The first time that Rita Manfredi, MD, FACEP, was assaulted in the emergency department (ED), she was five months pregnant. The emergency  physician ducked her chin to her chest just in time to avoid being kicked in the throat by an agitated female patient who was wearing heavy boots and sitting between two security guards. “I walked out of the room on these very jelly-filled legs and said, ‘I think we need some help in there,’” Dr. Manfredi recalled. The hospital, however, never followed up on the incident.

Dr. Manfredi

About four years ago, an even more distressing incident in a Washington, D.C.-area ED left her and colleagues badly shaken. A very large, mentally disturbed male patient who had been in a car accident rolled off the stretcher onto the floor. Dr. Manfredi helped several nurses try to get the patient back onto the stretcher. “The next thing I know I get smashed into the wall, and then the other nurses around me also got pushed back,” she said. The staff called for security officers, who stood in the doorway and failed to intervene.

About 10 minutes after the medical team calmed the patient and moved him to a resuscitation bed, he again pushed two nurses and then punched a physician assistant in the face after ripping his stethoscope in half. Summoned security officers again remained on the sidelines, and the ED team managed to regain control only by sedating the patient. This time, the team got lawyers and department heads involved; even so, the case was never resolved.

Much of the violence in EDs tends to be blamed on untreated mental illnesses or substance use disorders, Dr. Manfredi said. “But what is truly unspeakable and unforgivable is the system not providing some kind of safety for the [emergency care teams and staff]. That’s where the hang-up is, and that’s truly a bigger problem in emergency medicine now,” she said. “The system is failing us.”

An All-Too-Common Occurrence

Health care workers suffer more injuries from workplace violence than any other profession, reflected by a 2024 poll of ACEP members in which 91 percent of ED physicians reported that they or a colleague were the victim of violence within the previous year. Episodes of violence in which security officers fail to intervene is part of a troubling pattern, according to a majority of ACEP members (68 percent) who described their employers’ response in a recent poll as inadequate.

Jonathan Nover

The problem is also acute for ED nurses, who typically spend more time with each patient. In a 2024 survey of 999 nurses conducted by the Emergency Nurses Association (ENA), 20 percent reported experiencing physical violence within the previous two weeks, while more than half were subjected to verbal abuse, including insults and threats of violence. “I’ve had colleagues and team members that have been assaulted so bad that they could no longer practice as a nurse or required hospitalization,” said Jonathan Nover, MBA, RN, who worked as an ED nurse for two decades before assuming a leadership position at a New York City health system.

Dustin Bass

“It becomes this world where you have to be aware of your surroundings constantly,” said Dustin Bass, DNP, MHA, RN, president of the ENA and vice president of System Emergency Services at ECU Health in Greenville, North Carolina. That means always anticipating the potential for agitation or violence. One demand in the month-long nursing strike in New York City, in fact, was better protection against workplace violence. “I think it’s becoming harder and harder for a hospital or health system that didn’t want to address this to be able to continue to not address it,” said Jeffrey Rabrich, MD, president of New York ACEP and an emergency  physician in the Hudson Valley. “It’s at the forefront of everyone’s mind now.”

Dr. Rabrich

In its April 2025 research report, “Strategies for Sustaining Emergency Care in the United States,” the Santa Monica, California-based RAND Corporation — with support from the Emergency Medicine Policy Institute — found that the rise in violence from patients and family members is “pervasive” and a major contributor to ED staff attrition.¹ “Increases in demand and insufficient capacity can lead to ED crowding, boarding, longer wait times, and sometimes violence toward ED staff. These factors can also compromise the quality of care and can lead to burnout, moral injury—negative psychological, social, and spiritual effects—and attrition among emergency care health workers,” the report states.

Dr. Reeder

North Carolina State Rep. Timothy Reeder, MD, (R-Ayden), an associate professor of emergency medicine at East Carolina University in Greenville and ACEP member, said violence can contribute to both poorer patient care and job satisfaction. “It diverts our attention from the patients that we’re taking care of, not just the one who might be angry, but everybody else,” he said. “One of the big predictors of burnout is loss of control and if you’re unsafe in the environment, I believe that certainly contributes.”

To help mitigate the problem, the 2025 RAND report found strong support for two strategies: enforcing anti-violence policies in hospitals and enacting state or federal laws that increase the legal consequences for violence directed at health care workers. Those and other potential strategies, emergency physicians and nurses said, have been undermined by a lack of resources to institute deterrents such as metal detectors and security guards, as well as poor enforcement of existing policies and inconsistent guidance from regulatory agencies.

Better Reporting, Harsher Penalties

As chair of the New York ENA Government Affairs Committee, Nover played a key role for ENA, in a joint effort with NY ACEP, to pass a state law called the Workplace Violence Prevention for Health Care and Social Services Workers Act.

The act, signed into law in December 2025, and scheduled to take effect in September 2026, mandates programs to include annual workplace safety assessments that adhere to regulatory requirements established by CMS and security presence in EDs. The Act also requires hospitals to create workplace safety committees, develop violence safety plans, and share data. For EDs in catchments of more than one million people, the law requires an off-duty police officer or trained security guard to be onsite at all times, while smaller hospitals must at least have security officers in the hospital who are available to respond to ED incidents.

“This is a tremendous gain,” Nover said.

The law is the latest in a series of victories that ACEP and ACEP chapters have spearheaded to confront the crisis of workplace violence in EDs. In 2025, Ohio ACEP advocated for the passage of HB 452, aimed at preventing hospital violence, enhancing training, improving incident tracking and reporting, and strengthening security plans for emergency department staff. The law was passed by Ohio Governor Mike DeWine in April 2025.

New York ACEP, Dr. Rabrich said, would eventually like to see mandated weapon screening and restricted access at all facilities, as well as a permanent security presence in EDs, regardless of size. Although the association recognizes the costs involved, he said, the goal is to have uniform safety standards — perhaps facilitated through state or federal grants.

In North Carolina, the Hospital Violence Prevention Act, which went into effect on October 1, 2024, requires all hospital EDs to have at least one armed law enforcement officer onsite or to apply for an exemption. Some of the pushback suggested that violence was a bigger issue in larger facilities, said Rep. Reeder, the law’s sponsor. “What I argued was that those big institutions, the trauma centers, they actually have more staff and are more equipped to do this,” he said. “What I’m worried about is the 10-bed critical access hospital where there is no security.”

Dr. Casaletto

Jennifer Casaletto, MD, an emergency physician in Charlotte, North Carolina, and an ACEP board member, said violence in the ED became a greater concern after she moved from a large academic trauma center with a responsive hospital security force to a smaller freestanding ED in 2010. “As we went through that decade, the threats and violence became more prevalent,” she recalled. After several “pretty egregious episodes,” the facility failed to respond while the police informed the on-duty nurses that pressing charges for assault would require them to leave the hospital and come to the precinct mid-shift. 

The new state law, informed by ACEP members such as Dr. Casaletto and backed by the state’s chapter, also requires hospitals to collect and report data on violent incidents and makes assaults that cause physical injury to hospital and medical practice personnel a Class I felony.

The reporting requirement could overcome the reluctance of many hospitals to voluntarily detail violence that may reflect poorly on their institutions. “Nobody wants to put their own dirty laundry out there,” Dr. Manfredi said. As Dr. Casaletto and other doctors pointed out, however, the problem is nearly ubiquitous. “I think one of the big things that we all need to realize — hospitals included — is that this is not unique to one hospital, to one type of hospital, to a state, to a region and not even truly specific to a type of patient,” Dr. Casaletto said.

Dr. Rabrich said reporting could take the form of anonymized data to avoid singling out any one institution. To make informed decisions about violence prevention and enforcement, however, he maintained that data from every institution are necessary to clarify the patterns and magnitude of the problem. Advocates are also pushing for federal requirements that would make violent incidents reportable safety events. “We do that with medication errors, and we do it with falls; we do it with hospital quality issues,” Dr. Bass said. Similarly tracking violence could help point out where interventions are most needed. 

Increasing penalties for assaulting health care workers, as North Carolina and other states like New York have done, could provide another important deterrent. At the federal level, ACEP and ENA have advocated for the Save Healthcare Workers Act, introduced in the U.S. House and Senate in May 2025. Mirroring protections for airport and airline workers, the law would make assaulting hospital personnel a federal crime and institute harsher penalties for assaults during a public emergency or under certain other scenarios. Some critics have worried that harsher penalties could effectively criminalize mental illness, but Rep. Reeder noted that ED workers have expertise that could be tapped by law enforcement to help distinguish between a patient who becomes violent due to an underlying condition such as dementia and someone who is “truly volitional” in their actions. ACEP also maintains a state legislative dashboard to keep up on regulatory issues, including those designed to protect health care staff safety.

Sharing Best Practices

At New York ENA conferences, attendees have shared best practices and reported using everything from facial recognition software and AI-based weapons detection software, to panic buttons that can be worn or positioned at nursing desks. Nover conceded that many of the tools are expensive (while Dr. Manfredi warned that metal detectors aren’t infallible). Through their Workplace Violence Prevention Alliance, however, the New York ENA and ACEP chapters and collaborating associations have created a toolkit that health care workers can access to review best practices, such as effective anti-violence signage and de-escalation tactics. More EDs are also conducting simulations. “We practice caring for cardiac arrest; we do mock codes. A lot of institutions now are doing mock codes for an aggressive patient or a violent patient,” Nover said.

ACEP continues to embrace initiatives to address the problem, most recently, teaming with a coalition of health care organizations to call on CMS to issue guidance that facilitates posting signage in EDs discouraging violence, and developing a checklist to guide emergency physicians in conversations about violence prevention with colleagues and hospital leaders.

Despite the remaining challenges, several doctors said they’ve seen signs of progress and feel more supported by their workplaces. A few years ago, after a patient took a swing at Dr. Casaletto but missed, her hospital followed up on the ED incident report by offering her counseling and support the next morning, as well as asking whether she wanted to file a police report, needed help in doing so, and needed time off work to recover. Although she didn’t need any help that time, Dr. Casaletto was so surprised that she called back to express her gratitude.

The No Silence on ED Violence campaign, launched in 2019 by ENA and ACEP, is helping to raise awareness and encourage more open discussion about the phenomenon and its potential solutions. For victims of violence, ACEP also has created a peer-to-peer support network, which allows ED physicians to talk with a peer in the aftermath of an incident — support that Dr. Manfredi said she wishes she had received years ago. She said she now believes that ED violence requires a multifactorial, top-to-bottom strategy, including an emphasis on treating people with compassion and kindness. “I think we should try everything,” she said. “I’ve been working with folks in wellness and wellbeing for many years, and we’re not going to give up on it. We’re just going to keep trying different things.”

Bryn Nelson is a freelance medical journalist based in Seattle.

Reference

1. Abir M, Briscombe B, Berdahl CT, et al. Strategies for sustaining emergency care in the United States. RAND Corporation. Apr 7, 2025. https://www.rand.org/pubs/research_reports/RRA2937-1.html