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Research shows that patient violence spans care settings, starting in the out-of-hospital setting, continuing in the ED, and persisting into inpatient units.

More than a quarter of patients who exhibited violent behavior during a multi-setting health care encounter continued the violence in a subsequent care setting, according to study findings published in the Annals of Emergency Medicine.

“Prior literature has demonstrated workplace violence occurs within individual care settings; however, to our knowledge, this is the first study demonstrating longitudinal violence occurring across these care settings,” wrote study author Casey M. Clements, MD, PhD, of Mayo Clinic, and colleagues.

The observational cohort study at a Midwest quaternary academic center, which comprised an ED, hospital, and affiliated emergency medical services agency, examined whether workplace violence by patients follows them through successive points of care. Researchers reviewed all violent incidents recorded between December 1, 2022, and November 30, 2023, across the system’s emergency medical services (out-of-hospital), ED, and inpatient units.

The analysis captured 206 violent out-of-hospital encounters, 868 violent ED encounters, and 3,561 violent non-ED hospital encounters involving 2,251 unique patients. The authors examined rates per 100 encounters and—after adjusting for length of stay—per 10 patient-encounter hours, enabling comparisons across settings with different dwell times.

Aggression Carries Across Care Settings

The researchers discovered that, per 100 encounters, violence rates rose from 0.78 in the out-of-hospital setting to 1.06 in the ED and 6.37 in non-ED hospital settings. Yet after adjusting for vastly different dwell times, out-of-hospital clinicians still faced the highest intensity—18.02 violent events per 10 encounter-hours—versus 0.35 in the ED. Among 2,791 distinct encounters with at least one violent episode, 28.1% of patients carried aggression into a second setting, 12.6% into a third, and 7.5% into a fourth.

The authors underscored the trajectory: “Furthermore, 42% of patients who were violent toward out-of-hospital clinicians continued to be violent in the ED/hospital setting, and 21% of patients had been violent in the ED/hospital setting prior to being violent in a subsequent out-of-hospital encounter.”

Patient Profiles Vary by Encounter Location & Type

The researchers discovered that age profiles shifted with location: median age for out-of-hospital encounters was 40 years, 32 years in the ED, and 54 years in non-ED hospital settings.

“Prior research on our EMS agency’s entire patient population determined risk factors for workplace violence included younger patients and patients in whom substance use/intoxication was suspected or confirmed, with similar observations reported in a prior survey of ED nurses,” the authors wrote, noting that the pattern continued in their findings.

According to the study, patients less than 18 years old had the highest rates of verbal and physical violence. Older inpatients, by contrast, were more often reported for “unspecified aggression, agitation, or disorderly conduct.”

The authors suggested the possible roles of dementia or delirium in such older patient behavior, noting that these conditions affect up to 80% of patients in the ICU.

Reporting Gaps Blur True Picture

Out-of-hospital crews documented violence through a mandatory electronic-record field that, in earlier research, boosted event capture 36-fold, according to the authors. Inside the hospital, reporting is “highly encouraged but not a mandatory documentation feature,” the team noted, and pathways remain “complex and confusing.” They suggested that under-reporting may explain why ED and inpatient rates fell sharply when expressed per hour, and identified electronic, low-burden reporting tools as an immediate opportunity to improve surveillance.

Communication Barriers Hamper Prevention

Longitudinal violence, the authors argued, “may be exacerbated by established barriers in communication between different care settings.”

“These barriers preclude open sharing of knowledge of patients with prior agitation/violence,” the authors wrote, “and prevent creation of safety plans for use across multiple care settings.”

Because family or visitors only accounted for 3.6% of inpatient events—almost certainly an underestimate, according to the authors, who also called for systems that link incidents to non-patient perpetrators.

Care Transitions & Targeted Interventions

“Overall, 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,” the authors concluded. “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.