Ten major provider organizations are asking the Centers for Medicare & Medicaid Services (CMS) for guidance on how they can post signs discouraging violence against healthcare workers in the ED without running afoul of federal law.
Sent Tuesday, groups including the American Hospital Association (AHA) and the American College of Emergency Physicians (ACEP) highlighted an escalation in physical and verbal attacks during recent years. Such events may occur in the ED “on an almost daily basis” and threaten to further reduce the healthcare workforce due to burnout-related departures.
But amid various investments and programs for workplace violence prevention launched by hospitals, the groups said “the most basic element of prevention is often out of reach—that is, signage that sets expectations for respectful behavior and emphasizes that violence toward staff, patients or visitors is unacceptable and could have consequences.”
The issue, they wrote, is ambiguity in the agency’s expectations under the Emergency Medical Treatment and Labor Act (EMTALA).
The law, and the government watchdog that enforces it, discourage signage in the ED that could push patients in need of medical screening or stabilizing treatment out the door. The CMS has previously said additional signs could be posted in the ED if hospitals can show they wouldn’t deter such care.
“But when pressed for clarity of what could, and could not, be considered a deterrent, CMS has thus far declined to provide further explanation and overarching guidance, and instead stated that potential EMTALA violations are considered on a case-by-case basis,” the letter reads.
“This essentially forces hospitals who want to protect vulnerable frontline staff to take a leap of faith in posting signage that is their ‘best guess’ as compliant,” it continues. “Further confusing the issue, enforcement to date has been uneven, with hospitals reporting that surveyors sometimes question or cite even neutral workplace violence signs as potential EMTALA violations.”
The groups requested the CMS issue clear written guidance—such as a Quality, Safety & Oversight memo or an interpretive guidance update—on the issue that includes examples of acceptable workplace violence signage for the ED. They also asked that such clarifications be shared with surveyors and accreditors.
“Clinicians and staff must be protected from violence while they fulfill those obligations,” the groups wrote. “Clear, practical guidance from CMS on permissible ED signage would be a meaningful step toward that goal.”
Organizations that signed onto the letter were as follows: the AHA, the ACEP, the American Medical Group Association, the American Nurses Association, the American Psychiatric Association, the American Society of Health-System Pharmacists, America’s Essential Hospitals, the Children’s Hospital Association, the Emergency Nurses Association and the National Rural Health Association.
Healthcare workers bore the brunt of workplace violence ahead of the pandemic, accounting for about three-quarters of all U.S. nonfatal violence-related occupational injuries and illness even before a pandemic escalation.
A report released last summer estimated that the healthcare system bears a roughly $79 million burden due to healthcare workers missing work following injury due to violence. It also pointed to another $541 million of staffing-related costs for hospitals stemming from the nonphysicial effects of violence exposure such as emotional trauma, stress, burnout and decreased morale. Specifically, that nonphysical total comprised $139 million from employee absenteeism, $184 million due to worsened productivity and $218 million due to increased turnover.
More broadly, hospitals were estimated to spend $1.4 billion annually training their workers for violence preparation, $404 million on security personnel and related staffing, $59 million from investments in monitoring technologies and $306 million in other facility modifications tied to violence prevention.