Written by Shannon Markus
Spoon Feed
Most assaults were committed by socially and psychiatrically vulnerable patients, often during prolonged psychiatric boarding. Overcrowding, limited psychiatric services, and inadequate agitation management contribute to staff assaults and inequitable patient care.
Assessing assault in the ER––How can we improve safety?
This retrospective observational study examined 121 incidents of physical workplace violence (WPV) events in a Boston-area urban community ED from 2021–2023. Nearly half of assaults occurred after 12 hours of ED stay, often during psychiatric boarding. Most perpetrators were publicly insured, psychiatrically ill, and socially marginalized, with high rates of prior trauma, poverty, legal involvement, and substance use. Black patients were disproportionately represented relative to the ED population, mirroring known disparities in psychiatric care access and restraint use. Nurses and security officers were the most frequent victims. While most violent events followed behavioral redirection or confinement efforts, 1/3 of patients received no pharmacologic management for agitation (a missed opportunity!). They found staggeringly disproportionate numbers when compared to the general ED populations: 50% of patients involved in violent offenses were diagnosed with schizophrenia, 70% were on involuntary psychiatric holds, and 78% of assaults occurred during prolonged ED stays (i.e. boarding).
ED WPV largely involves vulnerable psychiatric patients within the context of ongoing structural problems in healthcare, like overcrowding, inadequate psychiatric services, ED boarding, understaffing, and limited access to community mental health care. So, priorities for prevention of WPV include reducing boarding, improving early agitation management, bolstering staff safety staffing, and increasing outpatient access to psychiatric services.
How does this change my practice?
In my own experience, the bulk of the victims of workplace violence are nurses and security personnel, and this study also reflects this. I take concerns from my nursing staff about agitation seriously. It’s easy for early warning signs to be overlooked by us physicians amid competing ED priorities (septic shock! resident question! EKG changes!), but it’s critical to prioritize the early recognition and management of agitation (verbal or pharmacologic) to deescalate situations before assaults occur. Proactive intervention enhances the safety of not only ED staff but protects our patients too.
Source
Workplace Violence in an Urban Community Emergency Department: A Deeper Dive into the Antecedents and Circumstances of Violent Behaviors. J Emerg Med. 2025 Oct;77:1-13. doi: 10.1016/j.jemermed.2025.07.012. Epub 2025 Jul 4. PMID: 40840095.
