ACEP Survey: Emergency Departments Under Siege
By Gary Evans
In a recent survey, two-thirds of emergency physicians reported a patient assaulted them in the past year, and more than one-third of respondents say they have been attacked more than once. The survey by the American College of Emergency Physicians (ACEP) revealed 31% of assaults involved a family member or friend of the patient.1
“It’s gotten to a level that is completely unsustainable,” emergency physician Alex Skog, MD, said at an ACEP press conference. “Emergency medicine is hemorrhaging nurses, technicians, and doctors that rightfully can no longer accept the ongoing violence that they experience daily.”
ACEP conducted the survey between July 25 and Aug. 1, 2022, netting responses from 2,712 emergency physicians. More than eight out of 10 respondents said ED violence has increased since they were last polled in 2018. In the 2022 ACEP survey, 85% said violence had worsened, with 45% saying it has “greatly increased.”
The ACEP definition of violence includes not only physical assaults, but verbal threats, some of them quite ominous in their specificity, said Christopher Kang, MD, FACEP, FAWM, president-elect of ACEP.
“It’s not just, ‘I’m unhappy’ or ‘I’m frustrated’ — it’s ‘I’m going to get back at you,’ ‘I am going to go get my gun and come back and kill you,’” Kang said. “It’s not just something that occurs every once in a while. For some of our members, it actually occurs several times — not just in a month or two, but in a week.”
Respondents placed much blame on the pandemic, with 66% reporting it has increased the amount of violence, and 69% reporting a loss of trust between patients and caregivers.
“I once had a patient’s family member with a gun holster on his hip threaten to kill me and kill my entire family after I told his father that he needed to be admitted because he had coronavirus,” Skog said.
The effects of the SARS-CoV-2 pandemic on healthcare violence have been multifactorial. “Two-thirds of physicians believe that there’s been an increased amount of violence, whether it’s [due to patient] frustration, lack of access to care, or the change in societal norms,” Kang said.
In addition to staffing shortages, violence in healthcare has ramifications that ripple out from the individual incident. Recently, a patient cut an emergency doctor on the forearm and threatened several other staff members, Skog said.
“When this happened, the whole emergency department was essentially paralyzed,” Skog noted. “So many staff were required to safely manage the situation that we had to divert all ambulances to other hospitals for several hours. This put a strain on the regional emergency medicine system and caused hours of additional delay in the care of all the other critically ill patients that were already in our emergency department.”
Although not connected to the ACEP survey, an emergency physician and blogger in South Carolina recently described a scene in the ED with the nightmarish detail similar to a painting by 16th-century Dutch master Hieronymus Bosch. Edwin Leap, MD, wrote: “Shooting or stabbing victims dropped off in the ambulance bay as a car screeches away from the scene. I recall one stabbed in the heart and brought in a pickup truck. … These events stop everything — it’s all hands on deck. But in the midst of life-saving efforts, the psych patient still screams, and the infant with fever still cries, and the senior with dementia still climbs out of bed and falls onto the floor.”2
Such conditions mixed with individual verbal or physical attacks contribute to 85% of ACEP respondents reporting “emotional trauma” and spikes in anxiety.
“There is a sense of emotional trauma that we cannot do the job that we believe we should be to doing, and that is to deliver [patient] care as quickly and rapidly as possible to all who present for care,” Kang said.
EDs represent large portions of medical care, with one study revealing about half of all healthcare is delivered in these settings.3 Given that, one might presume hospitals would prioritize violence prevention in EDs, but competing issues include patient satisfaction and the public view of the hospital. Although many states have enacted tougher laws for punishing those who attack healthcare workers, the reality is the offending patient is rarely taken into custody or charged with a crime.
“The lack of some consequences or accountability for the assailant is believed to be a significant contributor to the rise of violence since 2018,” Kang said.
Hospital Response Is ‘Minimal’
According to the survey, responses to violent incidents included flagging the patient’s chart (29%); hospital security arresting the patient for the assault or enlisting law enforcement to make the arrest (16%); hospital administration advising the healthcare worker to press charges (6%); and hospital security pressing charges (2%).
“Among those who gave ‘other’ responses (45%), many indicated that the hospital’s reaction is minimal: escorting the patient off property, restraining the patient, or in many cases, doing nothing,” the ACEP report authors noted. “’The administration rarely gets involved.’”
When administration does act, physicians note it is often to “de-escalate” the situation in a way that will appease the family or patient — not the physicians or staff.
“Several physicians indicate that they have been encouraged not to press charges for fear that it would promote a negative perception of the hospital,” the report authors wrote.
Thus closes a vicious cycle, as the likelihood that nothing will happen discourages emergency workers from reporting incidents.
Asked to describe their most recent assault, survey respondents listed verbal assault with threats of violence (64%); hit and slapped (40%); spit on (31%); punched (29%); kicked (26%); scratched (19%); bitten (6%); assaulted with a weapon (4%); and sexual assault (2%).
Emergency physicians reported psychiatric patients and those seeking drugs (42%) or those under the influence of drugs or alcohol (40%) are most often responsible for assaults in the ED.
The top three interventions ACEP survey respondents recommended were:
- More security (security guards, security cameras, security for parking lots, metal detectors, screen all visitors);
- Establish, communicate, and enforce clear policies;
- Report these incidents to the police.
- American College of Emergency Physicians. ACEP emergency department violence poll results. August 2022.
- Leap E. Reporting from the healthcare disaster. Sep 25, 2022.
- Marcozzi D, Carr B, Liferidge A, et al. Trends in the contribution of emergency departments to the provision of hospital-associated health care in the USA. Int J Health Serv 2018;48:267-288.
In a recent survey, two-thirds of emergency physicians reported a patient assaulted them in the past year, and more than one-third of respondents said they have been attacked more than once. The survey by ACEP revealed 31% of assaults involved a family member or friend of the patient.
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