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Date: October 30, 2025

Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM

Guest Skeptic: Dr. Suchismita Datta. She is an Assistant Professor and Director of Research in the Department of Emergency Medicine at the NYU Grossman Long Island Hospital Campus.

Case: It’s 7:34 pm. You just took a sip of your portable espresso machine coffee from your favourite Batman cup. It’s been 34 minutes into your Tuesday overnight shift. Things are a little crazy, but you are proud of yourself for getting your day colleague out on time.

Just then, your second-year resident walks briskly towards you and sits down next to you, an air of fluster about her. She is trying to keep her cool, but you can see her hands are trembling as she is putting in orders for the patient she just saw. You ask her what’s up, and she responds, “The intoxicated patient in bed 12 just threatened to punch me when I told him I couldn’t give him more pain medications. He said pretty awful things about me, called me names, and cursed at me… they called over security… but I still feel a little shook up about it… “ She looks down and shakes her head, and then looks back at you and asks, “How often does this actually happen? Violence against us?“

Background: Violence toward clinicians is not a rare event in the ED but rather a predictable occupational hazard. The Canadian Association of Emergency Physicians (CAEP) has called ED violence “unacceptable,” urging a system-wide, zero-tolerance culture and coordinated mitigation efforts across hospitals, EMS, and law enforcement. Their formal CAEP Position Statement on violence in the ED summarizes scope, risk factors, and policy recommendations for prevention and reporting [1].

In the US, the American College of Emergency Physicians (ACEP) maintains a consolidated resource hub on ED workplace violence, including policy statements and advocacy for federal legislation (OSHA standards and the SAVE Act) to mandate prevention programs and establish penalties for assaults on healthcare workers. ACEP’s 2022-member poll found 85% of respondents reported violence had increased in their ED over the prior five years, with 45% saying it had greatly increased. The 2024 follow-up highlighted that >90% feared threats or attacks in the prior year. These data align with the day-to-day experience of emergency physicians and underscore persistent underreporting and inadequate institutional responses [2].

Both CAEP and ACEP emphasize practical approaches such as environmental design, staffing and security policies, de-escalation training, standardized reporting, and partnerships with law enforcement. At the same time, they reject the idea that violence is “part of the job.”

Clinical Question: Among ED patients with, what is the prevalence of violent events against health care workers, and how does that compare with events formally reported to the hospital?

Reference: Boes et al. Prevalence of violence against health care workers among agitated patients in an urban emergency department. October 2025 AEM

  • Population: ED patients from a locked observation unit at Hennepin County Medical Center (Minneapolis, MN).
    • Exclusions: Patients known to be in custody at the time of the encounter were excluded from data collection.
  • Exposure: Agitation, defined as an Altered Mental Status Score (AMSS) ≥ +1 (range from −4 to +4). Observers then recorded whether the encounter included verbal abuse, a threat of violence, or a violent act against a health care worker.
  • Comparison: N/A
  • Outcome:
    • Primary Outcome: Assault against any health care worker, defined by Minnesota state statute as an act with intent to cause fear of immediate bodily harm or death, or intentional infliction/attempt to inflict bodily harm.
    • Secondary Outcomes: Verbal abuse of health care workers by agitated patients (distinct from threats), defined as harsh/insulting/derogatory language or gestures intended to frighten, humiliate, or belittle.
  • Type of Study: A secondary analysis of two prospective, observational studies conducted in the ED setting.

This is an SGEMHOP, and we are pleased to have the lead author on the episode, Dr. Brian Driver. He is a faculty emergency physician and Director of Clinical Research in the Department of Emergency Medicine at Hennepin County Medical Center.

Authors’ Conclusions: “Verbal abuse, threats of assault, and violent acts occurred frequently in ED patients with agitation and were underreported.”

Quality Checklist for Observational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Unsure
  7. Was the follow-up of subjects complete enough? Yes
  8. How precise are the results? Unsure 
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Unsure 
  11. Do the results of this study fit with other available evidence? Yes
  12. Funding of the Study. None is stated in the manuscript, while the authors declare no conflicts of interest.

Results: Across 17,873 screened encounters, 4,609 (26%) involved agitation (AMSS ≥ +1). Alcohol or drug intoxication was present in 4,108 (89%) encounters. Among agitated patients, the median age was ~36 to 39 years, about 50% were male, and the cohort included a substantial proportion of Black, non-Hispanic patients (40–46% across violence strata). The study took place in a locked ED observation unit within an urban safety‑net hospital with ~100,000 annual visits.

Key Result: Among agitated ED encounters, assaults were common, formal reports of verbal abuse were rarely reported, while most violent acts were reported.

  • Only 0.5% (9/1,786) of verbal-abuse events and 61.9% (224/362) of violent acts were formally reported to the hospital.

Listen to the SGEM podcast to hear Brian answer our five nerdy questions.

  1. External Validity: This was a single-center analysis in a locked ED observation unit that preferentially rooms patients with suspected intoxication. While you suggest similar patients would otherwise be mixed in general ED beds, concentrating intoxicated, agitated patients may change the observed prevalence and risk environment.
  2. Measurement Bias and Lack of Inter-Rater Reliability. Trained observers used standardized definitions, but inter-rater reliability was not reported, and observers were embedded in the clinical setting (not blinded), which can introduce observation/expectation bias. This is particularly important for subjective constructs like “verbal abuse.”
  3. Comparator Misalignment & Underreporting Bias: The “formal report” comparator aggregated events from anywhere in the ED, not just the studied unit or only agitated patients. Using the same denominator (n=4,609) overestimates reporting percentages and biases toward the null in observed–reported differences. Institutional reporting is also known to be incomplete. Don’t these differences limit the interpretation of the magnitude of underreporting? 
  4. Ascertainment Constraints: The authors note constraints such as language limitations (inability to capture some non-English events), areas not observed (triage), and binary counting at the encounter level (not tallying multiple events per visit). Each can attenuate or distort true prevalence. Could this not systematically shift some of the point estimates?
  5. Descriptive Design: As a prevalence study, it does not adjust for potential drivers of violence (staffing, throughput, intoxication level, and de-escalation availability), limiting inference about determinants or modifiable factors. These confounders make it challenging to know how best to address the problem of violence based on this data set.

Comment on the Authors’ Conclusion Compared to the SGEM Conclusion: We generally agree with the author that the rate of violence in agitated patients against health care workers is high and under-reported.

SGEM Bottom Line: Violence against ED staff is common and substantially underreported, especially for verbal abuse.

Dr. Suchi Datta

Case Resolution: You tell your resident that, sadly, her experience is not singular and that violence against healthcare workers is a problem, especially amongst agitated patients. You encourage her to report the incident, as there needs to be more documented encounters to help facility advocacy on a systemic level. You also provide her with some resources to help process her trauma. She is very thankful and goes on to talk to you about how the encounter made her feel. You take a walk outside to the trauma bay and, after some breathing exercises, feel strong enough to come back and continue running the ED the rest of the night.

Clinical Application: Be careful around agitated patients. Make sure you accurately report incidents of violence. We need to advocate for systemic changes to protect healthcare workers as per ACEP and CAEP. This includes more robust prevention, reporting, and accountability. Violence should not be part of our job.

What Do I Tell My Patient? N/A

Keener Kontest: Last week’s winner was Dr. Steven Stelts from New Zealand. He knew Magnesium got its name from Magnesia, a region in Thessaly, Greece. This is an area known in ancient times for its deposits of minerals and stones containing magnesium.

Listen to the SGEM podcast for this week’s question. If you know, then send an email to  thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.

Now it is your turn, SGEMers. What do you think of this episode on ED violence? What questions do you have for Brian and his team? Post your comments on social media using #SGEMHOP. The best social media feedback will be published in AEM.

Other SGEM Episodes:

  • SGEM#473: Did You Ever Have To Make Up Your Mind – Midazolam or Ketamine for Acute Agitation in the Pre-Hospital Setting
  • SGEM#449: Bad Boys What’cha Gonna Do – Patient Perceptions of Behavioral Flags in the ED
  • SGEM#328: I Can’t fight this Med Any Longer – Droperidol for Acute Agitation
  • SGEM#45: Vitamin H (Haloperidol for Psychosis)
  • SGEM#218: Excited Delirium Syndrome
  • SGEM Xtra: I’m So Excited – But Don’t Call It Excited Delirium

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

References:

  1. Drummond A, Chochinov A, Johnson K, Kapur A, Lim R, Ovens H. CAEP position statement on violence in the emergency department. CJEM. 2021 Nov;23(6):758-761. doi: 10.1007/s43678-021-00182-z. Epub 2021 Aug 5. PMID: 34351599.
  2. American College of Emergency Physicians. Violence in the Emergency Depeartment. https://www.acep.org/administration/violence-in-the-emergency-department-resources-for-a-safer-workplace Accessed October 21, 2025