Planning for response to an active shooter event, from both a victim and public safety perspective, began in earnest after the tragedy of Columbine High School in 1999. In 2008, the Department of Homeland Security (DHS) issued the guidance of “Evacuate, Hide Out, and Take Action,” which eventually became “Run, Hide, Fight.” However, the guidance of what to do when the active shooter was engaged in a hospital, nursing home or other healthcare setting did not exist.
Run, Hide, Fight was widely thought to be too harsh, especially with a vulnerable patient population, and worries of abandonment, ethics and possible criminal charges confused the matter. Some healthcare facilities ignored it; others made policy requiring staff to stay with patients. Others allowed staff to decide if they wanted to stay or leave. None of it, however, was evidence based, or included experts to help design a solution.
To design an active shooter response plan, you first need to define what an active shooter is. An active shooter event, as defined by the FBI, is one or more individuals engaged in killing or attempting to kill people in a populated area. Between 2000 and 2013, there were four active shooter incidents in healthcare facilities, resulting in 10 killed and 10 wounded.
Active shooter is a unique event, and is not a suspicious person, hostage situation, a brawl, a murder, suicide or knife attack. The distinction is important, because the response is unique. For example, during an event with a knife, barricading may be more feasible than during a firearm attack. For a hostage event, cordoning the area and evacuating nearby people may be a plan of action. During a murder or murder suicide, there may be no further threat. During an active shooter, everyone is at risk while the shooter or shooters are engaged.
In early 2013, the Healthcare and Public Health Sector Coordinating Council, part of the Critical Infrastructure Partnership Advisory Council, formed a multidisciplinary team to look at active shooter response in healthcare. The team was comprised of federal, state and private sector partners including clinicians, law enforcement, civil rights activists, attorneys, emergency planners, responders, fire, EMS and leaders from law enforcement active shooter training programs. The team discovered that not only was there confusion in how to prevent, respond and recover from an event in a healthcare setting, but there was a lack of knowledge by law enforcement of the hazards within a healthcare facility such as MRI machines, medical gases and hazardous materials.
The team published its consensus recommendation guide “Active Shooter Planning and Response in a Healthcare Setting” in the 2013, and later that same year, the federal government released “Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations.” In 2015, the team released an updated version of the Planning and Response Guide, which is available on the FBI active shooter website. The updated guidance includes a section for law enforcement responders, including tactics, crime scene operations and interoperability, as well as a section on behavioral health support. The team has committed to reviewing and updating the guidance annually and is currently meeting now, with an anticipated release this fall. The new guide will include staff and administrative tools, unified command issues and answers, recovery and behavioral health assessment teams.
So how do you respond to an active shooter event inside a healthcare facility, and how do you address ethical issues such as abandonment? There is one fundamental point in an active shooter incident: the fewer people in the hot zone, the fewer number of targets and potential victims. Getting people out of the immediate area of the shooter is the first priority. Hiding may not be adequate. Run, Hide, Fight is the recommendation for the immediate areas where the shooter is located. This may mean leaving patients behind, some of whom may not be able to evacuate themselves. It’s a life and death decision, and that is why it’s important to discuss these options with staff before an incident occurs.
It’s also important to remember that run, hide and fight are three separate options, and you may use more than one of them in the course of the event. For the rest of the healthcare facility (outside of the shooter’s location), locking down the unit is imperative, and not an easy thing to do. Knowing how to barricade doors without locks takes practice and planning. Those units should also monitor the situation and prepare to run if the shooter enters their immediate area.
What about ambulatory patients, visitors and contractors? The guidance recommends using plain language (and when appropriate, multilingual messaging) to announce what is happening and what to do. While some would argue that this could cause panic, decades of research on emergency communication have consistently showed that during an emergency, people do not panic from messaging, but rather don’t respond appropriately due to the lack of guidance. Make sure the message is easy to understand and give specific instructions to help save lives, such as “There is an armed intruder on 6 East. Everyone on 6 East should evacuate to another floor, and follow the instructions of staff. All others should stay away from 6E and follow staff instructions.”
The EMS response to a healthcare facility active shooter event is unique, as clinicians, medical supplies and equipment may be available on the scene. Understanding how to utilize these assets must be preplanned, and questions of whether the victims will be treated at the facility or transported elsewhere should also be pre-planned. While EMS providers are now being introduced to warm zone operations, medical staff are not. They could, however, be a welcome asset during an active shooter event.
EMS and healthcare providers must also remember that during a large scale attack, prehospital agencies from outside the service are may respond. Those agencies must also be part of the planning and training process, and they should have copies of plans, contact information, maps, communication, and access information. It’s important for all EMS units to understand the layout of the building or campus, hazards and command center locations.
Finally, behavioral health response needs to be planned before the incident, and needs to start as soon as the shooting has stopped. Mental health recovery can be a long-term process for EMS and healthcare providers, and having a coordinated response can ensure that our caregivers have the necessary resources to continue to do the great work we do.
Scott Cormier, NRP, CHEP, serves as vice president of emergency management, environment of care, and safety for Medxcel Facilities Management, and is a member of the board of directors of the International Association of EMS Chiefs.