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Violence against healthcare workers is on the rise


December 1, 2018

A new study by the American College of Emergency Physicians (ACEP) shows that violence in America’s emergency departments (ED) is increasing, causing harm to physicians, staff, and patients.

The new survey, released October 2, shows that nearly half (47%) of emergency physicians report having been physically assaulted while at work, with 60% saying those assaults occurred in the past year, according to ACEP. 

The survey polled some 3,500 emergency physicians across the United States and painted a picture of violence against hospital ED staff that is growing worse. Assaults against nurses have been well-documented, but this is one of the largest surveys on the topic that spotlights physicians.

Nearly eight in 10 emergency physicians say that violent incidents are affecting patient care, with 51% of those saying that patients also have been physically harmed. The statistics are alarming, if not surprising, as healthcare safety experts have known for years that violence in the ED has been on the rise. Its increase is largely a byproduct of the growing opioid epidemic as well as the closings of specialized mental health facilities.

Survey results pinpoint problems

According to the ACEP survey’s results, nearly seven in 10 emergency physicians say violence has increased in the past five years, with 25% reporting it has increased greatly.

“More needs to be done,” said Vidor Friedman, MD, FACEP, president of ACEP, in a written statement. “Violence in emergency departments is not only affecting medical staff, it is affecting patients. When violence occurs in an emergency department, patients can be injured or traumatized to the point of leaving without being seen. It also can increase wait times and distract emergency staff from focusing on other patients who urgently require a physician’s assistance.”

Almost half (49%) of respondents said hospitals can do more by adding security guards, cameras, security for parking lots, metal detectors, and visitor screening inside hospitals, especially in EDs.

“Nearly three-quarters (70%) of those assaulted say that their hospital administration or hospital security did respond to the incident, yet among those whose hospital responded, only 3% say that the hospital security actually pressed charges,” said Friedman.

Friedman says nearly all female emergency physicians (96%) reported that a patient or visitor made inappropriate comments or unwanted advances toward them, and 80% of male emergency physicians reported the same. 

More than a quarter (27%) of emergency physicians who were assaulted in the past year say assaults occurred more than once. Nearly a third (27%) of those assaulted got injured. About half of those injured (44%) reported being hit or slapped. Almost one-third say they have also been either punched, kicked, or spit upon. Almost all (97%) say a patient committed the assault. More than a quarter (28%) reported that they had been assaulted by a patient’s family member or friend.

Violence on the rise everywhere

In addition to the survey, a new study published in the Annals of Emergency Medicine found that despite increased security measures in Michigan, the problems of ED violence are getting worse in a state that already struggles with it.

The study, titled “Reassessment of Violence Against Emergency Physicians,” was published in the October 2018 issue and presented at the ACEP 2018 conference. 

“Emergency physicians across all demographics experience various forms of violence and are increasingly concerned about becoming a victim,” says Terry Kowalenko, MD, FACEP, an emergency physician in Michigan and co-author of the study. “Despite increased risks, our research found that there is very little published on topics such as situational awareness, verbal de-escalation, self-protection techniques, or weapons awareness for emergency physicians to use.”

But the problems aren’t limited to Michigan. In Massachusetts, a Boston Globe article chronicled the story of Dr. Sundeep Shukla, who was attacked by a psychiatric patient.

“[He] expected his patient would be upset to learn that he was stuck in the emergency room indefinitely. There was no psychiatric facility that had space for him. But Shukla did not predict what happened next,” the article read.

“The patient leaped off his gurney and punched Shukla, hard, in the jaw. Pain shot down his neck. Shukla, who now works at a hospital in Western Massachusetts, had little time to nurse his wound: Another ambulance arrived, and he rushed off to treat a stroke patient. Angry and distraught patients and family members have scratched, spit at, bitten, hit, and stabbed doctors and nurses working in hospital emergency rooms. One Massachusetts caregiver was so badly cut in an assault that she required eight hours of life-saving surgery.”

It’s something that happens across America’s EDs, and most healthcare workers accept at least some level of physical or verbal violence as part of their job.

“We have a lot of populations that pose risks to us in healthcare,” said Bonnie S. Michelman, CPP, CHPA, in a June 2017 webinar from the American Organization of Nursing Executives discussing the impact of violence in America’s healthcare facilities.

“Sometimes we don’t even know a patient may have severe psychiatric imbalance or problems,” Michelman said. “We have issues with gang members for many of our hospitals. We’re dealing with the opioid epidemic and certainly substance use disorder significantly throughout our country, and that is creating a lot of different issues for all of us.” She added that her staff now carries Narcan to help save lives.

“Even patients with Alzheimer’s or dementia have issues around violence at times where they are more prone to escalate quickly or be unpredictable in their behavior,” she said. “Head-injured patients, same thing. If you have an autism clinic or you treat patients with autism, that can be another high-risk population. Certainly, visitors can be a high-risk population; they may come in impaired or they may come in with a certain contraband. They may come in also in some behavioral health state that can create difficulty for your hospital. Finally, the homeless population tends to be a population that is untreated.”

According to Kowalenko, 72% of emergency physicians in Michigan reported experiencing violence in the past year. An increasing number of  physicians in 2018 reported feeling “constantly fearful” of becoming a victim of violence.

Other findings of the ACEP survey include the following alarming statistics from emergency physicians:

  • Almost three-quarters (71%) have personally witnessed others being assaulted during their shifts
  • More than 80% said a patient has threatened to return and harm them or their ED staff
  • Half reported that at least half of all assaults are committed by people who are seeking drugs or who are under the influence of drugs or alcohol
  • More than 40% believe that more than half of assaults are committed by psychiatric patients

It’s one thing to read the statistics, but it’s another to live them for real. The patient who punched Dr. Sundeep Shukla was informed by an outside therapist that if he checked into the ED, he would quickly be transferred to a psychiatric facility, Shukla told the Globe. Often, psychiatric patients —who may not be suffering from an acute condition—wait long hours to be seen by a physician because of overcrowding, which is a major precursor to patient anxiety and violence.

“I have seen a colleague kicked in the face; I’ve seen a nurse kicked in the chest and have to get medical treatment. I’ve seen patients spit on people and throw urine across the room,’’ Shukla said in the Globe report.

The dangers of working in the healthcare industry have long been known, and it’s been accepted that workers face a rate of workplace violence that is four times higher than in private industry overall, according to OSHA and the U.S. Bureau of Labor Statistics (BLS). “Intentional injury’’ by another person rose from 6.4 incidents per 10,000 hospital workers in 2011 to 9.0 per 10,000 hospital workers in 2016 (the most recent year of data), according to the BLS. 

Boston hospitals are no stranger to violence against physicians. In 2015, Brigham and Women’s Hospital cardiologist Dr. Michael Davidson was shot to death in an exam room by the son of a deceased patient. Since then, security measures at Brigham and Women’s have been improved, but the Globe article suggested that many Massachusetts emergency physicians support passing legislation that would increase criminal penalties for assaulting a healthcare worker. The Massachusetts nurses’ union  supports a bill that would require all healthcare facilities to annually assess the risk of violence, develop programs to minimize that risk, and allow employees who are victims of assault up to seven days’ paid leave. This would follow suit with states like California, where the passage of Senate Bill 1299 into state law requires healthcare employers to report rates of violence as well as enact plans to reduce the incidence of violence against their employees.

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