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Violent Attacks Against Emergency Physicians Remain a Problem

2020; Elsevier BV; Volume: 75; Issue: 2 Linguagem: Inglês

10.1016/j.annemergmed.2019.12.019

1097-6760

Maura Kelly,

Disaster Response and Management

When emergency physician Tamara O’Neal was killed1Gorner J. Gunman in Mercy Hospital shooting fired about 40 shots before dying in shootout with SWAT officer. November 21, 2018.https://www.chicagotribune.com/news/breaking/ct-met-chicago-mercy-hospital-shooting-details-20181121-story,amp.htmlDate accessed: December 17, 2019Google Scholar while leaving work in 2018, her tragedy became national news. The gunman took the lives of 2 additional victims before he died in a shoot-out with police. Mass shootings at hospitals are rare—but violent attacks on emergency physicians are all too common. Consider the case of an emergency physician at Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, who was knocked unconscious2Skene L. Our Lady of the Lake patient said he knocked doctor unconscious because 'he felt like it,' cops say. May 31, 2019.https://www.theadvocate.com/baton_rouge/news/crime_police/article_78a01b56-8398-11e9-895f-37fe7d3344b5.htmlDate accessed: December 17, 2019Google Scholar by a patient he’d never seen before. The patient’s explanation for why he did it? He “felt like it.” That episode is just one example of a startling and ongoing epidemic: emergency physicians are up against a disproportionate risk of being attacked every time they report to work. A recent poll3Marketing General IncorporatedACEP Emergency Department Violence Poll Research Results. September 2018.https://www.emergencyphysicians.org/globalassets/files/pdfs/2018acep-emergency-department-violence-pollresults-2.pdfDate accessed: December 17, 2019Google Scholar conducted by the American College of Emergency Physicians (ACEP) found that nearly half of all respondents (47%) had been physically assaulted at work. What’s more, the US Department of Labor’s Occupational Safety and Health Administration reports that workers in the health care industry are 4 times more likely to require days off to recuperate from a violent attack than those in private industries.4United States Department of LaborPreventing Workplace Violence in Healthcare.https://www.osha.gov/dsg/hospitals/workplace_violence.htmlDate accessed: December 17, 2019Google Scholar As if those statistics weren’t startling enough, the real numbers are probably even higher; because hospitals aren’t required to report attacks on health care workers, the current data likely reflect underreporting. Ryan Stanton, MD, an emergency physician who spoke to Annals, said he was not only threatened and verbally attacked on “countless” occasions during a 6-year stint he spent working in a hospital in downtown Lexington, KY, but also was physically assaulted 3 times there. During one attack, Dr. Stanton was trying to prevent a psychiatric patient from overdosing on pills when she bit him on the arm. But he was injured more seriously by a patient who was intoxicated on methamphetamine. When Dr. Stanton tried to calm the agitated patient (after he kicked a nurse into a sink), the patient responded by kicking Dr. Stanton in the chest. The nurse was injured so severely she had to take time off work—and she never returned to work in that emergency department (ED) again. Dr. Stanton spoke to police and hospital employers about the incident, but he was advised that because the patient was under the influence of methamphetamine, any charges he pressed “likely wouldn’t go anywhere or accomplish anything,” he said. Dr. Stanton’s experience jibes all too well with the data ACEP has gathered: the college found that hospital administrations respond in some way to nearly 7 of every 10 attacks, and yet in only approximately 3% of cases are any charges pressed. ACEP’s 2018 poll also found that close to 70% of respondents believed that violence in the ED had increased during the previous 5 years. Nearly 80% said that patient care is being affected, and more than half of individuals surveyed had witnessed patients being harmed, too. Approximately half said hospitals should do more, such as adding security guards, cameras, parking lot security, metal detectors, and increased screening inside facilities. Some hospitals have taken action, however, to make their facilities safer for staff and patients alike. The Cleveland Clinic in Cleveland, OH, recently installed a metal detector in its ED, and also hired plainclothes police officers to help keep order there, as NPR reported in April 2019.5Harris-Taylor M. Facing Escalating Workplace Violence, Hospital Employees Have Had Enough. April 8, 2019.https://www.npr.org/sections/health-shots/2019/04/08/709470502/facing-escalating-workplace-violence-hospitals-employees-have-had-enoughDate accessed: December 17, 2019Google Scholar In addition, the facility introduced wireless panic buttons on ID badges and added more safety cameras. Cleveland Clinic Chief Executive Officer Tom Mihaljevic gave NPR this explanation for why he pushed ahead with the new measures: “Daily—literally, daily—we are exposed to violent outbursts, in particular in [EDs].” Meanwhile, other hospitals have actually rolled back protections in recent months.6Hughes R. Changes spark security concerns at JFK Medical Center in Atlantis. July 24, 2019.https://www.wptv.com/news/region-c-palm-beach-county/changes-spark-security-concerns-at-jfk-medical-center-in-atlantisDate accessed: December 17, 2019Google Scholar JFK Medical Center in Atlantis, FL, recently removed its metal detectors, for instance, and also let a contract with the police department lapse in June. (A new contract was eventually negotiated, as reported by Ryan Hughes for WPTV, an NBC affiliate in Palm Beach, although it didn’t take effect until August 1.) Why did JFK remove its metal detector? WPTV cited a June announcement from JFK to employees about the matter: “We are always looking for ways to enhance and improve our patient and visitor experience at our hospitals,” the statement read. “That includes making them feel welcome and listening to their feedback.” The hospital didn’t respond to Annals’ repeated requests for comment. Nor is this the first instance of metal detectors’ losing cachet or coming under scrutiny. Whether they are effective, cost-efficient, or just window dressing for EDs has been hotly debated by experts for years and no consensus has emerged.7HCProSecurity checkpoint: Will metal detectors really make a big difference in your hospital's ED? April 1, 2004.http://www.hcpro.com/HOM-38694-742/Security-checkpoint-Will-metal-detectors-really-make-a-big-difference-in-your-hospitals-ED.htmlDate accessed: December 17, 2019Google Scholar Data suggest8Malka S.T. Chisholm R. Doehring M. et al.Weapons retrieved after the implementation of emergency department metal detection.J Emerg Med. 2015; 49 (355-258)Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar that metal detectors are effective in decreasing the numbers of firearms, knives, chemical sprays, and other weapons, but whether those confiscations led to a decrease in dangerous events in those EDs is less clear. What’s more, metal detectors can solve one problem and create others. EDs with metal detectors need a contingency plan for what to do with confiscated objects, including on-site safe storage. There are equipment costs, space considerations, additional staffing, and the logistic problem of multiple points of entry. ACEP9Huddy J. Design Considerations for a Safer Emergency Department.https://www.acep.org/globalassets/sites/acep/media/safety-in-the-ed/designconsiderationsforsaferemergencydepartment.pdfDate accessed: December 17, 2019Google Scholar has identified these and other adjacent issues in its document titled “Design Considerations for a Safer Emergency Department,” including the fact that metal detectors can cause delays in evaluation and care. (The use of electronic wands is preferred by some hospitals because they can be deployed on a more credible as-needed basis, although this can lead to profiling, a problem in its own right.) Although many experts believe in the usefulness of physical technologies such as metal detectors in combating ED violence, these alone are not enough. Recognizing that hospitals are unlikely to ever be as secure as a commercial airliner, many individuals emphasize the importance of preparing ED staff. Education is the key to staying safe, said Liz Even, associate director of the Standards Interpretation Group, for The Joint Commission (TJC), a nonprofit organization that accredits and certifies greater than 22,000 health care organizations and programs in the United States. “Recognizing the signs and symptoms of an escalating individual and quickly responding with the appropriate counteractions is the first step,” she said. “Many training programs also offer useful tips such as where to position yourself in a room when delivering bad news, entering a room with another individual as opposed to alone, tips for body language, and so on.” (TJC’s 2019 Quick Safety advisory, “De-escalation in Health Care,” has more guidance.10The Joint CommissionDe-escalation in health care. January 2019.https://www.jointcommission.org/-/media/tjc/documents/resources/workplace-violence/qs_deescalation_1_28_18_final.pdf?db=web&hash=DD556FD4E3E4FA13B64E9A4BF4B5458ADate accessed: December 17, 2019Google Scholar) Hospital leaders are urged to let their employees know that staff safety should be prioritized above all else, “a message that is sometimes difficult for those who work in emergency medicine [because they] are trained to run directly into chaotic situations instead of stepping back,” Even said. She added, “Violent situations can occur almost instantly, and seconds could be the difference in a staff member incurring or avoiding injury. All staff need to be trained to watch for warning signs, to speak up when they see something concerning, and to know that their concerns will be met with a unified approach to ensure the safety of all.” ACEP believes that violence in the ED is a serious problem, not only because staffers are so often injured but also because it affects quality of care downstream. “When violence occurs in an ED, patients can be injured or traumatized to the point of leaving without being seen,” said Vidor Friedman, MD, immediate past president of ACEP. “It also can increase wait times and distract emergency staff from focusing on other patients who urgently require a physician's assistance.” In the hopes of alleviating the problem, ACEP partnered with the Emergency Nurses Association to create a new public information campaign, which launched in November 2019.11Emergency PhysiciansNo Silence on ED Violence.https://www.emergencyphysicians.org/article/campaigns/no-silence-on-ed-violenceDate accessed: December 17, 2019Google Scholar The initiative, No Silence on ED Violence, provides resources to help improve workplace safety for individuals in emergency medicine. It’s also an attempt to alert policymakers, stakeholder organizations, and the public at large about the crisis. (ACEP also has more articles, videos, and other tools for emergency care teams accessible online.12American College of Emergency PhysiciansEmergency Doctors and Nurses Team Up on No Silence on ED Violence Campaign.https://www.acep.org/administration/violence-in-the-emergency-department-resources-for-a-safer-workplaceDate accessed: December 17, 2019Google Scholar) But the most significant action on ED violence may come from Congress. The Workplace Violence Prevention for Health Care and Social Service Workers Act (HR 130913Courtney J. Courtney’s Bill to Reduce Violence Against Health Care & Social Service Workers Passes Key House Committee. June 11, 2019.https://courtney.house.gov/media-center/press-releases/courtney-s-bill-reduce-violence-against-health-care-social-serviceDate accessed: June 11, 2019Google Scholar) was introduced by Rep. Joe Courtney (D-CT) in March 2019 and passed the House on November 21, 251 to 158, with 21 no votes. In approving the bill, all 219 Democrats who voted were joined by 32 of 189 Republicans. The bill can now move on to the Senate. Passage there is not guaranteed. One encouraging sign of its fate in the Senate, however, comes from language found in the most recent Senate appropriations bill. It required the Occupational Health and Safety Administration (OSHA) and the US Department of Health and Human Services to issue a report that would serve as a basis for the agencies to develop regulatory guidance for health care workplace violence prevention, said Ryan McBride, senior congressional lobbyist on public affairs for ACEP. Some senators, including Roy Blunt (R-MI), who chairs the appropriations committee, have expressed substantial interest in legislation like this. However, other members of his party may be harder to convince because many congressional Republicans are inherently skeptical of regulatory agencies such as OSHA. In addition, “development of these standards [for health care workplaces] began under the Obama administration,” which essentially counts as a demerit for many Senate Republicans, regardless of whether there is agreement on the actual issue at hand, McBride added. “All of this certainly makes passage of HR 1309 a tougher prospect.” The legislation itself aims to hold hospitals themselves responsible for attacks; for instance, by levying fines if covered incidents are not reported to OSHA. The bill would also require employers to protect health care workers from workplace violence by developing and implementing a comprehensive workplace violence prevention plan. (At the moment, such protections are optional.) “The [House] bill had more than 200 cosponsors, which shows there is wide support and some momentum,” said Laura Wooster, ACEP associate executive director for public affairs. Wooster is also pleased to report that OSHA has sought input from emergency physicians to creating federal workplace standards and protections for EDs.14American College of Emergency PhysiciansShare Your Experience with ED Violence and Help Shape New Federal Requirements.https://www.acep.org/federal-advocacy/federal-advocacy-overview/regs-eggs/regs--eggs3Date accessed: December 17, 2019Google Scholar At press, there was no word from the Senate, and with most congressional action grinding to a halt during the Trump impeachment hearings, and the expectation of more delays related to the 2020 election, the wait may be a long one. For now, the action will continue to play out at the local level. Dr. Stanton, who now works at a different hospital in Lexington, argues that hospitals should have a zero-tolerance policy for aggressive behavior. “I have found that hospitals don’t like the [public relations] of violence and thus try to sweep it under the rug,” he said. “They put ‘satisfaction and image’ over staff safety. Hospitals need to support staff and push for prosecution of violent patients. They must be flagged and easily identifiable, and police or security should be readily available to attend.” Workplace Violence: The Congressional Vote on HR1309Annals of Emergency MedicineVol. 76Issue 1PreviewA compelling and informative aspect of the excellent article on emergency department (ED) workplace violence1 was the vote count on the federal legislation. That bill was HR1309 (Workplace Violence Prevention for Health Care and Social Service Workers Act), supported by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association. As the article pointed out, the bill passed the House of Representatives 251 to 158, with 21 members not voting. Of the members who did vote, the Democratic representatives voted 219 to 0 in favor, and the Republicans representatives voted 32 in favor and 157 against. Full-Text PDF