Administration and Leadership, EMS Insider

Developing a Response Plan for an Active Shooter in a Healthcare Setting


Planning for response to an active shooter event, from both a victim and public safety perspective, began in earnest after the tragedy of the Columbine High School shooting in 1999. In 2008, the Department of Homeland Security issued the guidance of “evacuate, hide out and take action,” which eventually became “run, hide, fight.”

However, guidelines for an active shooter in a hospital, nursing home or other healthcare setting didn’t yet exist. “Run, hide, fight” was 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, while 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.

Defining Active Shooter

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.1

Active shooter is a unique event, and isn’t a suspicious person, hostage situation, a brawl, a murder, suicide or knife attack. The distinction is important, because the response to each 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 event, everyone is at risk while the shooter or shooters are engaged.

A Multidisciplinary Team

In early 2013, the Healthcare and Public Health Sector Coordinating Council, a 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 attorneys, emergency planners, responders, fire and EMS and leaders from law enforcement active shooter training programs.

The team discovered that not only was there confusion about how to prevent, respond to and recover from an event in a healthcare setting, there was also a lack of knowledge by law enforcement about the hazards in a healthcare facility, such as MRI machines, medical gases and hazardous materials.

The team published their consensus recommendation guide, “Active Shooter Planning and Response in a Healthcare Setting,2” in the summer of 2013 and later that fall the federal government released “Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations.”3

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 guide 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, with an anticipated update being released this fall. The new guide will include staff and administrative tools, unified command issues and answers, recovery and behavioral health assessment teams.

Responding to the Event

How do you respond to an active shooter event inside a healthcare facility, and how do you address ethical issues such as abandonment? There’s one fundamental point in an active shooter incident: The fewer people there are in the hot zone, the fewer targets and potential victims. Getting people out of the immediate areas of the shooter is the first priority.

Hiding may not be adequate. “Run, hide and 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’s why it’s important to discuss these options with staff before an incident occurs. It’s also important to remember that whilerun, hide and fight” are three separate options, 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 guidelines recommend using plain language (and, when appropriate, multilingual messaging) to announce what’s happening and what to do. Although some would argue that could cause panic, decades of research on emergency communication have consistently shown that during an emergency, people don’t panic from messaging, but rather don’t respond appropriately because of the lack of guidance. Making sure the message is easy to understand and giving specific instructions can 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 active shooter event is unique, as clinicians, medical supplies and equipment may be available on scene. Understanding how to utilize these assets must be preplanned. This plan should also include discussion about whether victims will be treated at the facility or transported elsewhere.

Although EMS providers are now being introduced to warm zone operations, medical staff are not. They could be a welcome asset during an active shooter event. It’s also important to understand the layout of the building or campus, hazards and command center locations.

EMS and healthcare providers must also remember that during a large-scale attack, prehospital agencies from outside the service may respond. Those agencies must also be a part of the planning and training process, and they should have copies of plans, contact information, maps, communication and access information.

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 assure our caregivers have the necessary resources to continue to do the great work we do.


1. Blair J, Schweit K. A Study of active shooter incidents, 2000–2013. Federal Bureau of Investigation, U.S. Department of Justice: Washington, D.C., 2014.

2. International Association of EMS Chiefs. (January 2017.) Active shooter planning and response in a healthcare setting. Retrieved May 25, 2017, from

3. U.S. Department of Health and Human Services. (November 2014.) Incorporating active shooter incident planning in to health care facility emergency operations plans. Retrieved May 25, 2017, from