Amid an epidemic of violence, America’s EDs have become overwhelmed by long waits and “boarding,” a haphazard way station for the lost: psychiatric patients, walking wounded, those arriving by emergency transport, and those who deferred treatment during the pandemic all awaiting an inpatient bed or a transfer.
The American College of Emergency Physicians (ACEP) and many other co-signing medical groups described the problem in a letter to President Biden.
“Boarding and ED crowding lead to increased cases of mortality related to downstream delays of treatment for both high and low acuity patients,” the groups wrote. “Boarding can also lead to ambulance diversion, increased adverse events, preventable medical errors, violent episodes in the ED, and higher overall healthcare costs.”1
The letter also included descriptive anecdotes from emergency physicians, describing what they are seeing every day. “In the past six months, three people have died in our ER waiting room,” an emergency physician wrote. “One was only noticed when he had been sitting for [more than] six hours and slumped to the floor. When he was found, he had been dead awhile. The patient had been triaged by a nurse, but [we are] in a very busy urban [hospital] where the waiting room is always packed, and people regularly wait eight hours to be seen. The ER physicians were never aware of this patient.”
Another physician described a patient who probably should have survived but could not get in to see a surgeon as her condition worsened. “Recently, I had a woman with abdominal pain in the ER,” an emergency physician wrote. “When she arrived, she had normal vital signs and was not really very sick. Testing showed that she had an infected gallbladder — a simple problem for any surgeon to treat. We called 27 hospitals before one in a different state called us back when a bed finally opened up. She spent 36 hours in our ER, and was in shock being treated with maximum doses of drugs to keep her alive when she was transferred. She didn’t survive.”
Other ACEP physician put it in grim terms: “It’s unsustainable, morally wrong, and dangerous for staff and for patients. How did we go from being healthcare heroes to an afterthought of the medical system?”
A System Failure
“Our system has failed our most vulnerable patients,” another emergency physician wrote. “We held a 14-year-old girl in a tiny ED room for 42 days awaiting transfer/placement for inpatient psychiatric care. Can you imagine being confined to a small room, without actually getting psychiatric care, for 42 days? This could have been the subject of a Stephen King novel.”
ACEP and their colleagues in the Emergency Nurses Association (ENA) visited Congress in May to lobby for legislation that would help address ED violence and close gaps in mental healthcare.
ACEP and ENA called for passage of the Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195 and S. 1176) and the Improving Mental Health Access from the Emergency Department Act. The latter bill would establish a grant program for EDs to increase access to follow-up psychiatric services for individuals who seek ED care for mental health problems.
By almost any commonly used measure, public mental health declined during the pandemic. This has particularly hit younger people, as a study revealed the pandemic resulted in “a striking increase in the rate of mental health ED visits among adolescents.”2
“The U.S. is experiencing a sharp increase in mental illness, and at the same time our healthcare system does not currently have the resources to adequately respond,” said Richard Mereu, JD, chief government relations officer for the ENA. “The mental health crisis [preceded] the pandemic, which has only made the situation worse.”
In addition to less access to mental health services, there has been social isolation, school closures, economic uncertainty, and all the attendant anxiety and depression from such factors. The mental health bill would include a grant program to link EDs with inpatient and outpatient psychiatric care and treatment options in their community.
“There is a lot of flexibility on how the grant program can be used and the funding can be used,” Mereu said.
Bleak Testimony
Add gang violence and drug addiction to the physical pain and mental angst in the ED and you have a setting seemingly designed for patient violence.
“I’m an emergency physician, and I have been a victim of both verbal assault and physical battery multiple times,” James Phillips, MD, FACEP, a Washington, DC-based emergency physician, said at the ACEP/ENA rally at the Capitol. “I’ve been called unspeakable names, threatened with harm, branded a racist, manipulated by real-time threats of frivolous malpractice lawsuits, and threatened with false reporting to medical licensing boards. I’ve been chased through the ER and forced to hide behind a door, and I’ve had someone spit in my face. Each of these incidents has been perpetrated by a different patient, and all of them have happened just this year.”
These stories are told so often by so many different healthcare workers it underscores how often violence occurs. On the same day Phillips spoke — May 3 — nurses in Bristol, CT, were lobbying for an antiviolence state law for healthcare.
“When I first started as a nurse, violence was at a minimum,” said Nancy LaMonica, MSN, RN, chief nursing officer at Bristol Hospital. “We might encounter it maybe once a month — somebody might yell at us, or somebody might grab our arm or kick at us. But over the past decade, we can say healthcare violence happens perhaps every day, every hour, every minute depending on which bed or patient room you enter.”
Tiara Brown, RN, a 14-year nursing veteran, said her family fears for her life when she goes to work. “I’ve been assaulted at least three times in my career,” she said. “I’ve been spit on and punched in the face. Most recently, I’ve been kicked in the chest. I’ve also been threatened to be raped and killed by patients.”
In reporting the assaults, Brown said she was told by law enforcement that it was unlikely that anything of consequence would happen to the patients. “All of the patients who have assaulted me and everyone else should be held accountable.”
Phillips has pressed charges against two patients — one for hitting him in the face with a phone, and one for threatening to return to the ED and kill him and a nurse. “And we weren’t even the people taking care of him,” he said.
Reporting to law enforcement is unusual because in-house barriers, paperwork, and administrators’ concern with liability and patient satisfaction translate to only a small percentage of healthcare workers reporting they were the victim of a crime.
On a personal level, Phillips said empathy for his patients has suffered. He has discouraged his young son from becoming a physician. “He tells everyone that he wants to be a doctor like daddy when he grows up,” Phillips said. “That breaks my heart, and it makes me angry. This job was supposed to be better than this. I wasn’t warned about this in medical school, and I am certainly not alone.”
Longstanding problems with violence in healthcare were made worse by the pandemic. There is a mass exodus of physicians and nurses forecast in the next few years. “Our system is truly on the brink,” Phillips noted. “The time to stand up and demand change is now. We need to take action to address the problem of workplace violence in emergency medicine, and in the entire house of medicine. We need to create a culture of safety in our hospitals so that these places, once regarded as safe havens and houses of healing for our patients, can perhaps begin to heal themselves.”
At a minimum, each hospital must be required to implement workplace violence protection programs. “When attacks do occur — and they will — administrators and executives should treat nurses and doctors as their most prized assets and support them fully as they navigate the complicated legal and medical fallout,” Phillips said. “The fear of retaliation from our supervisors must end.”
OSHA Standard Is Moving Forward
ACEP and ANA are pushing for passage of the Workplace Violence Prevention for Healthcare and Social Services Workers Act, which would require OSHA to issue and enforce a healthcare violence prevention standard. OSHA is pursuing a standard on a parallel track, moving forward with a healthcare violence prevention rule that includes these provisions:3
- Hazard assessments: Employers must perform regular hazard assessments based on their own injury records.
- Control measures: Employers must implement ways to mitigate the hazards found during the assessment.
- Training: Education and training are key elements of a workplace violence prevention program. Ensure all staff members are aware of potential hazards and established policies and procedures.
- Incident investigation and workplace violence log: Employers must maintain a workplace violence log and investigate incidents.
- Anti-retaliation: These policies encourage employees to report workplace violence incidents.
OSHA said it needs to enact a violence prevention standard because it has no recourse currently but to enforce its General Duty Clause, a somewhat unwieldly method to address violent incidents. Still, OSHA did just that in recently citing and fining Texas Children’s Hospital in Houston $15,625 for exposing behavioral health employees to physical threats and assaults.4
“On Nov. 10, 2022, an aggressive patient pulled a security officer to the ground by the hair and kicked them repeatedly in the chest and abdomen,” OSHA reported. “The officer, who was responding to an alert, lost consciousness, was taken to the emergency room, and hospitalized. OSHA found the employer had inadequate policies and procedures to protect employees from physical assaults by patients who exhibited violent behavior during medical surveillance and treatment.”
OSHA Panel Weighs In
With finalization of OSHA’s COVID-19 rule to protect healthcare workers looking increasingly unlikely due to the end of the national Public Health Emergency, a draft standard for violence prevention should move up on the priority list. At the Association for Occupational Health Professionals in Healthcare (AOHP) 2022 conference in Austin, TX, an OSHA official said the agency was awaiting review by the Small Business Regulatory Enforcement Fairness Act (SBREFA).
This process has been completed as of a May 1 report by OSHA’s Small Business Advocacy Review Panel. While OSHA was criticized and questioned, nothing seemed to be a dealbreaker.5
There were complaints of the need for the OSHA rule, duplication with The Joint Commission antiviolence standards, and a one size-fits-all approach that would bring smaller entities under the same regulation as hospitals. To this latter point, the panel recommended “OSHA’s proposed standard be flexible and allow employers to tailor their approaches to complying with the requirements of the rule to the size and complexity of their facility, setting, or industry while offering specificity where possible to alleviate confusion.”
Participants also expressed concerns about the high costs of complying with an OSHA standard. This was somewhat in conflict with the duplicative requirements argument, which would mean those already in compliance with other standards would not incur additional costs due to similar OSHA requirements.
The OSHA panel recommended a “review of existing regulations, guidance, and accreditation standards on workplace violence prevention in determining the need for a rule, avoid duplication unless necessary to mitigate risks associated with workplace violence, and ensure any OSHA requirements do not conflict with other governing bodies or standards-setting organizations.”
While the presumed goal was to hear the concerns of small entities, the report also included comments by large hospitals like the Montefiore Health System in New York City, which found little to like in OSHA’s efforts. “While much needs to be done to ensure hospital staff are protected from patient violence, a vague and overly burdensome standard will not accomplish that goal; rather, it will create more issues and undermine OSHA’s main goal: employee safety,” the hospital noted.
Phillips anticipated this stance in his comments at the ACEP/ENA gathering, saying, “Let’s be realistic. Healthcare companies and hospitals will not do enough unless they are forced to; otherwise, they would have done it by now.”
In other comments in the report, Bobbi Jo Hurst, RN, an occupational health nurse at Lancaster (PA) General Health and a member of the AOHP, disagreed with the OSHA proposal to keep a separate violent incident log. Instead, Hurst suggested including these reports in existing OSHA recordkeeping.
“We do believe that recordkeeping and trending is a priority, but [there] should not be another OSHA log,” Hurst stated. “Occupational health professionals continue to track and trend many types of incidents that are not serious enough to be on the log, and may even be near misses. This information assists us in developing programs to protect our employees.”
The review panel recommended “OSHA clarify its intention that, in many cases, employers would be able to use, or at least modify as applicable, their existing recordkeeping systems and program.”
Editor’s note: Comments on the OSHA SBREFA Report and related materials can be made through July 3 by visiting the public docket at: https://www.regulations.gov/do....
REFERENCES
- American College of Emergency Physicians. Letter to the president. Nov 7, 2022. https://www.acep.org/siteasset...
- Ferro V, Averna R, Murciano M, et al. Has anything changed in the frequency of emergency department visits and the profile of the adolescent seeking emergency mental care during the COVID-19 pandemic? Children (Basel) 2023;10:578.
- Occupational Safety and Health Administration. Prevention of workplace violence in healthcare and social assistance issues document. February 2023. https://www.osha.gov/sites/def...
- Occupational Safety and Health Administration. Department of Labor finds Texas Children’s Hospital failed to protect employees after security guard suffers serious assault by patient. May 10, 2023. https://www.osha.gov/news/news...
- Occupational Safety and Health Administration. Report of the Small Business Advocacy Review Panel on OSHA’s Potential Standard for Prevention of Workplace Violence in Healthcare and Social Assistance. May 1, 2023. https://www.osha.gov/sites/def...
Amid an epidemic of violence, America’s EDs have become overwhelmed by long waits and “boarding,” a haphazard way station for the lost: psychiatric patients, walking wounded, those arriving by emergency transport, and those who deferred treatment during the pandemic, all awaiting an inpatient bed or a transfer. The American College of Emergency Physicians and many other co-signing medical groups described the problem in a letter to President Biden.
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