Violence in U.S. Emergency Departments on the Rise ACEP Survey Highlights Growing Risk By CINDY SANDERS
Publisher’s Note: Just as we were going to press with this issue of Medical News, yet another act of violence grabbed national headlines when a physician and an emergency department staff member were shot at a VA Medical Center in Florida. By their very nature, emergency departments are high-stakes settings filled with vulnerable patients and frightened families. Increasingly, they are also high-risk settings for healthcare providers, staff and patients. Last fall, the American College of Emergency Physicians released data and insights into the rising violence in U.S. Emergency Departments. In a poll of more than 3,500 emergency physicians nationwide, nearly seven in 10 said ED violence is increasing, and nearly eight in 10 said the violence harms patient care. “More needs to be done,” said ACEP President Vidor Friedman, MD, FACEP, in presenting the survey results during the organization’s annual meeting. “Violence in emergency departments is not only affecting medical staff, it is affecting patients,” he continued. Findings from the poll, included: • 47 percent of emergency physicians reported having been physically assaulted at work, with 60 percent of those assaults occurring in the past year. • 71 percent personally witnessed others being assaulted during their shifts. • 77 percent said patient care was being affected with 51 percent of those saying that patients also have been physically harmed. • 50 percent believe the majority of attacks are from people seeking drugs or under the influence of drugs or alcohol. While 70 percent of those surveyed said hospital administration or hospital security did respond to the incident, only 21 percent said hospital security arrested the assailant or enlisted law enforcement to do so; 6 percent said hospital administration advised them to press charges; and 3 percent said hospital security pressed charges. The other 70 percent said response to the assault resulted in a behavioral flag being added to a patient’s chart or ‘other’ measure. The vast majority of physicians said patients were responsible for the attack, but 28 percent reported being assaulted by a patient’s family member or friend (results totaled more than 100 percent because some respondents had been attacked more than once). 83 percent of emergency physician respondents said a patient has threatened to return to harm them or their emergency staff. The most common types of assault are being hit, slapped, spit upon, punched, kicked or scratched. In addition, to physical attacks, 80 percent of male and 96 percent of female emergency physicians report having a patient or visitor make inappropriate nashvillemedicalnews
(L-R) Drs. Terry Kowalenko, Vidor Friedman and Leigh Vinocur present survey findings at an ACEP meeting.
comments or unwanted advances. 34 percent believe a lack of punitive consequence is the biggest contributing factor to the issue, and another 32 percent said behavioral health patients are driving the increases in violence (and 41 percent think the majority of attacks are from psychiatric patients). “Just in hospitals and healthcare in general, people are at their most vulnerable, and family members are at their most worried. The ER is the worst-case scenario for most, so it is this extremely volatile experience,” said Leigh Vinocur, MD, FACEP, past chair of ACEP’s Emergency Department Violence Committee and a national spokesperson for the organization. She added that when most people think about doctors and nurses being harmed or killed, they think of those practicing in war-torn counties. “Yet, here in the United States, it’s possible for your ER physician to become a victim of violence.” The reasons for increasing violence are multifactorial. “I always say the emergency department is a microcosm of society – gun violence, domestic violence, homelessness, psychiatric issues. As there is an increase in violence in society, it’s going to spill over into the emergency department,” noted Vinocur, a board-certified emergency physician with more than 25 years of experience. Add overcrowding and boarding into the mix of heightened emotions, and Vinocur said it isn’t surprising to see tempers flare. While nearly half the physicians surveyed have been physically assaulted and more than 70 percent have witnessed someone else be assaulted, Vinocur said the numbers climb even higher when verbal abuse is added to equation. And while this poll was conducted among emergency physicians, she said nurses are often on the front lines of the potential danger. “The person who is more hands-on with the patient is susceptible to even more abuse,” she pointed out. “If you look at the Bureau of Labor Statistics, being a healthcare professional is one of the most dangerous professions … and it’s very underreported,” Vinocur said, noting those in healthcare chose the profession to help people and often don’t
report incidences because they recognize patients are under stress and don’t want to stigmatize them. Even while being mindful the situation might cause patients and family members to act in ways they normally wouldn’t, Vinocur said she believes hospitals are trying to get in front of bad behaviors that could quickly escalate. “Hospitals and health systems realize it’s the safety of their employees and also the safety of their patients,” she said. Of increasing concern, however, are freestanding EDs and urgent care centers. While most hospitals have guards, Vinocur pointed out, “In these ambulatory settings where you are siloed and there’s no security, you are even more vulnerable … and a lot of healthcare is moving to ambulatory settings.” To offset the disturbing trend in violence, Vinocur said there are a number of concrete
steps facilities and health systems could take to improve safety. Additional security is one key step whether that is in the form of more guards or more cameras on site. When adding security cameras, it’s beneficial to have the devices visible so that individuals are aware their actions are being recorded. Improved visitor screening is another crucial step. In some areas, particularly large urban areas, metal detectors help screen for weapons. In addition, Vinocur said staff should be trained to ask patients if there is anyone who shouldn’t be allowed in to see them to help curb potential domestic violence interactions. “Training people to deescalate situations, too, is important … teaching hospital staff to recognize the signs of someone who is escalating as they are starting to get more and more agitated,” she said. Vinocur noted clinicians could also play a vital role in easing agitation through clear communication with patients and family members to keep them up to speed. While it’s easy for physicians to get distracted because they are so busy, she said it’s crucial to be aware of how stressful the situation is for patients and their families and why it’s so important to foster engagement. “Tensions run high,” Vinocur concluded. “Open communication can help allay fears and help mitigate out-of-control feelings. It can help ameliorate the very emotional experience of healthcare.” And a calmer emergency department is ultimately a safer one.
Every Minute Matters, continued from page 8 as bad, but we now know that more blood given faster improves outcomes. And we have a massive transfusion protocol where we deliver large parcels of blood to the operating room – almost equivalent to the blood volume in one human – and we watch patients get better immediately.” VUMC also is driving research behind traumatic brain injuries and the lifelong impact of head injuries. “Trauma has longterm effects that are cognitive in terms of missed brain injuries,” Guillamondegui said. “A lot of patients have long-term emotional or cognitive dysfunction that no one will ever relate to trauma because of a clear CT scan.” He said he expects those effects to be a major area of study over the next few years, as researchers work to better understand the long-term cognitive outcomes of trauma. “As a teaching hospital, we’re constantly looking at trauma outcomes and research,” Guillamondegui said. “We’re very introspective, so we’re always looking back to make sure what we’ve done is best for our patients. That means care changes based on outcomes over time, which allow us to deliver state-of-the-art care.”
Tennessee Trauma Centers There are 12 designated trauma centers and four comprehensive regional pediatric centers in the state. Half of the trauma centers are designated as Level 1, with Vanderbilt University Medical Center serving Middle Tennessee. Knoxville, Memphis, Chattanooga, Johnson City and Kingsport also have Level 1 centers. Tennessee has two Level 2 centers – TriStar Skyline in Nashville and Bristol Regional in the TriCities. The state has four Level 3 centers, all clustered in Middle Tennessee: TriStar Summit Medical Center in Hermitage, TriStar Horizon Medical Center in Dickson, Sumner Regional Medical Center in Gallatin, and TriStar StoneCrest Medical Center in Smyrna.
Nashville Medical News March 2019