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ED Violence Pushes Out Top Employees

Providers demand tougher penalties, better protection

By Dorothy Brooks

While multiple factors can figure into an emergency provider’s decision to leave his or her profession, receiving threats or winding up as assault victims while on the job easily can be the final straw. Those who work in the ED say the violence in this setting is only growing worse.

According to a survey conducted by the American College of Emergency Physicians (ACEP) earlier this year, 85% of EPs said violence in the ED has become worse over the last five years, with 45% indicating that it has increased greatly. Further, among the more than 2,700 respondents, 66% reported they were assaulted within the past year, with more than one-third indicating they were assaulted more than once during this period.

“It is not just that [this violence] occurs once in a while; for some of our members, it actually occurs several times — not just in a month, but in a week,” said ACEP President Christopher Kang, MD, FACEP, during a briefing with reporters about the survey results. “A lot of times, these assaults are instigated by or involve patients, but ... [the attacks] increasingly involve their family members or friends as well.”

Alexander Skog, MD, president of the Oregon chapter of ACEP, spoke about one recent incident of violence in his facility. A patient had to be placed in restraints to prevent him from attacking paramedics on the way to the hospital.

“Shortly after we started taking care of the patient, he charged an ED technician, tearing his shirt and wrestling the technician to the ground,” Skog said. “While trying to remove the patient from the ED technician, a doctor was cut across the forearm.”

Even several days following the incident, Skog said the patient remained in the ED because psychiatric services believed he was so volatile and violent that they did not have enough resources to take care of him safely.

“While the physical trauma of events like this is unacceptable, the greater effects ... may be less obvious,” Skog observed. “When this happened, the whole ED was essentially paralyzed. 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 other critically ill patients who were already in our ED.”

Skog shared a story he heard about a nurse who had come from an inpatient unit to help during the incident tell another nurse she would never visit the ED to help again because she said it was just not safe. “I have been scared for my safety as well, and the safety of my family, too,” Skog said. “I once had a patient’s family member with a gun holster on his hip threaten to kill me and my entire family after I told his father that he needed to be admitted because he had coronavirus.”

This turmoil affects all the dedicated personnel who work in the ED. “Emergency medicine is hemorrhaging nurses, technicians, and doctors who rightfully can no longer accept the ongoing violence that they experience daily,” Skog said.

Better security measures are needed, but ACEP maintains that too often, people who commit violence against healthcare workers are not held accountable for their actions. “Only 2% of hospital security [personnel] actually press charges,” Kang noted. “Even though some states have enacted legislation saying that it could be a misdemeanor or sometimes a felony to actually assault or harm a healthcare worker ... unfortunately, many times what occurs afterward continues to allow this cycle of violence to continue.”

While there has been ample discussion on whether the effects of the pandemic have, in fact, fueled this rise in violence against healthcare workers, ACEP survey respondents expressed little doubt about this. Kang suggested social isolation, lack of access to care, and recommendations for precautions have negatively affected the patient-physician relationship. “Nearly seven in 10 respondents say that the COVID-19 pandemic has eroded the overall trust, not just in physicians but the entire ED staff,” Kang said. “Nine out of 10 emergency physicians agree that the violence that occurs, whether it is threats or harm, actually [negatively affects] patient care.”

For instance, 85% of survey respondents indicated ED violence has led to longer wait times, and more than half said this often results in patients leaving before receiving care. “This has a profound impact on the sense of duty that EDs have about seeing every patient as quickly as possible, especially when we have waiting rooms that are full,” Kang observed. “Somewhere along the way ... there is a sense of emotional trauma that we cannot do the job that we believe we should be doing, and that is literally to deliver the care as quickly and rapidly as possible to all who present.”

Skog maintained the issue of violence in the ED must be a top priority for both healthcare organizations and lawmakers. “Now more than ever, I feel that we will lose these frontline medical professionals unless action to increase accountability and add protection in the ED [are] addressed with the seriousness and urgency required to stem the tide of violence,” he said.

In addition to the No Silence on ED Violence campaign that both ACEP and the Emergency Nurses Association have established (, ACEP is advocating for passage of two pieces of legislation currently before Congress. The Safety From Violence for Healthcare Employees Act would establish penalties for individuals who threaten or assault healthcare workers. The Workplace Violence Prevention for Health Care and Social Service Workers Act would require the Department of Labor to address workplace violence in the healthcare and social service sectors.