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Q&A: Best practices for active shooter response and prevention in hospitals


January 1, 2018

Editor’s note: This Q&A was taken from the January ASHE webinar, “Active Shooter - Best Practices for the Worst Case,” with speakers Kevin M. Tuohey, executive director for research compliance at Boston University & Boston Medical Center; Constance Packard, CHPA, executive director, support services for Boston Medical Center/Boston University Medical Campus; and Thomas Smith, CHPA, CPP, owner of Healthcare Security Consultants, Inc. Here they discuss the unique risks in healthcare facilities, emergency rooms, mental health services, and other treatment facilities, and they address preparedness through operations and design.

Q: Can you tell me how an active shooter incident at a hospital can affect the staff who work there?

Constance Packard: A son came into an institution [Brigham and Women’s Hospital] months after his mother had died and went looking for the cardiologist. He shot that cardiologist and then shot himself. I can tell you a year and a half later that there’s people at that hospital that are still traumatized today. They still talk about it today: the safety, the security, the concerns, and were they ready? These things happen so unprovoked and are unpredictable, but they can happen.

Q: What is the best way to start planning for violent incidents such as active shooters in a hospital?

CP: We go through assessing risk many times and so we're prepared for many things, although it doesn't always go right. If you don't educate and train and communicate to your staff to see how prepared they are, then you could have the worst-case scenario. Doing risk assessments is time-consuming; they're required, but they don't have to be done annually. They could be done more often. This past winter in Boston, where we used to take our homeless people was to a shelter over a bridge called Long Island. Well, the bridge failed, and we had nowhere to put 1,200 homeless men and women each and every day. They ended up near my neighborhood at Boston Medical Center, so going back and reviewing that risk assessment was important. What did those risks bring to the hospital quality of life, dealing with the homeless population and making sure we could give care? We had to have another risk assessment done for that type of change in our environment.

Q: Tell us something about the importance of getting leadership support for conducting drills.

CP: We were doing our first tabletop exercise and then it was going to go into a live-action drill, which was the first time active shooters were being talked about in healthcare facilities. It took us 18 months to plan that drill—law enforcement, clinicians, suspects—a whole lot of work in an outpatient setting, and we were able to close a building down to do it, and lo and behold on that morning, somewhere around 9:30, I got a phone call from the president of the hospital that said “There's been a shooting at a hospital in Baltimore; we need to cancel this drill.” And with all due respect, we're not going to cancel the drill, and I got the leadership to support us. They were concerned that employees would [disrespect] the sympathy and empathy of our colleagues in Maryland and that we were just going to push through and not care about that. That’s not the case. What we did was go with the drill so our employees felt that we were concerned about their safety and we wanted to learn the lessons then.

Q: In your opinion, how important is it to train on a regular basis?

CP: If we did not train as much as we had in the past, we would not have been as prepared for the bombing of the Boston Marathon. Every hospital was affected on that day, and it happened quickly. It was chaotic, we didn’t know how many patients we were going to get, and we didn’t know if they were going to survive. There was a lot that happened on that day, and it was not only on the day of the bombing—on Friday we had the arrest of the terrorists and then weeks and months to follow.
I wouldn’t want to have that event happen and not know who is on my crisis response team. It was very emotional, it was traumatic, and you just didn’t know how we were going to communicate to each other’s hospital when loved ones were separated. Children were at a different hospital, mothers and fathers were separated. People who come to run the Boston Marathon do not know their way around Boston and didn’t even know which hospital they were at, so you need to know your crisis response teams. They will also help you reduce workplace violence.

Q: Who should be trained? Is it only the physicians and nurses in a hospital that should be trained to respond?

Tom Smith: We had a gentleman drive up to the valet parking at our hospital, and the valet attendants had all been trained on observing suspicious behavior and what proper procedures to take when they saw something suspicious. They saw the butt of a sawed-off shotgun in between the seats in the front seat of this patient’s car. The patient went in for his appointment in the urology clinic. This particular hospital had a police department, and the hospital police comes in and found a vest with shotgun shells, and they're not the kind that are used for bird hunting.
In addition to what they found, there were several hundred rounds for a pistol, and so the concern there was that this gentleman was in the clinic with a physician in his appointment; and not knowing what the intent was, they went and visited in the clinic with them, interrupted his appointment, and sure enough he had a concealed weapon with him at the time.
He ultimately got through his appointment, but he was also charged with carrying this weapon. So the point here being in terms of training is that the frontline staff are often the folks that are going to see something unusual and suspicious, and they need to be included in your training programs.

Q: Can you give an example of a low-cost way to help improve a facility’s response to an active shooter situation?

TS: During an event, you’re not going to find a lot of people that are going to be able to direct the law enforcement folks to the location, so you have to have a plan in place. One facility I was at earlier this year identified each door in the facility with a very large number. Typically, when I do assessments, I’m walking around the perimeter to the building. I notice if there's a number on every exit door, and normally it’s the little numbers that you put up there to do your fire inspections, but this was a great big number that you could see from yards away. You could see what number that door was, and that’s very helpful when law enforcement or emergency responders are coming to a door that’s not the main entrance or a door that they’re not used to responding to. So it’s a low-cost type of thing you can do that can help you in lots of things—whether it’s construction or wayfinding or getting people around in an adverse active shooter–type event.

Q: How often should a facility do a hazard vulnerability assessment (HVA)?

CP: We do one annually. I can tell you what started out as fires, floods, and electrical failure now involves workplace violence and terrorism. It is part of a vulnerability assessment; it has to be. We’re seeing it happen at different areas, whether it's these active shooters that happen in malls and movie theaters. You know hospitals are on that list, so if we wouldn't assess where we are in the probability and risk, it would be shame on us.

Q: Any ideas on how to make a drill lifelike?

CP: What we did is we had a unit and it was contiguous to another unit. There were patients right outside that door, but we were lucky enough that it was down for construction and renovation for a few weeks, so we had to get the production crews in 5 a.m. to 5 p.m. to get it done. And the reason why we did it is we wanted it to look as real and as challenging as possible. You can't always do these drills just sitting at the table. You want to see people running in, you want to have the clinician see what it's like to have a person pull a gun on them, and so I took advantage of that situation. I also took advantage of having the law enforcement folks come in to plan with us because when they arrive they don't know where to go; they don't know you. You give them the address, you tell them what floor—some units, the way they're designed you could be going completely into a different building because they're contiguous to each other. So I suggest that if you haven't invited your partnership in yet, bring them in, especially if you have some construction or renovation going on. They want to practice and they want to learn, too. Don’t make it their first time there on the day of a worst-case scenario. I get asked what keeps you up at night—this is it, my friends: workplace violence and active shooters, the worst-case horrific event of losing a colleague and the trauma and emotion that goes with it.

Q: Are there any ideas about how to change the physical environment of a facility to make it safer from active shooters?

Kevin Tuohey: If you’re designing a new space or you're renovating this space, maybe there's a good idea to have a specification in your design plans that says every 10 rooms [there’s a safe room], and maybe that says we're going to have a different kind of hardware, we're going to have a different kind of door. Maybe we’re going to have a different door that allows you to go from the ED into a safe room and then outside the ED into an area that's secure. It’s just food for thought, but it puts it into the design realm, and it makes it a heck of a lot easier when things happen—alternative entries and egress if violence happens in certain areas. It happens in EDs, even though it's now expanding beyond that. If your ED is shut down because of an active shooter, how are you going to get those people that are trying to help in there? When you can't get in, what are your alternative means of getting an emergency responder in?

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