It was the man’s first day out of jail in 10 years. “He was a pretty intimidating looking guy,” Dr. Friedman said. “He threatened me and he threatened the staff, so we appropriately restrained him, which only increased his agitation. The fourth time he said he was going to kill me, he told me he was going to put an ice pick in my heart. When his buddies came to pick him up, I had the police escort him to the city limits, and I didn’t sleep at home for a week. This is the kind of thing that health care workers are exposed to on a fairly regular basis.”
The ACEP survey found that emergency physicians across all demographics experience various forms of violence and are increasingly concerned about violence in the ED. “We know that there is gross underreporting of [violence in the ED],” said Terry Kowalenko, MD, FACEP, chair of emergency medicine at Oakland University William Beaumont School of Medicine, Rochester, Mich., and coauthor of a new study that assessed violence against emergency physicians in that state. “Some studies have shown it to be under 50%. The other thing is, it’s very difficult to predict who the perpetrator will be, or who the victim will be. We did find that the time you spend with the patient certainly increases your chances of violence perpetrated against you. Clearly, there are consequences to the victim, the perpetrator, the institution, and potentially, other patients.”
Doug Brunk/MDedge News
From left, Terry Kowalenko, MD, ACEP President Vido E. Friedman, MD, and Leigh Vinocur, MD, discuss violence in the ED.
According to Dr. Kowalenko’s own research, 72% of emergency medicine physicians in Michigan reported experiencing violence in the past year. In 2018, an increasing proportion of that state’s emergency physicians reported feeling “constantly fearful” of becoming a victim of violence (8.1% vs. 1.2% in 2005), with 22% reporting feeling frequently fearful (up from 9.4% in 2005).
For the ACEP-sponsored survey, on Aug. 21, 2018, Alexandria, Va.–based Marketing General sent an email to 31,389 ACEP members, inviting them to answer 22 questions in an effort to understand emergency physicians’ views on the level, type, frequency, and impact of violence experienced in the ED. By the time polling closed 6 days later, 3,539 surveys were completed, for a response rate of about 11%. Clinicians in California led the way with 8% of total responses, followed by those in Texas (7%), New York (7%), Florida (5%), Pennsylvania (5%), and Ohio (5%). Nearly two-thirds of respondents (71%) were male, and 25% work for emergency departments with annual patient volumes between 50,001 and 75,000, while another 39% work for departments with even higher volumes.
Nearly half of respondents (47%) reported being physically assaulted while at work in the ED, while 71% have witnessed an assault. Only 10% have experienced neither. The majority of assaults were committed by patients (97%), but 28% involved a patient’s family member or friend. The most common form of assault was a hit or a slap (44%), while other frequent forms of violence included being spit on (30%), punched (28%), or kicked (27%).
Among those who have been physically assaulted, 48% reported that at least half of all assaults were committed by people believed to be seeking drugs or who were under the influence of drugs or alcohol, while 41% said that more than half of assaults were committed by psychiatric patients.
“Our emergency departments are kind of a microcosm of all the challenges that we face today in society: gang violence, gun violence, domestic violence, and psychiatric illnesses [for which] we have a shortage of beds,” said Leigh Vinocur, MD, FACEP, former chair of ACEP’s Emergency Department Violence Committee. “Then there is the opioid crisis.” She added that being in an emergency department can be “an emotionally volatile experience for people from all walks of life. People come in hurt. They’re at their worst; they’re frightened, they’re vulnerable and stressed.”
Courtesy ACEP
More than three-quarters of ACEP survey respondents (77%) believe that violence in the ED has harmed patient care, primarily by loss of productivity (81%), emotional trauma (81%), increased wait times (80%), and less focus from emergency staff or physicians (76%). In addition, 49% ranked “increase security” as the most important step hospitals can take to increase ED safety, while the top three contributing factors to violence in the ED were no adequate punitive consequence or response toward the attacker (34%), behavioral health patients (32%), and absence of adequate protective mechanisms for physicians/staff (15%).
When asked how the hospital administration or hospital security responded to the assault, 28% said that the hospital or nursing staff put a behavioral flag in the patient’s medical chart, while 21% said that hospital security arrested the patient for the assault or enlisted law enforcement to arrest the patient.
Finally, nearly half of respondents indicated that hospitals could do more by adding security cameras, metal detectors, and increasing visitor screening. “Obviously this is site-specific,” Dr. Friedman said. “We’re not saying that every emergency department in America needs to have a metal detector out front, but this needs to be something that institutions take seriously, to protect both patients and the providers that work there.”