Violence in the Trauma Bay and Emergency Department

Educational Objectives

The goal of this program is to improve mitigation of violence against health care workers. After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate between affective and predatory violence.
2. List measures that can decrease violence against health care workers.

Summary

Introduction: clinicians, at some point in their careers, realize their job to be dangerous working in the trauma bay and emergency department (ED); violence against health care workers (HCWs) is not new, and the incidence has been increasing; 75% of critical care professionals, especially nurses in the intensive care unit, experienced violence during the past year; violence against HCWs is the third leading cause of serious workplace injury; the Center for Disease Control and Prevention reported that ≈73% of workplace injuries are in HCWs; ≈25% of HCWs considered quitting over hospital violence; surgeons are also attacked; violence is generally not considered a part of practice in health care; however, violence risk exists and is worsening

Types of threats in hospital violence: include criminal intent (less common), aggrieved customer or client (most common), worker on worker (“going postal”), interpartner violence, or ideologic terrorism (rare); belligerent patients can hurt HCWs but are usually manageable; however, the main problem is an individual entering the hospital or the ED with the intent of hurting or killing HCWs

Biologic modes of aggression: affective violence — includes violence because of emotions; it is sudden, quick, resolves quickly, and might be managed through de-escalation, which requires training; predatory violence — is done with planning; there is an intention of hurting, although not showing signs of agitation; it is sudden and inexplicable; the attacker has high-risk behavior; it is less frequent, commonly involves weapons, and frequently requires intervention from law enforcement

Need to discuss violence: Chang (2023) reported a case of a resident being punched in the face by a trauma patient because of asking questions about his health and alcohol and drug abuse; although there was no permanent injury, the resident was affected by the event and had a disability to work for several weeks; another case was of stalking of a surgeon by a patient with multiple convictions; these are traumatic experiences; warn trainees about workplace violence; people usually do not discuss mental injuries caused by violence; when there is a potential risk to life, decision-making ability becomes disrupted; bad attitudes among clinicians themselves and hospital administrators may blame the victim; this can be a source of moral injury or burnout; problems worsen if coworkers are not supportive and administrators fail to recognize and manage the issue; surgeons should discuss and offer support if violence happens to their coworkers

Managing violence: HCWs should have the imagination that workplace violence could happen at any time and prepare for it; administrators should have a policy, should train people, should not ignore such behaviors from patients, should not tolerate bullying behaviors, should note behavioral issues, should provide adequate security measures to maintain the risk-free environment, take disciplinary actions against individuals at fault, and form a threat management team

Threat assessment: is important to evaluate threats and ensure that the pathway to violence is not being continued; administrators may also hire consultants to visit and analyze the workplace for safety

Threat mitigation: measures to mitigate threats and prevent violence include training, setting up the institution and facility to make it less vulnerable, being active against cyberstalking, assault, and murder attempts, and being prepared for, eg, active shooters

Metal detectors: installed at the hospital may not be similar to the ones installed at the airport; they can be of low profile (eg, hidden under a carpet) and provide silent alerts to security personnel if a weapon is detected; the number of weapons detected increased at the speaker’s institution after installing metal detectors

Armed hospital security: about 50% of hospitals have armed security; determining what security agents should carry is a difficult decision; it is a cultural and a leadership decision, involving significant training and cost; a conducted energy device (TASER) reduces the risk for physical assault but cannot handle every situation; physicians should be involved in decision making about hospital security

Legislation advocacy: significant variations exist between states about how well they protect HCWs against assault; there is a bill to establish federal workplace violence prevention programs; some states require employers to have a violence prevention program in place; currently, 38 states have laws that increase penalties for assaulting HCWs, especially in the ED; it is not a felony to assault doctors and nurses in California

Readings

Caruso R, Toffanin T, Folesani F, et al. Violence against physicians in the workplace: Trends, causes, consequences, and strategies for intervention. Curr Psychiatry Rep. 2022;24(12):911-924. doi:10.1007/s11920-022-01398-1; Chung, Sophie H. MD. A lasting impact. Ann Surg. 2023;278(3):e466-e467. doi:10.1097/SLA.0000000000005932; Dadfar M, Lester D. Workplace violence (WPV) in healthcare systems. Nurs Open. 2021;8(2):527-528. doi:10.1002/nop2.713; Yücel Özden KB, Sarıca Çevik H, Asenova R, et al. Guardians of health under fire: Understanding and combating violence against doctors. Aten Primaria. 2024;56(9):102944. doi:10.1016/j.aprim.2024.102944.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Doucet was recorded at Medical Disaster Response, held on April 14, 2024, in Las Vegas, NV, and presented by the Trauma and Critical Care Foundation. For information on future CME activities from this presenter, please visit https://www.trauma-criticalcare.com/. Audio Digest thanks the speakers and the presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM420201

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.