‘I have been punched, but nothing more than that.”

That's the response Paul Biddinger, MD, an associate professor of emergency medicine at Harvard Medical School and the Harvard School of Public Health, gives when asked if he has ever been assaulted at work.

“I've been punched by people I didn't anticipate, such as an elderly demented patient who throws a punch in an unexpected way, and I've been punched by an aggressive, psychotic patient and was able to avoid injury because I knew it was coming,” he said.

Violence — verbal and physical — is an everyday occurrence in America's emergency departments, so commonplace that those who experience it tend to downplay it. “There isn't a single individual within the ED that I think is immune to it,” said Terry Kowalenko, MD, the chair of emergency medicine at Oakland University William Beaumont School of Medicine in Rochester, MI, who has written multiple articles on workplace violence in emergency medicine, including an analysis in the Journal of Emergency Medicine. (2012;43[3]:523.) “No matter your gender, your job title, or any other factor, you're not immune to it. And studies have shown that it's not related to the type of ED you work in. You are at risk for violence in a rural or urban ED and everything else in between.”

In fact, you could easily say that the emergency department is the single most dangerous workplace in America outside of law enforcement. Statistics show that almost 75 percent of workplace assaults occur in a health care setting and that violence disproportionately affects ED staff. (N Engl J Med 2016;374[17]:1661.) For more than a decade, research has documented the elevated levels of workplace violence that emergency physicians, nurses, technicians, and clerical staff experience on a daily basis.

Nearly eight in 10 emergency physicians nationwide report being the target of physical violence over the past year. (N Engl J Med 2016;374[17]:1661.)

More than 65 percent of emergency residents at a cross-section of New York City hospitals had experienced physical violence during a shift, and 78 percent had experienced verbal threats. (West J Emerg Med 2016;17[5]:567.)

More than half of emergency physicians in a national study report having been assaulted by a patient or visitor. (J Emerg Med 2006;31[3]:331.)

Nearly 75 percent of emergency attendings in Michigan had been subject to at least one verbal threat over the previous year, while 28 percent had been assaulted and nearly 12 percent had been confronted outside the ED. (Ann Emerg Med 2005;46[2]:142.)

Nurses and technicians, because of their greater face-to-face time with patients, are at even higher risk than emergency physicians. Emergency nurse Gordon Gillespie told the Robert Wood Johnson Foundation in 2015 that he had been assaulted dozens of times during nearly two decades in his field.

One hundred percent of emergency department nurses reported verbal assault and more than 80 percent reported physical assault over the past year. (N Engl J Med 2016;374[17]:1661.)

One in four nurses reported experiencing physical violence more than 20 times over the previous three years, and indicated that they had been verbally abused more than 200 times over the same time period. (J Nurs Adm 2009;39[7-8]:340.)

Three in four nurses experienced verbal or physical abuse from patients and visitors in 2014, with emergency nurses at significantly higher risk than those in other specialties. (J Emerg Nurs 2014;40[3]:218.)

Intoxicated individuals and those with psychiatric disorders are usually the perpetrators of physical assaults, said Dr. Kowalenko, who led the 2005 Michigan study. “The vast majority of assaults and threats are perpetrated by patients, but a significant minority of visitors have also been assailants. And surprisingly, in our survey at least, 52 percent of physical assaults were perpetrated by males, which means that 48 percent were female, or nearly a 50-50 split statistically.”

Only Part of the Picture

If anything, however, the existing data understate the level of workplace violence in the ED because of multiple factors, including inconsistent definitions and understanding of what constitutes an assault, the perceived “hassle” of going through the reporting process to document an incident and an ever-higher threshold for what many emergency department staff consider violence as they become inured to it.

“If you're shoved by a patient and it ends right there, your likelihood of staying to write up the incident or report it to the police is very low,” Dr. Kowalenko said. “It's not infrequent that whatever the reporting mechanism is, it's viewed by people who are working as being onerous. You've just finished a 12-hour shift, you're exhausted, and now you have to do at least 20 more minutes of paperwork to report an incident when you didn't actually suffer an injury. You can imagine the under-reporting.”

But taking the time to report an incident, no matter how onerous the process may be, is essential, he said. “This situation will not change until we make sure that the people in a position to make a difference know how much it happens.”

When Michigan's legislature was considering a bill in 2013 that would increase the penalties for assaulting health care workers, it so happened that a state representative was touring the emergency department at the University of Michigan Health System where Dr. Kowalenko worked at the time. “In the middle of the afternoon, the congressman witnessed a patient assault and become very verbally aggressive with our staff. He was shocked. He said, ‘I never imagined. If I hadn't seen it with my own eyes, I wouldn't have believed how bad it could get. I was scared and I wasn't anywhere close to it.’ The congressman, not a supporter of the legislation previously, left the ED that day a big supporter,” Dr. Kowalenko said.

Definitions are also a problem, said James Phillips, MD, an instructor in emergency medicine at Harvard Medical School, the director of the counterterrorism program at Beth Israel Deaconess Medical Center, and an author of the 2016 New England Journal of Medicine article on workplace violence in emergency medicine. “Assault doesn't mean just unwanted physical touching. That's battery. Assault can be verbal. But we don't even have consensus definitions in the reporting or research world to compare data between studies and hospitals. And there are discrepancies between what academic researchers are measuring vs. what the federal government is measuring.”

The Bureau of Labor Statistics primarily records violence that results in missed work days, but if the event did not cause an injury that kept the individual out of work, it is not recorded. Nor is verbal violence.

And only one state — California — currently requires that violent events that take place in hospitals or health care settings be reported to the state. Passed in 2016, that legislation took effect in January and requires that hospitals keep a written record of any violent incident against a hospital employee or other health care worker. The information will be made available on public websites beginning in 2018.

In Search of Evidence

What can be done? A 2011 report on ED safety and security discusses a number of approaches, including:

Engineering controls, such as closed-circuit video, curved mirrors, employee safe rooms, bright and effective lighting, minimal furniture in crisis treatment areas and counseling rooms, and metal detectors;

Work practice controls, such as requiring that all assaults (verbal and physical) be reported, staffing the ED with appropriately trained security guards at all times, and establishing policies and procedures for secured areas and emergency evaluations; and

Safety and health trainings on such topics as recognizing high-risk situations, de-escalating and defusing potential violence, and self-defense and safe methods to apply restraints.

Multiple systemic and individual approaches to preventing violence in the ED have been suggested, but many of them lack solid evidence, said Dr. Biddinger, also the vice chairman for emergency preparedness in the department of emergency medicine at Massachusetts General Hospital. “Much of the literature on the subject is speculative. Engineering solutions, such as designing spaces so that you do not have areas where a patient or family member can hide and all hospital staff can see the treatment areas well, placing lots of panic buttons that are easily accessible, and having good video surveillance in public spaces, these all seem like good ideas, and it's not that I disagree, but the data that support this are not as robust as we would like them to be.”

He said the focus should be at least as much on staff interventions and training as on physical design. “Access control, video cameras, and so on play an important role, but it's just as important, if not more so, to train medical staff to recognize and de-escalate volatile situations and protect their own safety if they find themselves in a violent situation. But only a very small number of physicians and nurses in EDs have received such training.”

Mass General offers Management of Aggressive Behavior (MOAB) training for all physicians and nurses, and it is also available to nonclinicians. “Too few of us working in EDs across the country have had such specific training in recognizing the early escalation signs that patients or family members may exhibit, and how our posture or stance and body language can either calm or exacerbate a situation,” Dr. Biddinger said. “Much of the training is scenario-based. Some is discussion of how to a defuse situation, acknowledge someone's anger or aggression, and gracefully exit the scene or call for help, often using a code word to summon police or security.”

Dr. Biddinger said he has not been assaulted since going through the training, which also uses simulated knives and guns for escape techniques. “I hope very much in my career that I don't have someone pull a weapon in front of me, but I'm more confident now that I can react in a way that gets me out of situation without harming the patient.”

Other hospitals have also instituted training programs like MOAB. Valley Hospital in Ridgewood, NJ, recently stepped up its awareness and de-escalation training for medical staff, added a special de-escalation unit with teams on call 24/7, and purchased mobile alert tags that can be attached to staff members' badges or lanyards to call for the unit in dangerous situations. Called Code Atlas, the unit includes 90 specially trained staff, at least four of whom are always on duty.

“Each hospital needs a multidisciplinary committee specifically tasked with reviewing the problem of violence against their staff,” said Dr. Phillips. “Start by figuring out entry-level interventions you can do and what changes you need to make in the recording and reporting process. And at a national level, since there are no federal guidelines in place that lay out what a workplace violence prevention program for hospitals should be and none of the accrediting organizations have mandates or requirements for such programs, we need leading organizations like the Joint Commission to take a look at the current policies and requirements for workplace violence programs and consider revising them, so that we have policies that are not just lip service.”

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