Violence Commonplace in the Emergency Department Worldwide


CME NUGGETS

Ed Susman

Mr. Susman is a freelance medical writer based in Florida, USA. He travels worldwide to report from medical conferences, writing regularly for wire services, internet websites, and medical journals such as the Journal of the National Cancer Institute and AIDS.

For comments, edwardsusman@cs.com


DENVER, Colorado – The emergency room is where victims of violence are brought to be treated, but often violence erupts there as well – often by unruly patients of their distraught and angry relative, researchers reported here at the annual meeting of the American College of Emergency Physicians.

In a survey among hospital workers in Saudia Arabia and the United Arab emirates, Razan Faisal, MD, an emergency room physician at King Fahad Specialty Hospital, Damman, Saudi Arabia, said about 21 percent of men and 21 percent of women working in hospitals in those countries said they had been physically attacked in the workplace.

In her oral presentation, Dr. Faisal also said that 54.6 percent of men and 45.5 percent of women said they had witnessed physical violence in the emergency room.

And 79.2 percent of men and 73 percent of women who responded to the survey said they had experienced either verbal abuse, sexual harassment or both while on the job.

Faisal said that 47.3 percent of the abuse was directed at them from patients’ relatives; the patients directed the abuse at men 30.9 percent of the time, and it was the patient involved in the abuse 24.9 percent of the time, the women reported. Others committing abuse were fellow staff members and members of management or superior.

“We think our findings are what have been reported elsewhere in places like the United States and Western Europe,” Dr. Faisal said. “I think our findings are what are found in most emergency departments around the world.”

In commenting on the study, Ken Marriott, MD, assistant professor of clinical emergency medicine at the University of Texas Health Science Center at San Antonio, said, “Violence in the emergency department happens often. Verbal abuse from patients or their friends of relatives happens almost every day; a threat probably happens every 2-3 days, and an actual act of violence will occur about once a week.

“I have had my eyes gouged; I have been shoved or punched. I have seen one intern literally knocked out cold by someone who sucker punched him,” Dr. Marriott said. “So the findings in the Saudi Arabian study do not surprise me. It happens everywhere.”

He said that in most cases where injury is minor, the hospital administration encourages the staff member who has been assaulted to not report the incidents.

That was also true in the survey analysis that Dr. Faisal and colleagues did. In the survey that included 492 health care workers – 54 percent of whom were doctors, Faisal said 75.7 percent of the men and 69.5 percent of the women who responded said they did not report the incidents. Remarkably, she reported that a high percentage of the health care workers were unaware if their employer even had a policy on how to handle or report these incidents.

“Violence and abuse among health care workers in emergency departments are common and can be serious,” Dr. Faisal said. “Most of these incidents can be prevented, but action by responsible authority was not taken in many occasions.”

ER docs under treat arrhythmia

In another study at the meeting, researchers suggested that emergency room physicians tend to under treat patients who are found to have atrial flutter or atrial fibrillation in the emergency department. As many as 65 percent of patients are discharged without being prescribed oral anticoagulants, the mainstay of treatment of these arrhythmia.

But that is actually good news, reported Bory Kea, MD, associate professor of medicine at Oregon Health Sciences University, Portland, because it represents nearly a 50 percent increase in prescribing these drugs in the period from 2010 to 2017. In that time frame, oral anticoagulant prescriptions have risen from 16 percent of patients to 27.9 percent.

In her oral presentation at the annual scientific assembly of the American College of Emergency Physicians, Dr. Kea said, “However, there remains an opportunity to improve atrial fibrillation-flutter thromboprophylaxis as more than half of the eligible patients in 2017 were not receiving appropriate stroke prevention action within 10 days of their index visit.”

“We are not doing nearly enough,” she said. She especially noted that treatment of women and of people older than 74 years is particularly lacking.

Kea and colleagues gathered information on the treatment of patients with atrial fibrillation and flutter from the emergency departments of 21 community hospitals, and included patients in the study who were newly diagnosed with non-valvular atrial fibrillation or atrial flutter and were discharged from the emergency department after being assessed as high risk for stroke based on a CHAD2DS2-VASc score that was 2 or greater. The researchers excluded patients who had already been prescribed oral anticoagulants.

Dr. Kea suggested that “under treatment suggest misunderstanding of the net clinical benefit associated with oral anticoagulation in the elderly. I believe that most people would accept a certain level of bleeding rather than experiencing a disabling stroke. We have an opportunity to address gender and age differences to improve stroke prevention in high risk atrial fibrillation and atrial flutter.”

The study looked at more than 10,000 patients over the 2010-2017 period, and found that 75 percent of those patients did not receive any action to reduce their risk of stroke after finding they were high risk due to atrial fibrillation and atrial flutter, Dr. Kea reported.

She said her study does have some limitations, particularly that only patients who were member of the Kaiser Permanente system in California who had prescription coverage were included in the study, and that there was a possibility that there was incorrect classification of atrial fibrillation or atrial flutter, and the diagnoses were based on hospital codes for atrial fibrillation and atrial flutter. There was also limited clinical data that could be extracted from claims information.

The average age of the participants in the study was 73.7 years; 61.1 percent of the population studied was women; 82 percent of the population were identified as white; 7.2 percent identified as Asian and 4.5 percent identified as black. About 7.6 percent of the patients identified as having Hispanic ethnicity.

Hallways breed delirium

If you are a patient in a hospital and you spend a long time lying in a bed in the emergency room hallway, you are at a greater risk of developing in-hospital delirium than other patients, reported Thomas Perera, MD, associate professor of emergency medicine at Zucker School of Medicine/North Shore University Hospital/Hofstra University, Manhasset, New York.

“Emergency departments are the worst possible place for people who are at risk,” Dr. Perera said in his presentation at the meeting. “Patients are in a frightening environment, there is no schedule and every time they turn around we switch providers. The only place I can think of that is worse than just being in the emergency department is being in the hallway in the emergency department. You are going to get bumped by everybody, the noise level is horrendous.”

He reported that you were more likely to develop delirium if you spent 49.9 percent of the time in the emergency department in a hallway bed compared to control who spent about 30 percent of their time in the hallway and did not develop in-hospital delirium (P<0.001).

In their analysis, researchers tried to determine if time of day or numbers of the people in the emergency department might have impacted development of delirium, but there was little correlation, Perera said. “Hallway time, absolutely correlated with delirium,” he said.

“I have spent enough time with elderly patients to the point where I debate whether I should admit them or send them home,” Perera said. “Admitting people to the hospital is not a great thing to do. Somewhere between 14 percent and 50 percent of patients – especially the elderly – will develop hospital delirium. It has both long and shortterm morbidity associated with it; it is known to increase the likelihood and speed up the development of dementia.

With this situation in mind, Perera and colleagues attempted to scrutinize what was happening to patients in the emergency department corridors and see what happened to them as far as delirium was concerned.

They reviewed patient records for adults in 2018 whose medical records mentioned agitation, hallucinations, metabolic encephalopathy and delirium and also used as surrogates for delirium, prescriptions ordered in the hospital for lorazepam, quetiapine, haloperidol and valproic acid, and also for bed orders such as constant observation, enhanced supervision, and level one and level two restraints. There were new diagnoses since being admitted to the hospital.

The researchers also found that hallway time correlated with a longer length of stay in the hospital, the number of room transfers also was associated with development of delirium.

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