Emergency Department Violence Fact Sheet

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Emergency Department Violence

Main Points

  • Protecting emergency patients and staff from violent acts is fundamental to ensuring quality patient care.
  • Nearly half (47 percent) of emergency physicians polled report being physically assaulted, with more than 60 percent of those saying it occurred in the past year. [i]
  • Emergency patients can be traumatized to the point that they leave without being seen.
  • Nearly 7 in 10 emergency physicians say emergency department violence has increased in the past 5 years, with a quarter of them reporting it has increased greatly. [ii]
  • ACEP encourages all states to enact legislation that establishes maximum categories for offenses and criminal penalties against individuals who commit violence against health care workers.[iii]
  • Hospitals can do more by adding security, guards, cameras, security for parking lots, metal detectors, and increasing visitor screening inside hospitals, especially in emergency departments

What is the magnitude of the problem and why should we care?

The majority of assaults on health care workers were by patients or visitors.[iv]  Pushing/grabbing and yelling/shouting are the most prevalent types of violence. Eighty percent of incidents occurred in patient rooms.[v]  ACEP conducted a survey of more than 3,500 emergency physicians nationwide to obtain their views on the type, frequency, effects (on medical staff and patients) of violence and solutions. Nearly half (47 percent) of emergency physicians report being physically assaulted.  About half of those assaulted report being hit or slapped.  Almost one-third of those say they were punched, kicked or spit on.  Nearly all women who are emergency physicians (96 percent), and 80 percent of men, reported that a patient or visitor made inappropriate comments or unwanted advances toward them.

According to a study [vi] in the Annals of Emergency Medicine that looked specifically at emergency department violence in the state of Michigan, despite increased security measures in Michigan, the problems of emergency department violence are getting worse.  The research points out that 72 percent of emergency physicians in Michigan reported experiencing violence in the past year.  Additionally, more physicians in 2018 reported feeling “constantly fearful” of becoming a victim of violence.

The violence happened most frequently while the nurses were triaging patients, restraining or subduing patients or performing invasive procedures. Most of the violence occurred at night between 11pm and 7am.[vii]

There is significant stress to emergency department staff, and to medical patients who seek treatment in the emergency care system, if the emergency department is a site of frequent violence. This risk also increases the difficulty of recruiting and retaining highly qualified personnel. Patients with medical emergencies deserve a place of care that is free of physical dangers from other patients, and care from staff that is not distracted by individuals with behavioral or substance-induced violent behavior.

Why has there been an increase in emergency department and hospital violence?

The primary reason is an overall increase in violence in society. This includes:

  • Increased presence of gangs, particularly in urban, inner-city settings.
  • Prolonged waits for patients seeking medical care, sometimes compounded by unpleasant waiting room environments.
  • Increased prevalence of drug and alcohol use in society.
  • Increased numbers of private citizens arming themselves related to perceived threats of violence in their neighborhoods.

Use of emergency departments for “medical clearance” of drug- and alcohol-related arrests. Half of emergency physicians report that at least half of all assaulted are committed by people who were seeking drugs or who were under the influence of drugs and/or alcohol.[viii]

  • Failure of community mental health systems, and subsequent referral of lots of patients into the medical emergency system.

Unavailability of acute psychiatric treatment, so emergency department provide “psychiatric clearance.” More than 40 percent of emergency physicians say more than half of assaults are committed by psychiatric patients.  The severe shortage of psychiatric beds in almost all hospitals and lack of intensive outpatient resources is leaving these patients stranded for hours and even days in the ER and in some instances can result in violence episodes.

  • Distrust of physicians, nurses and paramedics since they may represent the “establishment” to some population segments.

How should emergency staff deal with potentially violent individuals?

Emergency staff should trust their senses if they feel uncomfortable around a patient. They should be vigilant and not isolated. They should call security when they first become aware of a threat.

In addition, emergency staff should maintain a safe distance, if possible, and keep an open path for the patient or the staff to exit. They should present a calm, caring attitude and not match threats or give orders. It’s important to acknowledge the person’s feelings and avoid behaviors that may be interpreted as aggressive. Eye contact should be limited.

What measures can be taken to anticipate and manage the incidence of emergency department violence? 

Emergency departments should have a plan for managing potentially violent situations. This plan should include who responds, who will serve as a team leader, each person's responsibility (including the team leader), and the steps that should be taken to respond. In addition, each hospital and emergency department must base its responses to violence on physical location, types of patient population served, and histories of prior violent incidents. Some measures that can be taken are:

  • Train Personnel.--Increase training of doctors, nurses and security personnel about de-escalation techniques (and “take down” techniques), how to recognize potentially violent patients early and getting help before incidents occur.
  • Secure Environments:
    • Use 24-hour presence of trained security officers and closed-circuit television cameras with 24-hour trained observers (especially useful in low-traffic areas).
    • Place "panic buttons" unobtrusively in several locations of an emergency department.
    • Use direct phone lines to security in the hospital or local police departments.
    • Control access and egress between the emergency department and other areas of the hospital.
    • Use coded badges or wristbands for patients and visitors.

What are the clues to potential violence? 

  • Behavioral clues
    • Posture: tense, clenched
    • Speech: loud, threatening, insistent
    • Motor: restless, pacing, easily started
  • Historical and epidemiologic clues
    • History of violence (especially if frequent, serious or unprovoked)
    • Threats or plans of violence
    • Symbolic acts of violence
  • Kind of Diagnosis. Certain diagnoses are associated with violent behaviorubstance abuse: either acute intoxication or withdrawal
    • Acute psychoses (especially acute mania or acute schizophrenia)
    • Acute organic brain syndrome
    • Personality disorders
    • Partial complex seizures, temporal lobe epilepsy
  • Time of Day. Incidents are more likely to occur on a night shift.

—At the University of California at Irvine, 31.8 percent of violent incidents occurred between 11 p.m. and 7 a.m., while only 13.3 percent of the patient volume was seen during these hours.

Should security officers in emergency departments carry firearms? 

There is much controversy over this issue. The New York City Health and Hospitals Corporation estimated that to arm 1,200 hospital police officers in New York City would cost $800 for firearms certification; $500,000 for firearms, ammunition and equipment; and $700,000 for psychological/physical screening, background investigations and use of training ranges.

Many hospital staff members believe there is increased liability if officers are armed, especially if they take guns home. Other concerns include the risk of violent patients taking weapons away from officers, making already dangerous situations worse. Some facilities arm security officers who patrol parking lots and buildings, but do not permit them to carry weapons in the hospital itself. The decision process often is influenced by the speed of police responses to calls for help and how often violence occurs.

Another option to arming security officers is to emphasize crime prevention among hospital staff. Employees are encouraged to think about personal safety, secure personal items and alert security when they see anything suspicious. Some hospitals implement a training program like “neighborhood watch.”  The decision about arming security personnel is an individual one. But the key is to have a plan that employees know and are trained to implement.

For additional information on this topic, see the following documents:

Protection from Violence in the Emergency Department Policy Statement

https://www.acep.org/Clinical---Practice-Management/Protection-from-Physical-Violence-in-the-Emergency-Department-Environment/

Violence-Free Society Policy Statement  

http://www.acep.org/Clinical---Practice-Management/Violence-Free-Society/

[i] Marketing General Incorporated, Emergency Department Violence Poll, September, 2018, http://newsroom.acep.org/2018-10-02-Violence-in-Emergency-Departments-Is-Increasing-Harming-Patients-New-Research-Finds

[ii] Marketing General Incorporated, Emergency Department Violence Poll, September, 2018, http://newsroom.acep.org/2018-10-02-Violence-in-Emergency-Departments-Is-Increasing-Harming-Patients-New-Research-Finds

[iii] Emergency Nurses Association, “50 State Survey Criminal Laws Protecting Health Professionals,” Jan. 2014. https://www.ena.org/government/State/Documents/StateLawsWorkplaceViolenceSheet.pdf

[v] Emergency Nurses Association, Emergency Department Violence Surveillance Study, 2011.  http://www.ena.org/IENR/Documents/LC%202011_EDVS%20Study.pdf

[vi] Annals of Emergency Medicine, Kowalenko, T “Reassessment of Violence Against Emergency Physicians, Research Forum Abstract 368, 2018 file:///C:/Users/mbaldyga/Downloads/2018Kowalenko-MIchigan%20ED%20Violence.pdf

[vii] “Emergency Department Violence: An Overview and Compilation of Resources”, April 2011. http://www.acep.org/workarea/DownloadAsset.aspx?id=81782

[viii] Marketing General Incorporated, Emergency Department Violence Poll, September, 2018, http://newsroom.acep.org/2018-10-02-Violence-in-Emergency-Departments-Is-Increasing-Harming-Patients-New-Research-Finds