Communication Challenges in Addressing Patient Behavioral Flags

Date: July 31, 2024 Reference:  Gonzales RE, Seeburger EF, Friedman AB, and Agarwal AK. Patient perceptions of behavioral flags in the emergency department: A qualitative analysis. AEM July 2024 Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY. He is the Vice Chair of the Emergency Department and Program Director of the EM residency program at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County. Case: You’re three coffees deep into your night shift when emergency medical services (EMS) bring in a highly agitated 34-year-old male patient with a questionable psychiatric history and possible substance use.  He is actively fighting with the police and EMS personnel.  The paramedic apologizes to you, saying the patient was picked up while having a loud verbal altercation that was about to turn violent and he was unable to administer any medications or get a story, let alone intravenous (IV) access, even with eight police officers on scene.  While you do not recognize the patient, your colleague on the other team comes over and says to you “Oh, I know that guy, he’s a real piece of work.  Be careful you don’t get hurt!  Don’t you wish we got a heads up about these kinds of patients in the chart?” Background: Violence in emergency departments (EDs) has reached alarming levels, creating significant challenges for healthcare professionals. In an American College of Emergency Physicians (ACEP) survey from August 2022, two-thirds of emergency physicians reported being assaulted in the past year with one-third resulting in injury.[1] This disturbing trend has only been exacerbated by the COVID-19 pandemic, which has intensified stress levels, overcrowding, and labour shortages in hospitals. In a 2024 poll of ACEP members, 91% of emergency physicians said that they, or a colleague, was a victim of violence in the past year. A supermajority (68%) of those emergency physicians said they did not feel their employer’s response was appropriate and half reported nothing was done about the violence.[2] Violence in the ED is not just directed against physicians. A 2024 survey by the Emergency Nurses Association (ENA) found that more than half of its members reported being verbally assaulted, threatened with violence, or physically assaulted in the previous 30 days. Additionally, a Press-Ganey analysis indicated that two nurses are assaulted every hour. It's estimated that up to 80% of workplace violence cases involving nurses go unreported, suggesting that the actual incidence of violence is likely much higher than reported figures.[3] ​The violence faced by emergency healthcare workers has profound impacts, including physical injuries and psychological trauma. Many healthcare workers report experiencing severe stress and burnout due to these violent encounters. Studies indicate that the rate of serious injuries from workplace violence is six times higher for hospital workers than for all other private sector employees in the United States​.[4] In response to this unacceptable violence in the ED, there have been calls for legislative action. The "Workplace Violence Prevention for Health Care and Social Service Workers Act" and the "Safety From Violence for Healthcare Employees Act" (SAVE) are two key pieces of legislation aimed at mitigating workplace violence and establishing federal criminal penalties for assaults on healthcare workers. These efforts are supported by organizations like the ENA, ACEP, and the American Nurses Association (ANA)​.[5] To address the issue of ED violence, various strategies have been recommended, including better training in de-escalation techniques, improved reporting systems, and more robust workplace violence prevention programs. There is also an emphasis on supporting healthcare workers' decisions to refuse care in dangerous situations and ensuring that law enforcement is involved in managing violent i...