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Hospitals take a stand against violence


June 22, 2017

Facilities that have seen the worst say now is the time to prepare for it

The frequency of violent incidents in U.S. hospitals and the communities surrounding them is increasing faster than the training needed to deal with those incidents. That’s the consensus of hospitals that have treated victims from some of America’s worst tragedies in recent history, including the Orlando Pulse nightclub shooting, the sniper-like shooting and killing of several police officers in Dallas, and the Boston Marathon bombing.

It’s time to start taking the threat for real, according to a series of recent stories in Hospitals and Healthcare Networks (H&HN) magazine, which feature sobering conversations with security and medical personnel from some of the U.S. hospitals that have dealt with such events.

In 2016 alone, there were 385 mass shooting incidents in the U.S., according to statistics from the Gun Violence Archive. More than 1,500 people were injured and 458 were killed in these shootings, which represents an increase of about 24% from just the year before. These events are real, they are frequent, and they don’t always make the national news.

Behind these shootings are first responders and the hospitals that serve the community, and along with every event, there are inevitable stories about overwhelmed ER staff and the need to beef up training to deal with future tragedies. This hasn’t escaped the notice of the American Hospital Association (AHA), which has begun serious discussions about overhauling the way U.S. hospitals deal with mass casualty incidents.

“It was certainly an accumulation of things, but I think the tipping point came as a result of the tragedies and carnage in both Orlando and Dallas,” Melinda Reid Hatton, senior vice president of the AHA, told the magazine. “We asked whether or not we in the hospital community should be doing more to combat violence, both in the community that inevitably ends up on the doorsteps of the hospital, and also violence in our facilities that is inflicted on our colleagues and staff.”

As a result, the AHA has launched perhaps the biggest discussion that hospital leaders in the U.S. have ever had about dealing with violent incidents, the response, and the aftermath. Called “Hospitals Against Violence,” the effort seeks to bring together the AHA’s 5,000 hospital members to share best practices and gain deeper insights into the impact that violence has on hospitals and their patients.

As the threat of an active shooter becomes more and more real, hospitals have been thinking more about the plans they have in place for dealing with such an event.

“Only in the last two years are hospitals talking about [active shooters],” says David Callaway, MD, FACEP, director of operational and disaster medicine at Carolinas Medical Center in Charlotte, North Carolina. Carolinas is one of many hospitals across the U.S. looking at ways to decrease the threats presented by armed intruders, while keeping the overall environment of the facility calm and welcoming—and the staff unarmed. “We are in an environment where underlying violence is considered acceptable. We are expected not only to survive, but turn right around, respond, and treat casualties.”

Despite the shock and terror an active shooter provokes, it’s important to remember that when a shooting occurs in a hospital, the incident can be contained. The hospital can be locked down, first responders can show up and isolate the threat, and a well-rehearsed plan can be executed to help keep patients safe.

But when a shooting occurs outside the doors of the hospital, events can quickly spiral out of control without proper communication and protocols in place. This became quite clear in places such as Aurora, Colorado, where a gunman opened fire in a crowded movie theater and police were forced to drive critically injured patients to the hospitals in cruisers, giving hospital staff very little time to react. In Orlando, the shooting at a gay nightclub happened right outside the doors of the hospital, leading to false reports that the shooter had made his way into the hospital and continued shooting. And in Dallas, at least five police officers who had been shot by a sniper in a parking garage were rushed to nearby hospitals, giving staff extremely short notice of their arrival.

“You would be surprised by how many have the mentality of ‘it won’t happen here,’ or people who truly underestimate the threat of what is capable of happening in their own community—or, for that matter, at their facility,” Dan Birbeck, a captain with the Dallas County Hospital District Police Department, told H&HN. “Some of the places that we go to are more robust and prepared and get the big picture of preparedness, but there are others that are way behind the curve.”

Hospitals are constantly training to prepare for a violent incident—it’s part of the “all hazards” approach of emergency planning, and it’s required by accreditation agencies such as The Joint Commission and CMS. And let’s face it, it’s also crucial from a public relations standpoint to give the impression that your hospital is ready for anything. But that assumes everything that could happen can be trained for.

“Very few hospitals in America have a true mass casualty protocol,” Paul Biddinger, MD, chief of emergency preparedness and head of Massachusetts General Hospital’s Center for Disaster Medicine in Boston, told the magazine. Mass General received an influx of patients after the Boston Marathon bombing in 2013.

“Most hospitals have systems by which they can call surgeons, extra emergency physicians, you name it, but rarely are a whole series of actions embedded deeply across the institution, including their admitting office, their laboratories, their radiology,” continued Biddinger.

It goes without saying that hospitals need to improve their planning when it comes to managing and responding to violent incidents in the community. You may think you have it all down, but facilities who have been there say otherwise. Here are some of the biggest takeaways from their experiences.

Accept that it can happen to you. There’s a sense in certain areas of the country that certain incidents can’t occur—and that’s just not true. While mass casualty incidents tend to happen in larger cities, that doesn’t mean rural communities and hospitals are immune to them. Think of the Planned Parenthood clinic in Colorado Springs that was attacked by a lone gunman in November 2015, or the December 2013 school shooting in Newtown, Connecticut, that killed 26 people, including 20 children. Violence knows no boundaries, and hospitals must be ready, no matter where they are.

You won’t have warning. You may train with your local police and fire department, monitor the emergency frequencies, and have the best communication plans and equipment money can buy. Still, your worst nightmare will occur in the middle of the night, on a holiday, while most of your staff are home sleeping. You must be ready for the unthinkable, and have a plan in place to mobilize the needed people and resources at a moment’s notice.

“With a lot of events, the only warning you get is a victim being brought in the door,” wrote John Hick, MD, an emergency medicine specialist at Hennepin County Medical Center in Minneapolis, in a column in H&HN. “Plan on making do with what you have in-house for the first 30 minutes or so, and make sure that your callbacks are to the people you’re going to need in the early aftermath—the trauma surgeons, emergency medicine, and others.”

Adopt a team culture and drill together. In a crisis, the entire hospital will need to come together, and that includes janitors, security guards, doctors, and interns. If your emergency plan doesn’t include all people, along all departments, then your preparations are seriously flawed. If the staff who are likely going to be present during an emergency aren’t trained in triage, first aid, or the basic aspects of the hospital’s emergency plan, how will they be of use when the walls are falling down around you?

Ensure you have enough resources. Now is the time to figure what you need to have in stock, what is expired, and how you will become restocked in the event of a crisis. How will vendors get to you when the community is in crisis mode and roads are closed? Do you have a mutual aid agreement with other hospitals in town who can help restock you? If you do, what’s your backup plan if those hospitals are busy responding to the same crisis?

Take care of your staff. This is a crucial and often overlooked part of any emergency plan. How will you help your staff, both physically and mentally, in a crisis situation? They may be called on to help out in the most stressful situation they’ve ever encountered, performing triage and making life-and-death decisions. Are you ready with counselors who can help them debrief after the worst has passed? Orlando Health set up counseling sessions for its team members just four hours after the Pulse shooting. In Boston, Biddinger said his facility relies on “micro zoning,” which is the practice of placing a doctor and a nurse in a single ED room to wait for a patient, rather than in a hallway or other open area, so they can focus solely on the patient in front of them instead of the chaos unfolding around them. And in Dallas, Parkland Hospital set up various therapy resources for employees, ranging from casual peer gatherings to formal counseling, to help staff deal with the officer shootings on their own terms.

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