BACKGROUND:Agitation is a common clinical presentation associated with up to 2.6% of emergency department (ED) visits per year. The science of identifying, predicting, and managing agitation has rapidly progressed over the past decade, leading to broad recommendations about initial approaches and management strategies. OBJECTIVE:The purpose of this clinical review is to review existing literature on the etiology, recognition, and management of agitation to help clinicians and staff who care for these patients. METHODS:A narrative review was performed of articles published from 1984 to 2026. DISCUSSION:Standardized approaches to agitation management are discussed, highlighting both existing literature and research gaps. There is broad agreement on 5 main objectives of the approach to the agitated patient in the ED: address safety issues for the patient and ED staff, an expedited clinical assessment, identifying a presumptive etiology of agitation in order to guide treatment, verbal de-escalation as an initial management strategy, and judicious medication administration. CONCLUSIONS:This review shows that practices like verbal de-escalation, therapeutically-indicated medication administration, and multidisciplinary teamwork are imperative to improving care and reducing mistrust, longer hospital stays, use of restraints, and physical assaults on ED staff and ultimately, workplace violence. In particular, verbal de-escalation should be a first-line treatment. There is agreement that the etiology of agitation should guide management, but less agreement on particular drug combinations if medication is needed. Recommendations are given but further research is necessary.

QuestionWhat has been the trend in hospital-based shootings over the past 25 years in the US?FindingsThis systematic review of 327 news articles of unique hospital-based shooting events found an overall incidence of 25.2 hospital-based shootings per year, which primarily occurred in large, urban, and southern US hospitals. Nearly one-third of shootings were potentially preventable by weapons screening.MeaningThese findings underscore the need for hospital-specific prevention strategies, alongside broader societal efforts, to address rising firearm violence. This systematic review examines trends in US hospital-based firearm violence from 2000 to 2024. ImportanceHospital-based shootings represent an extreme form of workplace violence, with notable consequences for staff, patients, and visitors. Despite growing concern, these events remain poorly understood.ObjectiveTo categorize hospital-based shootings from 2012 to 2024 and incorporate prior published events between 2000 and 2011 to examine trends in shootings over a 25-year span.Evidence ReviewEvents in this systematic review of acute care hospital-based shootings in the US from January 1, 2012, through December 31, 2024, with subgroup analysis of previously published data trending shootings over 25 years (January 1, 2000, through December 31, 2024), were identified using EBSCO Regional Business News, ProQuest US Newsstream Collection, Gun Violence Archive, and Google News Search. Selected shooting events involved at least 1 injured person (a nonperpetrator or perpetrator) that occurred within or on the immediate property of the hospital.FindingsA total of 327 news articles of unique hospital-based shooting events (5.2 per year per 1000 hospitals) were included from a review of 6658 articles, spanning 47 US states (94.0%). There was an overall incidence of 25.2 hospital-based shootings per year. Between 2012 and 2024, shootings increased by a mean (SD) of 1.7 (0.5) events per year, from 14 to 34 events (8.4% increase per year). Large hospitals accounted for the highest rate of shootings (258.1 events per 1000 hospitals). Events primarily occurred in urban settings (314 [96.0%]), and 161 (49.2%) occurred in the US South. Nearly one-third (105 [32.1%]) were potentially preventable by weapons screening. From 2000 to 2024, shootings increased by a mean (SD) of 1.1 (0.2) events per year, from 6 to 34 events (6.4% increase per year). A positive correlation was found in annual firearm fatalities in hospital settings and US firearms fatalities overall between 2012 and 2023 (r = 0.42).Conclusions and RelevanceThis systematic review found that hospital-based shootings in the US have increased steadily over the past 25 years, representing an intersection between broader national trends in workplace and firearm violence. Large hospitals, those in the US South, and hospitals in urban communities are particularly at-risk settings. These findings underscore the need for hospital-specific prevention strategies, including consideration of weapons screening technology, alongside broader societal efforts to address rising firearm violence.

Importance:Hospital-based shootings represent an extreme form of workplace violence, with notable consequences for staff, patients, and visitors. Despite growing concern, these events remain poorly understood. Objective:To categorize hospital-based shootings from 2012 to 2024 and incorporate prior published events between 2000 and 2011 to examine trends in shootings over a 25-year span. Evidence Review:Events in this systematic review of acute care hospital-based shootings in the US from January 1, 2012, through December 31, 2024, with subgroup analysis of previously published data trending shootings over 25 years (January 1, 2000, through December 31, 2024), were identified using EBSCO Regional Business News, ProQuest US Newsstream Collection, Gun Violence Archive, and Google News Search. Selected shooting events involved at least 1 injured person (a nonperpetrator or perpetrator) that occurred within or on the immediate property of the hospital. Findings:A total of 327 news articles of unique hospital-based shooting events (5.2 per year per 1000 hospitals) were included from a review of 6658 articles, spanning 47 US states (94.0%). There was an overall incidence of 25.2 hospital-based shootings per year. Between 2012 and 2024, shootings increased by a mean (SD) of 1.7 (0.5) events per year, from 14 to 34 events (8.4% increase per year). Large hospitals accounted for the highest rate of shootings (258.1 events per 1000 hospitals). Events primarily occurred in urban settings (314 [96.0%]), and 161 (49.2%) occurred in the US South. Nearly one-third (105 [32.1%]) were potentially preventable by weapons screening. From 2000 to 2024, shootings increased by a mean (SD) of 1.1 (0.2) events per year, from 6 to 34 events (6.4% increase per year). A positive correlation was found in annual firearm fatalities in hospital settings and US firearms fatalities overall between 2012 and 2023 (r = 0.42). Conclusions and Relevance:This systematic review found that hospital-based shootings in the US have increased steadily over the past 25 years, representing an intersection between broader national trends in workplace and firearm violence. Large hospitals, those in the US South, and hospitals in urban communities are particularly at-risk settings. These findings underscore the need for hospital-specific prevention strategies, including consideration of weapons screening technology, alongside broader societal efforts to address rising firearm violence.

STUDY OBJECTIVES:To determine the rate of violent patient encounters continued across longitudinal health care settings and to assess for rates of violence among individual care settings. METHODS:We conducted an observational cohort study from December 1, 2022, to November 30, 2023, within a large, quaternary academic center's emergency department (ED), hospital, and affiliated emergency medical services agency. Patients from out-of-hospital encounters who exhibited workplace violence were compared with those being violent within the ED/hospital. Accounting for patient length of stay, rates of violence were reported with 95% confidence intervals (CI). RESULTS:A total of 206 out-of-hospital (0.78 per 100 encounters, 95% CI 0.68 to 0.89), 868 ED (1.06 per 100 encounters, 95% CI 1.00 to 1.14), and 3,561 non-ED hospital (6.37 per 100 encounters, 95% CI 6.17- to 6.58) violent encounters were included in final analysis, representing 2,251 unique patients. Among the 2,791 distinct patient encounters across all care settings with ≥1 violent incident, 783 patients (28.1%, 95% CI 26.4 to 29.8) continued violence into a second care setting, 353 (12.6%, 95% CI 11.4 to 14.0) into a third, and 208 (7.5%, 95% CI 6.5 to 8.5) into a fourth. The out-of-hospital setting had the highest rate of reported violence per 10 patient encounter hours (18.02, 95% CI 15.63 to 20.67), followed by the ED (0.35, 95% CI 0.33 to 0.38). CONCLUSION:Our findings reveal that workplace violence spans multiple care settings, beginning in the out-of-hospital setting, continuing through the ED, and persisting into inpatient units following admission. Future research should explore contributing factors such as care transitions and underlying risk factors to inform targeted interventions aimed at preventing violence and safeguarding health care staff.

Importance There is a clear benefit to body armor against firearms; however, it remains unclear how these vests may influence day-to-day patient encounters when worn by emergency medical services (EMS). Objective To determine the association of ballistic vests worn by EMS clinicians with workplace violence (WPV) and disparities in care among racial and/or ethnic minority patients. Design, Setting, and Participants Prospective cohort study of a volunteer-based sample of EMS clinicians at a large, multistate EMS agency encompassing 15 ground sites across the Midwest from April 1, 2023, to March 31, 2024. Data were analyzed from May to June 2024. Exposure External ballistic armor being used by a group of self-selected clinicians on every run. Main Outcomes and Measures Prevalence and characteristics associated with WPV and with declines of treatment and/or transport compared between crews with 1 or more vested vs no vested members. Results A total of 156 of 415 staff (37.6%) opted in to wear the vests, including 77 male participants (49.4%). Prevalence of WPV was higher for vested crews (1.11 vs 0.85 cases per 100 runs; adjusted risk ratio [aRR], 1.28; 95% CI, 1.10 to 1.50; P = .001) and was due to higher rates of verbal abuse. The presence of 1 or more vested crew members increased the likelihood of all patients declining EMS treatment and/or transport; however, effect size was highest among patients with an unknown race and/or ethnicity (2234 [21.1%] vs 2134 [16.5%] patients; aRR, 1.19; 95% CI, 1.10 to 1.27; P < .001), followed by racial and/or ethnic minority patients (708 [16.7%] vs 399 [13.8%] patients; aRR, 1.18; 95% CI, 1.05 to 1.33; P = .01). Analyses of individual minority groups revealed a significant increase only in Black or African American patients declining treatment and/or transport by vested crews (461 [17.6%] vs 223 [13.7%] patients; RR, 1.28; 95% CI, 1.10 to 1.49; P = .002). Conclusions and Relevance In this cohort study, vested crews experienced increased prevalence of WPV compared with nonvested crews. Use of vests increased the frequency of all patients declining EMS treatment and/or transport. Among minority groups, there was a significant increase in Black or African American patients declining treatment and/or transport. Agencies should consider benefits and unintended consequences of EMS clinicians wearing body armor.

OBJECTIVES:Within our emergency medical services (EMS) agency, workplace violence (WPV) is captured through a documentation feature in the electronic medical record. Leveraging this data, we implemented WPV dispatch alerts for addresses where physical violence occurred. Our primary objective was to assess the association of these alerts on the rate of WPV against EMS clinicians. METHODS:This observational cohort study took place 11/20/2022-11/20/2024 at a hospital-affiliated EMS agency with 23,300 average annual ground calls for service. Alerts were implemented on 12/26/2023 and consisted of a notification at time of dispatch stating "WPV Flag- Information only: previous documented assault at this address." Alerts were updated monthly with a 1-year expiration, unless renewed due to repeat physical violence. Rate of WPV in the pre-alert period (11/20/2022-12/25/2023) was compared with the post-alert period (12/26/2023-11/20/2024) using risk differences (RDs) and 95% confidence intervals (CIs). RESULTS:A total of 254 (0.78 per 100 EMS calls, 95% CI: 0.69 - 0.89) violent incidents (verbal abuse and physical assault) occurred pre-alerts compared to 153 (0.53 per 100 calls, 95% CI: 0.46 - 0.63) post-alerts (RD= -0.25 cases per 100 calls, 95% CI: -0.37 to -0.12, p < 0.001). Among these were 96 (0.30 per 100 calls, 95% CI: 0.24 - 0.36) assaults pre-alerts, compared to 63 (0.22 per 100 calls, 95% CI: 0.17 - 0.28) post-alerts (RD= -0.07 cases per 100 calls, 95% CI: -0.16 to +0.01, p = 0.068). Seventy-seven alerts were placed on identifiable addresses; among these, two (2.6%) were renewed due to repeat physical violence and 31 (40.3%) were ultimately removed due to no repeat violence in a 12-month period. During the post-alert period, EMS clinicians were dispatched a total of 853 times to addresses with preexisting alerts (median = 6; range: 1 - 234 dispatches per address), although this included calls with alerts specific to the address but a different unit number from the initial alert (e.g., same nursing facility but different resident unit number). CONCLUSIONS:Providing EMS clinicians with alerts on addresses with previous physical violence at time-of-dispatch was associated with a significant decrease in the rate of WPV against EMS clinicians overall within our agency.

Lack of reliable diagnostics for the presence, type and severity of infection in patients presenting to emergency departments with non-specific symptoms poses considerable challenges. We developed TriVerity, which uses isothermal amplification of 29 mRNAs and machine learning algorithms on the Myrna instrument to determine likelihoods of bacterial infection, viral infection and need for critical care interventions within 7 days. To validate TriVerity, the SEPSIS-SHIELD study enrolled 1,222 patients with clinically adjudicated infection status and need for critical care intervention within 7 days as endpoints. The TriVerity Bacterial and Viral scores had higher accuracy than C-reactive protein, procalcitonin or white blood cell count for the diagnosis of bacterial infection with area under the receiver operating characteristic (AUROC) of 0.83, and viral infection (AUROC = 0.91). The TriVerity Severity score had an AUROC of 0.78 for predicting illness severity and allowed reclassification of risk for critical care interventions compared to clinical assessment (quick Sequential Organ Failure Assessment) alone. Each of the three scores had rule-in specificity >92% and rule-out sensitivity >95%. Comparison of antibiotics administration at presentation with post-follow-up adjudication found that TriVerity could potentially reduce false positives and false negatives for inappropriate antibiotics use by 60-70%. Further clinical testing in an interventional setting is needed to prove actionability and clinical benefit of TriVerity.

RATIONALE AND OBJECTIVES:Triple rule out CT protocols (TRO-CT) have been advocated as a single test to simultaneously evaluate major causes of acute chest pain, in particular acute myocardial infarction (MI), acute pulmonary embolism (PE), and acute aortic syndrome. However, it is unclear what patient populations would benefit from a such comprehensive exam and current guidelines recommend tailoring CT protocols to the most likely diagnosis. METHODS:We retrospectively reviewed TRO-CT scans performed from the Emergency Department (ED) at our institution from April 2021 to April 2022. Charts were reviewed to calculate clinical risk of MI, PE, and acute aortic syndrome using conventional clinical scoring systems (HEART score, PERC score, ADD-RS). TRO-CT findings and 30-day clinical outcomes were recorded from chart review. RESULTS:1279 patients ED patients scanned with TRO-CT were included in the analysis. 831 patients (65.0%) were at-risk for two or more clinical risk scores. At TRO-CT, 381 (29.8%) patients had obstructive CAD. 91 (7.1%) had acute PE. 7 (0.5%) had acute aortic syndrome. At 30-day clinical follow up, 28 patients (2.2%) had the diagnosis of acute MI (95% CI: 1.5-3.2%). 90 patients (7.0%) had the diagnosis of acute PE (95% CI: 5.7-8.6%). 7 patients (0.5%) had the diagnosis acute aortic syndrome (95% CI: 0.2-1.2%). A low-risk HEART score was associated with a 0.3% 30-day clinical diagnosis of acute MI (95% CI: 0.0-1.6%). Low-risk-PERC was associated with a 2.9% 30-day clinical diagnosis of acute PE (95% CI: 0.7-8.7%). Low-risk ADD-RS was associated with a 0.3% 30-day clinical diagnosis of acute aortic syndrome (95% CI: 0.0-1.8%). CONCLUSIONS:We found a high clinical overlap in the presentation of acute MI, acute PE, and acute aortic syndrome based on clinical risk scores. Further studies will be needed to compare a TRO-CT algorithm to a standard-of-care algorithm in patients presenting to the ED.

This study aimed to systematicically evaluate and quantify the prevalence of weapons in the health care setting. A systematic search of MEDLINE, Embase, Scopus, Web of Science, CINAHL, and EBSCO MegaFILE was performed from inception to January 12, 2024. The primary outcome was the prevalence of weapons in the health care setting on patients and/or visitors. Prevalence was pooled across studies and estimated using a random effects model. Subgroup analyses were done based on types of weapons, characteristics of weapon carriers, weapons screening/detection technology, and screened population characteristics. A total of 14 observational studies were included. All studies were from the United States and were published between 1984 and 2023. Weapons prevalence ranged from 0.4% to 26.3% among populations screened in the included studies. The overall pooled weapons prevalence was 4.0% (95% CI, 2.0%-7.8%). Most weapons were bladed (3.8%; 95% CI, 1.5%-8.9%), followed by other weapons (0.6%; 95% CI, 0.3%-1.3%), and firearms (0.1%; 95% CI, 0.02%-0.5%; P<.01). Weapons prevalence was 2.0% (95% CI, 0.7%-5.8%) among individuals entering the hospital setting, compared with 1.6% (95% CI, 0.7%-3.4%) of individuals entering the emergency department and highest (24.3%; 95% CI, 21.6%-27.2%) when major trauma patients were hand-searched. Prevalence was higher in males than that in females (11.1% vs 3.1%; P=.01). Weapons should be expected on individuals presenting to hospitals in the United States; however, prevalence varied widely based on the setting, type of patients, and detection method.

Many patients in the emergency department present with signs and symptoms that arouse concern for sepsis; however, other explanations are also possible. There are currently no rapid tests used in clinical practice that reliably distinguish the presence of a bacterial or viral infection vs. a non-infectious etiology and can predict a patient’s likelihood to decompensate. The diagnostic and prognostic uncertainty in “gray zone” patients complicates the decision to begin therapy as clinicians need to balance the risk of withholding therapy vs. the risk of the therapy itself (e.g., overtreatment with antibiotics and hospitalization, which is costly, potentially harmful, and contributes to antibiotic resistance). The TriVerity™ Test uses isothermal amplification and machine-learning algorithms to quantify and interpret mRNA expression levels to determine both likelihood of bacterial infection, viral infection, or no infection, and whether the patient will likely require one or more critical interventions within 7 days. The three scores each fall into one of five interpretation bands ranging from Very high to Very low. Testing takes approximately 30 minutes using the proprietary Myrna™ Instrument with an operator hands-on-time of under one minute. We enrolled 1,222 patients from 22 emergency departments (ED) to validate the performance of the TriVerity Test. Patients were treated as per local standard of care and were followed for 28 days. Bacterial and viral TriVerity results were validated against clinically adjudicated infection status; the illness severity TriVerity result was validated against the need for at least one critical interventions within 7 days. The bacterial TriVerity result had high AUROC for the diagnosis of bacterial infection (0.83; 80% CI 0.81–0.85) and divided bacterial infection likelihood scores into five interpretation bands with increasing likelihood ratios of infection ranging from Very low (LR- 0.08, 80% CI 0.06–0.11) to Very high (LR + 8.04, 80% CI 5.72–11.78). The AUROC for the bacterial TriVerity result was significantly higher compared to AUROCs for C-reactive protein, procalcitonin or white blood cell count. Similarly, the viral TriVerity score showed high AUROC for the diagnosis of viral infection (0.91; 80% CI 0.90–0.93) and likelihood ratios from Very low (LR- 0.09, 80% CI 0.05–0.14) to Very high (LR + 40.93; 80% CI 29.11–79.23). The TriVerity Illness Severity score showed a high AUROC for the prediction of illness severity (0.77; 80% CI 0.77–0.81) with scores divided into five interpretation bands with increasing likelihood ratios ranging from Very low (LR- 0.22; 80% CI 0.14–0.33) to Very high (LR + 11.33; 80% CI 7.31–17.00). TriVerity illness severity results allowed marked re-classification of the risk for “ICU-level care” as compared to clinical assessment (qSOFA scores) alone. In conclusion, TriVerity provides rapid, highly accurate and actionable results for the diagnosis and prognosis of patients with suspected acute infection and/or sepsis, supporting a major unmet medical need. TriVerity may improve personalized management of patients with suspected acute infections and suspected sepsis for improved overall healthcare outcomes.

Objectives: To determine the prevalence and associated risk factors of workplace violence (WPV) experienced by emergency medical services (EMS) clinicians across a large, multistate ground/air EMS agency. Methods: We used a prospective cohort study design from 1 December 2022 to 30 November 2023. A checkbox was added within the electronic medical record (EMR) asking staff to indicate whether WPV occurred. Patient characteristics, encounter (run), and crew factors were abstracted. Potential risk factors for WPV were assessed using logistic regression, with the occurrence of any form of violence as the primary outcome of interest. Models were both univariable, assessing each risk factor individually, and multivariable, assessing all risk factors together to identify independent factors associated with higher risk of WPV. Multivariable model results were reported using adjusted odds ratios (aORs) and 95% confidence intervals. Results: A total of 102,632 runs were included, 95.7% (n = 98,234) included checkbox documentation. There were 843 runs (0.86 per 100 runs, 95% CI 0.80-0.92) identified by EMS clinicians as WPV having occurred, including verbal abuse (n = 482), physical assault (n = 142), and both abuse and assault (n = 219). Risk factors for violence included male patient gender (aOR 1.45, 95% CI 1.24-1.70, p < 0.001), Richmond Agitation-Sedation Scale (RASS) >1 (aOR 16.97, 95% CI 13.71-21.01, p < 0.001), and 9-1-1 runs to include emergent (P1; aOR 1.75, 95% CI: 1.17-2.63, p = 0.007) and urgent (P2; aOR 1.64, 95% CI 1.08-2.50, p = 0.021) priority, compared to P3/scheduled transfer or P4/trip requests. Factors associated with lower risk for violence included older patients (aOR per 10 years = 0.95, 95% CI 0.91-0.98, p = 0.007) and run time of day between 0601-1200 h compared to 0000-0600 h (aOR 0.67, 95% CI 0.51-0.88, p = 0.004). Only 2.7% of violent runs captured through the EMR were reported through official processes. Conclusions: Verbal and/or physical violence is recognized in nearly 1% of EMS runs. We recommend prioritizing WPV prevention and mitigation strategies around identified risk factors and simplifying the WPV reporting process in order to reduce staff administrative burden and encourage optimal capturing of violent events.

OBJECTIVE:Acts of violence occurring in the healthcare setting that involve weapons result in significant morbidity and mortality. New passive weapons screening technology (PWST) offers a potential protective measure. Our objective was to quantify the volume of weapons detected and deterred from our emergency department (ED) over a 12-month period and determine whether it led to weapon-carrier hostility towards frontline staff. METHODS:Mixed-methods study involving a descriptive analysis of weapons detection data and a survey study of security staff regarding weapon-carrier hostility at point of deterrence within the ED of a large, academic, Level 1 trauma center in a Midwest city with an average annual volume of 80,000 patients. The study was deemed exempt by the IRB. RESULTS:Between 11/1/22 and 10/31/23, 1741 weapons were detected, including knives (n = 1390; 79.8 %), firearms (n = 69; 4.0 %), and other/improvised weapons (n = 282; 16.2 %). Prior to implementation of PWST, average monthly weapons detection was ≤1. Security staff responded to the survey question in 534/1741 (30.7 %) interactions where a weapon was detected. The majority indicated the weapon-carrier was not upset with prevention of weapon(s) from entering (n = 470; 88.0 %). CONCLUSION:We found a concerning rate of attempts to bring weapons into our ED. This does not include weapons which may be entering the ED undetected via patients transported by emergency medical services (EMS) or on persons entering through other hospital entrances. Security perception was that most weapon-carriers were not upset with this intervention.

OBJECTIVES:The objectives of this study were to: (1) understand the personal impact of workplace violence (WPV) on staff within a large multistate emergency medical services (EMS) agency, (2) describe the impact of WPV on subsequent patient interactions, examining how experiences of violence affect the quality of care provided by EMS clinicians, (3) examine the influence of WPV on perceived workplace safety among prehospital personnel and its correlation with retention in the EMS field, and (4) solicit recommendations from staff for the prevention and mitigation of WPV in the future. METHODS:We conducted virtual focus groups and individual interviews with 22 prehospital personnel using a descriptive qualitative design within a large multistate Midwest EMS agency between 4/5/2023-6/20/2023. Data were analyzed using Thematic Analysis to identify common perceptions among and across participants. RESULTS:Major themes of personal impact; impact on patient interactions; influence of WPV on career longevity/sustainability; and relationship between EMS culture and WPV were identified. Overall, participants shared the perception that WPV is "part of the job", and that verbal abuse was so common that they hadn't previously considered it as violence. Participants provided several examples of WPV and described how these experiences impacted them personally (e.g., hypervigilance) and impacted their subsequent interaction with patients (e.g., quicker to use restraints, loss of empathy). Participants shared the perception that EMS is no longer valued or respected by patients or communities. Several voiced concerns for the next generation of colleagues and nearly all participants reported the need for education and training in situational awareness, de-escalation, and self-defense tactics. Participants referenced desire for more coordination and communication with law enforcement, change in culture of abuse from patients without repercussions, and improved agency mental health support and peer support/mentoring following a violent event. Despite experiences with WPV, the majority reported plans to remain in EMS. CONCLUSIONS:Emergency Medical Services personnel are commonly traumatized by violence in their work and nonphysical violence is underappreciated. Despite its impact on staff and subsequent patient interactions, most participants reported plans to remain within EMS. Multi-faceted system-focused efforts are needed to shift toward and support a zero-tolerance culture for WPV.

Introduction: Healthcare workers, particularly those in the emergency department (ED), experience high rates of injuries caused by workplace violence (WPV). Objective: Our goal was to establish the incidence of WPV among multidisciplinary ED staff within a regional health system and assess its impact on staff victims. Methods: We conducted a survey study of all multidisciplinary ED staff at 18 Midwestern EDs encompassing a larger health system between November 18–December 31, 2020. We solicited the incidence of verbal abuse and physical assault experienced and witnessed by respondents over the prior six months, as well as its impact on staff. Results: We included responses from 814 staff (24.5% response rate) for final analysis with 585 (71.9%) indicating some form of violence experienced in the preceding six months. A total of 582 (71.5%) respondents indicated experiencing verbal abuse, and 251 (30.8%) indicated experiencing some form of physical assault. All disciplines experienced some type of verbal abuse and nearly all experienced some type of physical assault. One hundred thirty-five (21.9%) respondents indicated that being the victim of WPV has affected their ability to perform their job, and nearly half (47.6%) indicated it has changed the way they interact with or perceive patients. Additionally, 132 (21.3%) indicated experiencing symptoms of post-traumatic stress, and 18.5% reported they have considered leaving their position due to an incident. Conclusion: Emergency department staff suffer violence at a high rate, and there is no discipline that is spared. As health systems seek to prioritize staff safety in violence-prone areas such as the ED, it is imperative to recognize that the entire multidisciplinary team is impacted and requires targeted efforts for improvement in safety.

Background: Heart Failure (HF) is a primary diagnosis for hospital admission from the Emergency Department (ED), although not all patients require hospitalization. The Emergency Heart Failure Mortality Risk Grade (EHMRG) estimates 7-day mortality in patients with acute HF in ED settings, but further validation is needed in the United States (US). Objectives: To validate EHMRG scores by risk-stratifying patients with acute HF in a large tertiary healthcare center in the US and analyze outcome measures to determine if EHMRG risk scores safely identify low-risk groups that may be discharged or managed in ED observation units (EDOUs). Methods: A retrospective cohort analysis of 304 patients with acute HF presenting to an ED at a large, tertiary healthcare center was completed. EHMRG scores were calculated to stratify patients according to published thresholds. Mortality and major adverse cardiac event (MACE) rates were analyzed. Results: No deaths occurred in very low and low-risk EHMRG groups at 7 days post discharge. 30-day mortality was significantly less in the lower risk groups (3.1%) when compared to all other patients (11.1%). MACE rates at 30 days in the very low risk group (15%) were significantly less when compared to all other patients (31.3%). Hospitalizations occurred in 23.4% of patients in lower risk groups. Conclusions: ED risk stratification with EHMRG differentiates high-risk patients requiring hospitalization from lower risk patients who can be safely managed in alternative settings with good outcomes. Data supports improved pathways for patients with acute HF during a time of high hospital volumes. (C) 2022 Elsevier Inc. All rights reserved.

Acts of violence occurring in the healthcare setting that involve weapons result in significant morbidity and mortality to staff and bystanders. New passive weapons screening technology (PWST) offers a potential protective measure against these low-frequency, high-impact events. Our study objective was to quantify the volume and rate of weapons detected and prevented from entering our emergency department (ED) over a 12-month period following implementation of PWST at the main entrance. This descriptive study took place within the ED of a large, academic, Level 1 trauma center in a small urban city in the Midwest with an average annual patient volume of 80,000 patients and 24/7 security presence. PWST at the main ED entrance was instituted on 1/17/22; prior to this date, no point-of-entry weapons screening was performed. Monthly and annual weapons detection data were collected and compared to number of patient encounters where patients arrived through the main entrance. Due to technical limitations, PWST was not implemented at the ambulance garage's point-of-entry and therefore all encounters where patients arrived through the garage (via law enforcement or ambulance) or from the rooftop helipad (air medical transports) were excluded from analysis. Weapons detected on law enforcement officers entering the ED were also excluded. The study was reviewed by the Mayo Clinic Institutional Review Board and deemed exempt. Between 4/1/22 and 3/31/23, 247,926 individuals (patients and visitors) passed through the ED PWST scanner, from which 1,728 weapons were discovered and prevented from ED entry. An additional 13 weapons were detected through non-PWST means (99.3% of weapons detected through PWST). Weapons included knives (n = 1,217; 69.9%), firearms (n = 117; 6.7%), and other/improvised weapons (n = 407; 23.4%). Prior to implementation of PWST, average monthly weapons detection was <1. A total of 80,968 ED patient encounters occurred during the study period, 59,006 (72.9%) in which patients arrived through the main ED entrance. There was a median monthly weapons detection rate of 3.0 (range 1.8-3.9; Figure 1) per 100 ED patient encounters. Our findings demonstrate a concerning rate of attempts to bring weapons into our ED. This rate does not include weapons which may be entering the ED (and hospital) undetected via patients transported by emergency medical services (EMS). Future efforts should attempt to quantify this missing rate to provide a comprehensive incidence of weapons brought into the ED which would contribute towards safety measures for EMS as well. All individuals entering the main ED entrance are subject to screening, therefore we are unable to determine how many weapons were carried by patients versus visitors. However, given that violence against staff is perpetrated by both patients and their visitors, we believe the overall rate of weapons detected and deterred from both is significant.

BackgroundDespite broad awareness of the opioid epidemic and the understanding that patients require much fewer opioids than traditionally prescribed, improvement efforts to decrease prescribing have only produced modest advances in recent years. Methods and findingsBy using a collaborative model for shared expertise and accountability, nine diverse health care systems completed quality improvement projects together over the course of one year to reduce opioid prescriptions for acute pain. The collaborative approach was flexible to each individual system's goals, and seven of the nine participant institutions definitively achieved their desired results. ConclusionsThis report demonstrates the utility of a collaborative model of improvement to bring about real change in opioid prescribing practices and may inform quality improvement efforts at other institutions.

Abstract Background The COVID-19 pandemic resulted in unprecedented increases in mortality in the U.S. and worldwide. To better understand the impact of the COVID-19 pandemic on mortality in the state of Minnesota, U.S.A., we characterize the changes in the causes of death during 2020 (COVID-19 period), compared to 2018–2019 (baseline period), assessing for differences across ages, races, ethnicities, sexes, and geographic characteristics. Methods Longitudinal population-based study using Minnesota death certificate data, 2018–2020. Using Poisson regression models adjusted for age and sex, we calculated all-cause and cause-specific (by underlying causes of death) mortality rates per 100,000 Minnesotans, the demographics of the deceased, and years of life lost (YLL) using the Chiang’s life table method in 2020 relative to 2018–2019. Results We identified 89,910 deaths in 2018–2019 and 52,030 deaths in 2020. The mean daily mortality rate increased from 123.1 (SD 11.7) in 2018–2019 to 144.2 (SD 22.1) in 2020. COVID-19 comprised 9.9% of deaths in 2020. Other categories of causes of death with significant increases in 2020 compared to 2018–2019 included assault by firearms (RR 1.68, 95% CI 1.34–2.11), accidental poisonings (RR 1.49, 95% CI 1.37–1.61), malnutrition (RR 1.48, 95% CI 1.17–1.87), alcoholic liver disease (RR, 95% CI 1.14–1.40), and cirrhosis and other chronic liver diseases (RR 1.28, 95% CI 1.09–1.50). Mortality rates due to COVID-19 and non-COVID-19 causes were higher among racial and ethnic minority groups, older adults, and non-rural residents. Conclusions The COVID-19 pandemic was associated with a 17% increase in the death rate in Minnesota relative to 2018–2019, driven by both COVID-19 and non-COVID-19 causes. As the COVID-19 pandemic enters its third year, it is imperative to examine and address the factors contributing to excess mortality in the short-term and monitor for additional morbidity and mortality in the years to come.