McGuire, Sarayna S.

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.

ABSTRACT Background Older adults experience age‐related physiological changes that alter the pharmacokinetics and pharmacodynamics of certain medications, which may necessitate reduced dosing. Our objective was to assess emergency department (ED) and hospital outcomes of older patients administered opioids by emergency medical services (EMS) clinicians. Methods Retrospective cohort study of adults ≥ 65 years who received an opioid between 2019 and 2024 within a health system‐affiliated EMS agency. We excluded patients with an advanced airway and those with no documented weight. Maximum single and cumulative weight‐based opioid dosages were classified as low, therapeutic, or high. Outcomes were measured in the ED/hospital and compared using Poisson regression with Huber/White standard errors, adjusted for age, sex, vitals, Glascow Coma Scale, emergency severity index, and chief concern. Results were reported as adjusted risk ratios (aRRs). Results A total of 6406 patients, including 747 (11.7%, 95% CI: 10.9–12.5) with a high opioid dose, 3663 (57.2%, 95% CI: 56.0–58.4) with a therapeutic dose, and 1996 (31.2%, 95% CI: 30.0–32.3) with a low dose, were included. Receipt of a high maximum single opioid dose versus a low/therapeutic dose (excluding patients receiving a concomitant sedative) was associated with increased risk of altered responsiveness (aRR = 1.28, 95% CI: 1.03–1.58) and delirium (aRR = 2.43, 95% CI: 1.08–5.45) in the ED/hospital setting. When 311 (4.9%) patients who received a concomitant sedative were included, patients who received a high opioid dose similarly had an increased risk of altered responsiveness (aRR = 1.28, 95% CI: 1.06–1.56) and delirium (RR = 2.65, 95% CI: 1.25–5.59), compared to a low/therapeutic dose. There was no difference in outcomes of hypoxia, death within 30 days, or ED length of stay between dose groups. Conclusion Prehospital administration of high opioid doses to older patients was associated with increased rates of altered responsiveness and delirium. These findings highlight how out‐of‐hospital care can impact a patient's ED and hospital course.

Objectives: To determine the frequency with which emergency medical services (EMS) clinicians recognize patients enrolled in hospice and describe their prehospital management. Methods: Observational cohort study of patients enrolled in hospice who were transported by EMS within a health system between May 5, 2018, and June 4, 2023. Two physicians reviewed each encounter to determine whether interventions were comfort-focused (hospice philosophy) or life-sustaining care. Interrater reliability was 100% (k = 1.0). Descriptive statistics are provided. Results: EMS clinicians identified hospice enrollment in 51% ( n = 46) of 88 encounters. Most patients (90%, n = 79) received comfort-focused care. Life-sustaining care was provided to four patients identified as hospice-enrolled and included cardiopulmonary resuscitation, an advanced airway, and vasopressors ( n = 1, 25%); spinal immobilization ( n = 2, 50%), and naloxone ( n = 1, 25%). Conclusion: Most patients received care consistent with the philosophy of hospice. However, EMS clinicians may have only identified half of patients enrolled in hospice. This demonstrates an opportunity to improve recognition of patients’ care preferences, starting in the out-of-hospital setting.

ImportanceThere 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).ObjectiveTo 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 ParticipantsProspective 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.ExposureExternal ballistic armor being used by a group of self-selected clinicians on every run.Main Outcomes and MeasuresPrevalence 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.ResultsA 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 RelevanceIn 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.

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.