Addressing the Rising Tide of Violence in Emergency Departments

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 incidents​.[6] ED violence is unfortunately not an isolated problem in the USA with other countries facing similar issues. The Canadian Association of Emergency Physicians (CAEP) has a position statement on ED violence.[7] This document highlights the serious problem of workplace violence in EDs, emphasizing the need for enhanced safety measures and support for healthcare providers. These include increased security measures, staff training in de-escalation techniques, and the implementation of policies to protect healthcare workers. The underlying cause for the rise in ED violence is likely multifactorial, including difficulties for patients accessing medical and psychiatric care, increasing burdens on ED with significant overcrowding, a highly stressed and under-resourced health care delivery system and perpetual staffing concerns.  Several interventions have been developed to address the issue of ED violence. These have ranged from zero-tolerance policies to engaging with violent patients. [6] However, a Cochrane SRMA reported a lack of evidence that any of these interventions are effective at mitigating healthcare violence.[8]  One strategy that was not reviewed in the Cochrane publication was the use of behavioural flags in the electronic health record (EHR) to alert clinicians that a patient had a violent or unsafe event in a prior visit.  While there are positive aspects to an early warning system for ED staff, there is a concern that existing bias or inequity in our system may negatively impact our patients when using such behavioural flags. Clinical Question: How would patients in the emergency department feel about the use of behavioural flags in the EHR and their utility as a strategy to mitigate violent or unsafe events? 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 Population: Emergency department patients Interest: The use of behavioral flags in the EHR to identify the risk of unsafe events Context: Patient perceptions of the use of behavioral flags as a method of risk reduction for ED violence and better management of aggressive or unsafe patient behaviors Type of Study: Thematic analysis of semi-structured interviews Rachel Gonzales This is an SGEM HOP and we are pleased to have the lead author on the show Rachel Gonzales. She is a research project manager at the Center for Health Care Transformation and Innovation and the Department of Emergency Medicine at the University of Pennsylvania. Rachel is passionate about identifying new solutions to promote equity in health care and increase access to health and health care for underserved populations. Authors’ Conclusions: “While many saw flags as a helpful tool to mitigate violence, concerns around negative impacts on care, transparency, and equity were also shared. Insights from this stakeholder perspective may allow for health systems to make flags more effective without compromising equity or patient ideals.” Quality Checklist for Qualitative Studies: Was there a clear statement of the aims of the research? Yes Is a qualitative methodology appropriate? Yes Was the research design appropriate to address the aims of the research? Yes Was the recruitment strategy appropriate to the aims of the research? Unsure Was the data collected in a way that addressed the research issue? No Has the relationship between the researcher and participants been adequately considered? Yes Have ethical issues been taken into consideration? Yes Was the data analysis sufficiently rigorous? Yes Is there a clear statement of findings? Yes How valuable is the research? Unsure Financial conflicts of interest. No Results: This qualitative analysis included 25 adult patients in the ED of a large, urban, academic medical center who had no history of a behavioral flag in their EHR. The mean age was 49 years, 56% were male, 72% identified as Black or African American, 24% as White, and 4% as Asian and participants reported various levels of education. Key Results: They identified five major themes from the potential benefits of behavioural flags, the potential harms, transparency of flags, equity and some ideas to improve the flag system. Five Major Themes: Potential Benefits: Participants saw behavioral flags as useful for improving the knowledge or care of patients, mitigating violence, and signalling patients to improve their behavior. They believed flags could provide better understanding and preparedness for healthcare providers, which could enhance patient care and safety. Potential Harms: Participants expressed worries that flags could misrepresent a patient's true character or behavior, negatively impact care seeking, and lead to substandard care. They feared that flags might label patients unfairly based on isolated incidents or subjective judgments, potentially discouraging them from seeking future care and affecting the quality of care they receive. Transparency and Patient Awareness: There was a strong sentiment that patients should be informed if a flag is placed in their chart. However, concerns were also raised that informing patients might escalate the situation, leading to potential conflicts during the ED visit. Equity: Participants highlighted issues of bias and inequity in flag placement, with concerns that racial disparities observed in the placement of flags could perpetuate inequitable treatment. They noted that cultural or class differences could also contribute to these disparities. Ideas for Improvement: Suggestions for improving the flag system included considering the context and circumstances when placing a flag, taking further action when a flag is present to ensure safety, incorporating patient input or perspective into the flagging process,