EMERGENCY DEPARTMENT VIOLENCE FACT SHEET

MAIN POINTS
1. Protecting emergency patients and staff from violent acts is fundamental to
ensuring quality patient care.

2. More than 75 percent of emergency physicians experienced at least one

violent workplace incident in a year.[i]

3. 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.[ii]

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.[iii] Pushing/grabbing and yelling/shouting are the most prevalent
types of violence. Eighty percent of incidents occurred in patient rooms.[iv]

 More than 70 percent of emergency nurses reported physical or verbal

assault by emergency patients or visitors (2013). [v] 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.[vi]

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 :
1. Increased presence of gangs, particularly in urban, inner-city settings.
2. Prolonged waits for patients seeking medical care, sometimes compounded
by unpleasant waiting room environments.
3. Increased prevalence of drug and alcohol use in society.
4. Increased numbers of private citizens arming themselves related to
perceived threats of violence in their neighborhoods.
5. Use of emergency departments for “medical clearance” of drug- and alcohol-
related arrests.
6. Failure of community mental health systems, and subsequent referral of
lots of patients into the medical emergency system.
7. Unavailability of acute psychiatric treatment, so emergency department
provide “psychiatric clearance.”
8. 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 :
1. 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.

2. 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.

3. Use coded badges or wristbands for patients and visitors.

What are the clues to potential violence?

1. Behavioral clues
  Posture: tense, clenched
 Speech: loud, threatening, insistent
 Motor: restless, pacing, easily started

2. Historical and epidemiologic clues

 History of violence (especially if frequent, serious or unprovoked)
 Threats or plans of violence
 Symbolic acts of violence

3. Kind of Diagnosis. Certain diagnoses are associated with violent behavior:

 Substance 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

4. 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 occur.

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 similar to “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.