Terry Kowalenko

Workplace Violence in Emergency Medicine: Current Knowledge and Future Directions

BACKGROUND Workplace violence (WPV) has increasingly become commonplace in the United States (US), and particularly in the health care setting. Assaults are the third leading cause of occupational injury-related deaths for all US workers. Among all health care settings, Emergency Departments (EDs) have been identified specifically as high-risk settings for WPV. OBJECTIVE This article reviews recent epidemiology and research on ED WPV and prevention; discusses practical actions and resources that ED providers and management can utilize to reduce WPV in their ED; and identifies areas for future research. A list of resources for the prevention of WPV is also provided. DISCUSSION ED staff faces substantially elevated risks of physical assaults compared to other health care settings. As with other forms of violence including elder abuse, child abuse, and domestic violence, WPV in the ED is a preventable public health problem that needs urgent and comprehensive attention. ED clinicians and ED leadership can: 1) obtain hospital commitment to reduce ED WPV; 2) obtain a work-site-specific analysis of their ED; 3) employ site-specific violence prevention interventions at the individual and institutional level; and 4) advocate for policies and programs that reduce risk for ED WPV. CONCLUSION Violence against ED health care workers is a real problem with significant implications to the victims, patients, and departments/institutions. ED WPV needs to be addressed urgently by stakeholders through continued research on effective interventions specific to Emergency Medicine. Coordination, cooperation, and active commitment to the development of such interventions are critical.

Comparison of the effects of bolus vs. slow infusion of 7.5% NaCl/6% dextran-70 in a model of near-lethal uncontrolled hemorrhage

Bolus infusion of of 7.5% NaCl/6% dextran-70 (HSD-B) improves outcome from controlled hemorrhage. In contrast, HSD-B during uncontrolled hemorrhage increases bleeding and short-term mortality. The purpose of this study was to compare the effects of bolus vs. slow infusion of HSD in a near-fatal vascular injury hemorrhage model. Sixteen (15-20 kg) swine with 4-mm aortic tears were hemorrhaged to a pulse pressure of 5 mmHg. An ultrasonic flow probe was placed proximal to the aortic tear for continuous blood flow (AF) measurements. Group I (slow infusion; n = 8) was resuscitated with 8 mL/kg of HSD at 0.4 mL/kg/min. Group II (bolus infusion; n = 8) was resuscitated with 8 mL/kg of HSD at 1.33 mL/kg/min. In both groups, HSD infusion was followed by administration of 30 mL/kg of shed blood at 3 mL/kg/min. Hemorrhage volume and 90-min mortality were greater in group II (79+/-11 mL/kg; 75%) compared with group I (43+/-9 mL/kg; 12.5%) (P(Hem) < 0.001; P(Mort) = 0.04). Mean arterial pressure (MAP) and AF were greater in group II compared with group I during the first 15 min of resuscitation. In group I, MAP, AF, cardiac indices, and O2 delivery gradually returned to baseline levels and were significantly greater than group II at 30 min and throughout the remainder of the protocol. In this model of near-lethal uncontrolled hemorrhage, slow infusion of HSD restored cardiodynamics while minimizing hemorrhage volume and mortality. Resuscitation regimens that cause early increases in blood flow and pressure may result in greater hemorrhage and mortality than those regimens that yield comparable flow and pressure increases late in resuscitation.

Using Action Research to Plan a Violence Prevention Program for Emergency Departments

INTRODUCTION Although there are numerous studies that show that emergency department (ED) violence is a prevalent and serious problem for healthcare workers, there is a lack of published evaluations of interventions aimed at reducing this alarming trend. Using an action research model, the authors partnered with six hospitals to plan, implement and evaluate a violence prevention and management intervention. Phase one of this project involved gathering information from employees, managers and patients using focus groups. METHODS Ninety-seven persons participated in one of twelve focus groups. The Haddon matrix was used to develop focus group questions aimed at gathering data about the pre-assault, during assault, and post-assault time frames and to compare these findings to planned strategies. Analysis consisted of identification of themes related to intervention strategies for patients/visitors, employees, managers, and the work environment. RESULTS Thematic analysis results supported the relevance, feasibility, and saliency of the planned intervention strategies. With the exception of a few items, employees and managers from the different occupational groups agreed on the interventions needed to prevent and manage violence against ED workers. Patients focused on improved staff communication and comfort measures. DISCUSSION Results support that violence in the emergency department is increasing, that violence is a major concern for those who work in and visit emergency departments, and that interventions are needed to reduce workplace violence. The Haddon matrix along with an action research method was useful to identify intervention strategies most likely to be successfully implemented and sustained by the emergency departments.

Occupational and demographic factors associated with violence in the emergency department

Violence against health care workers is a serious and growing problem. The objectives of this cross-sectional study were to (a) describe the frequency of workplace violence (WPV) against emergency department (ED) workers; (b) identify demographic and occupational characteristics related to WPV; and (c) identify demographic and occupational characteristics related to feelings of safety and level of confidence when dealing with WPV. Survey data were collected from 213 workers at 6 hospital EDs. Verbal and physical violence was prevalent in all 6 EDs. There were no statistically significant differences in the frequency of violence for age, job title, patient population, and hospital location. Sexual harassment was the only category of violence affected by gender with females having a greater frequency. Feelings of safety were positively related to the frequency of WPV. Females were significantly more likely to feel unsafe and have less confidence in dealing with WPV. The study findings indicate that all ED workers are at risk of violence, regardless of personal and occupational characteristics. Feelings of safety are related to job satisfaction and turnover. Violence has serious consequences for the employers, employees, and patients. It is recommended that administration, managers, and employees collaborate to develop and implement prevention strategies to reduce and manage the violence.

Implementation of a Comprehensive Intervention to Reduce Physical Assaults and Threats in the Emergency Department

INTRODUCTION The purpose of this study was to test the effectiveness of a comprehensive program to reduce the incidence of workplace violence (WPV) against ED providers by patients and visitors. METHODS An intervention study was conducted with 3 intervention and 3 comparison emergency departments. Participants completed monthly surveys during an 18-month period to measure violent event rates before and after the WPV intervention implementation. Descriptive statistics were used to describe violent events. Analysis of variance was used to assess if the emergency departments participating in the WPV intervention experienced a significant reduction in violence rates compared with nonintervention emergency departments. RESULTS On average, participants experienced more than 6 incidents of violence during the 18-month study period. Although the study hypothesis was not supported, 2 intervention sites had a significant decrease in violence. DISCUSSION This study emphasizes the risk of WPV to ED workers and highlights the need for prevention programs. Future research needs to be conducted to test additional comprehensive WPV prevention interventions.

Alcohol and trauma-in every age group

BACKGROUND The purpose was to determine the proportion of alcohol-positive (AlcPos) trauma patients in different age groups and any association with mortality using the National Trauma Data Bank. METHODS Several variables were extracted from the National Trauma Data Bank (version 6.2) using MS Access 2007: age, alcohol presence, Injury Severity Score (ISS), and discharge status (alive vs dead). Age groups for logistic regression were arbitrarily defined as follows: 0 to 10, 11 to 20, 21 to 39, 40 to 64, and older than 64 years. RESULTS Approximately 47% of all trauma survivors were tested for alcohol (621,174 of a total of 1,311,137), and 28% of those were AlcPos (176,107/621,174). The proportion of AlcPos patients gradually increased to maximum at 22 years, when 46% (6797/14,732) tested were AlcPos. The proportion AlcPos gradually declined to 35% by age 50 years, then to 15% (2516/16,244) by age 66 to 70 years. The ISSs were significantly higher in AlcPos patients in all age groups (P < .01). Mortality rates were higher in AlcPos children (up to age 20 years) and in adults older than 40 years. The AlcPos patients who were 21 to 39 years old had lower mortality compared with alcohol-negative patients. Logistic regression analysis (controlling for ISSs) revealed that being AlcPos did not play a role in mortality until age 21 to 39 years (AlcPos lower mortality) and in age 40 to 64 years and older than 65 years (AlcPos higher mortality). CONCLUSIONS Trauma patients of all ages may be AlcPos. Being AlcPos is a marker for greater injury in all age groups. After controlling for ISSs, trauma patients 40 years and older who were AlcPos have increased mortality. This study suggests a role for alcohol testing in all age groups.

General Competencies are intrinsic to emergency medicine training: A multicenter study

OBJECTIVES The Accreditation Council for Graduate Medical Education (ACGME) has promulgated six areas called General Competencies (GCs) that residency programs are required to evaluate. The authors sought to determine if these domains were an intrinsic part of emergency medicine (EM) residency training by using a global assessment evaluation device. METHODS This was an observational, multicenter, cross-sectional study that compared GC acquisition between first-, second-, and third-year (EM1, EM2, and EM3) residents. Five postgraduate year (PGY) 1 to PGY 3 allopathic EM programs in Michigan participated. A global assessment form using a 1 through 9 ordinal scale with 86 scoring items was given to program directors for each resident in their programs. Analysis of variance (ANOVA) was used to compare the means between EM1, EM2, and EM3 scores. RESULTS Five EM programs evaluated 150 residents. The GC scores were as follows: Patient Care: EM1 4.92, EM2 5.79, and EM3 6.40; Medical Knowledge: EM1 4.90, EM2 5.80, and EM3 6.46; Practice-based Learning and Improvement: EM1 4.60, EM2 5.48, and EM3 6.16; Interpersonal and Communication Skills: EM1 4.99, EM2 5.39, and EM3 6.01; Professionalism: EM1 5.43, EM2 5.68, and EM3 6.27; Systems-based Practice: EM1 4.80, EM2 5.48, and EM3 6.21. ANOVA showed statistically significant differences (p < 0.001) for all GCs. CONCLUSIONS EM residents from several residency programs showed statistically significant progressive acquisition of the ACGME GCs using a global assessment device. This suggests that the GCs may be an intrinsic component in the training of EM residents.

The Development of Sustainable Emergency Care in Ghana: Physician, Nursing and Prehospital Care Training Initiatives

BACKGROUND Ghanas first Emergency Medicine residency and nursing training programs were initiated in 2009 and 2010, respectively, at Komfo Anokye Teaching Hospital in the city of Kumasi in association with Kwame Nkrumah University of Science and Technology and the Universities of Michigan and Utah. In addition, the National Ambulance Service was commissioned initially in 2004 and has developed to include both prehospital transport services in all regions of the country and Emergency Medical Technician training. Over a decade of domestic and international partnership has focused on making improvements in emergency care at a variety of institutional levels, culminating in the establishment of comprehensive emergency care training programs. OBJECTIVE We describe the history and status of novel postgraduate emergency physician, nurse, and prehospital provider training programs as well as the prospect of creating a board certification process and formal continuing education program for practicing emergency physicians. DISCUSSION Significant strides have been made in the development of emergency care and training in Ghana over the last decade, resulting in the first group of Specialist-level emergency physicians as of late 2012, as well as development of accredited emergency nursing curricula and continued expansion of a national Emergency Medical Service. CONCLUSION This work represents a significant move toward in-country development of sustainable, interdisciplinary, team-based emergency provider training programs designed to retain skilled health care workers in Ghana and may serve as a model for similar developing nations.

Competence and Challenges of Emergency Medicine Training as Reported by Emergency Medicine Residents

BACKGROUND The American Board of Emergency Medicine conducts an annual survey of residents in Emergency Medicine, the Longitudinal Study of Residents in Emergency Medicine survey. OBJECTIVE This study was undertaken to describe self-reported competence and challenges facing Emergency Medicine (EM) residents. METHODS In this descriptive, observational analysis of the Longitudinal Study of Residents in Emergency Medicine survey, survey data from 1996-2008 were compared for 70 survey items. Responses were analyzed with means and 95% confidence intervals by post-graduate year (PGY) and over time. RESULTS A total of 496 residents were included in this study. Most participated for 3 years, for a total of 1320 total responses. The most serious day-to-day challenges reported by residents (overall median scores of 3 or more) included knowing enough, keeping up with the medical literature, having enough time for personal life, ancillary support, and having enough time for family. Current level of competence in areas deemed weakest by residents included grant writing, contract negotiation, academic writing, disaster planning, research, and financial management. Residents reported improved competence in most (15 out of 16) areas from PGY-1 to PGY-3 year of training. Resident reports of competence did not change significantly over time from 1998-2008 (15 out of 16 items). CONCLUSIONS Emergency Medicine residents identified several important day-to-day problems, including knowing enough, keeping up with the medical literature, and having enough time for a personal life. PGY-3 residents reported improved competence in almost all aspects of EM work and clinical EM as compared to PGY-1 residents. Knowledge of perceived competence and problems among EM residents is crucial to the development of improved educational approaches to address these issues.

Development of a Data Collection Instrument for Violent Patient Encounters against Healthcare Workers

Introduction: Healthcare and social workers have the highest incidence of workplace violence of any industry. Assaults toward healthcare workers account for nearly half of all nonfatal injuries from occupational violence. Our goal was to develop and evaluate an instrument for prospective collection of data relevant to emergency department (ED) violence against healthcare workers. Methods: Participants at a high-volume tertiary care center were shown 11 vignettes portraying verbal and physical assaults and responded to a survey developed by the research team and piloted by ED personnel addressing the type and severity of violence portrayed. Demographic and employment groups were compared using the independent-samples Mann-Whitney U Test. Results: There were 193 participants (91 male). We found few statistical differences when comparing occupational and gender groups. Males assigned higher severity scores to acts of verbal violence versus females (mean M,F=3.08, 2.70; p<0.001). While not achieving statistical significance, subgroup analysis revealed that attending physicians rated acts of verbal violence higher than resident physicians, and nurses assigned higher severity scores to acts of sexual, verbal, and physical violence versus their physician counterparts. Conclusion: This survey instrument is the first tool shown to be accurate and reliable in characterizing acts of violence in the ED across all demographic and employment groups using filmed vignettes of violent acts. Gender and occupation of ED workers does not appear to play a significant role in perception of severity workplace violence.