Continuing Violence From the Out-of-Hospital Setting to the Emergency Department and Hospital: A Cohort Study on Longitudinal Violence in Health Care

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.