On January 20, 2026, the American Hospital Association joined nine other organizations, including the National Rural Health Association, the American Medical Group Association, and the American Nurses Association, in urging CMS to issue clear guidance on the use of signage meant to discourage threats and acts of violence against healthcare workers in emergency departments, while remaining consistent with the Emergency Medical Treatment and Labor Act (EMTALA).
In their letter, the organizations describe violence in emergency departments as a daily reality for many clinicians, noting that emergency physicians, nurses, and other staff “routinely experience physical assaults, verbal abuse, and threats on an almost daily basis while delivering care.” As a result, the letter warns, many are leaving a workforce that is already under strain.
Federal workplace safety agencies have long recognized that healthcare workers, like law enforcement officials and workers who handle cash transactions, are at elevated risk of workplace violence. That risk has recently been poignantly portrayed in popular medical dramas, including HBO’s The Pitt.
What such fictional portrayals do not fully convey is how little formal guidance exists for hospitals navigating these situations in real life. While The Pitt’s characters move decisively through an emergency department marked by signs declaring that “Aggressive Behavior Will Not Be Tolerated,” real-world hospitals must navigate overlapping and sometimes unclear federal regulatory requirements.
The Occupational Safety and Health Administration defines workplace violence broadly as “any act or threat of physical violence, harassment, intimidation, or other threatening behavior that occurs at the worksite,” but notes that there are currently no OSHA standards specific to workplace violence.
By contrast, EMTALA sets out specific obligations for Medicare-participating hospitals with dedicated emergency departments. The statute requires hospitals to provide an appropriate medical screening examination to individuals who come to an emergency department seeking care and, if an emergency medical condition is identified, to provide stabilizing treatment or an appropriate transfer. In that context, signage declaring “zero tolerance for abuse” or warning that aggressive behavior will result in removal from the premises may be interpreted as discouraging individuals from remaining for evaluation or treatment, which could raise concerns about compliance with EMTALA’s requirements.
In prior correspondence cited in the January letter, CMS staff have indicated that hospitals may post signage only if they can demonstrate that it would not deter individuals from remaining for evaluation, while declining to define what constitutes a deterrent.
That uncertainty, the organizations write, has practical consequences. Hospitals seeking to protect frontline staff are often left to rely on “their best guess” as to whether signage will be viewed as EMTALA compliant, with enforcement varying across surveyors and regions.
The January request builds on earlier concerns about emergency department signage. In 2019, the Missouri Hospital Association cautioned its members against posting “zero-tolerance” signage related to violence, and in 2013, a CMS regional official warned that posters intended to deter inappropriate opioid-seeking behavior could be viewed as coercive or intimidating and potentially inconsistent with EMTALA.
The signatories to the letter argue that, absent additional clarification from CMS, hospitals will continue to operate within a framework shaped largely by enforcement history and informal signals rather than clear, prospective rules. In their view, “clear, practical guidance from CMS on permissible emergency department signage would be a meaningful step toward” supporting both EMTALA compliance and safer workplaces.