Instructions for the Review

Briefings on The Joint Commission May 2015

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Continuing Education Objectives After reading this article, you will be able to:

• Identify the five missions an organization has during an ac-

tive shooter event

• Describe considerations when building a plan for an active

shooter scenario

• Discuss statistics that staff can be educated about to iden-

tify potential active shooter situations

• Discuss the concept of Run, Hide, Fight

Editor’s note: Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, is a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor. Special thanks to Brad Keyes, CHSP, for his assistance with clarifying emergency management requirements in this article.

It feels as if not a day goes by without talking about the need for active shooter planning in pub- lic spaces, including hospitals. This plays into the ongoing need for hospitals to address Emergency Management, Environment of Care, and other safety- related standards and regulations. But where do we look for advice on preparing for what we hope is an incident we will never have to deal with? The Federal Emergency Management Agency (FEMA) and the Assistant Secretary for Preparedness and Response,

Active shooter preparation Training for before, during, and after an emerging event

in conjunction with the FBI and the departments of Health and Human Services, Homeland Security, and Justice, released a report in December 2014 address- ing just that, titled “Incorporating Active Shooter Incident Planning into Healthcare Facility Emergency Operations Plans.”

Active shooter incidents are defined as those in which an individual is “actively engaged in killing or attempting to kill people in a confined and populated area,” according to the Department of Homeland Security.

Healthcare facilities “are faced with planning for emergencies of all kinds, ranging from active shoot- ers, hostage situations, and other similar security challenges, as well as treats from fires, tornadoes, floods, hurricanes, earthquakes, and pandemics of infectious diseases,” the report states. “Many of these emergencies occur with little to no warning; therefore, it is critical for healthcare facilities to plan in advance to help secure the safety, security, and general welfare of all members of the healthcare community.”

So while active shooter incidents can be pooled under the same category as other dramatic incidents of dan- ger, they have their own unique challenges that need to be anticipated (as do all disaster issues). Hospitals need to have plans and procedures for these events, and those plans must be living documents: They must

behavioral health disorder,” says Cooke. “So we know that, at least minimally, a third of the patients we’re treating have a comorbidity.”

In the end, care providers are not just treating a person with diabetes whose eyesight has begun to be affected, or whose legs are in pain. Providers must focus on the emotional and behavioral aspects of care as well as the physical characteristics.

“How do we shift the culture? Through a lot of educa- tion,” says Cooke. “It also takes a serious effort to con- vince politicians that we need to bring back behavioral

health resources and provide improved parity.” Some organizations are starting to establish inte-

grated care models that work to manage both the physical and behavioral needs of the patient. They surely will have better outcomes in the long run.

“We need to get over the denial, ignorance, stigma that surrounds substance abuse and behavioral health disorders,” says Cooke. “We as healthcare providers need to understand and accept the immensity of this issue and how the lack of treatment is affecting our everyday lives and our communities.” H

Briefings on The Joint CommissionMay 2015

9HCPRO.COM© 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

be routinely reviewed and consider all types of hazards, including the possibility of an active shooter or a terror- ist event, FEMA writes.

Law enforcement is perpetually learning about the best way to respond to these events. Hospitals should take cues from such lessons and build those best prac- tices into their own plans.

Disaster planning, for active shooters or otherwise, is a holistic endeavor. It’s not just safety and security personnel who should be involved. Staff, patients, and visitors must also be provided with the education they need to prepare. In addition, special care should be taken to address the following categories of people: • Children • Older adults • Pregnant women • Individuals with disabilities • Individuals who live in institutional settings • Individuals from diverse cultures • Individuals with language proficiency challenges • Individuals without easy access to transportation • Homeless individuals • Patients with chronic medical conditions • Patients with pharmacological dependencies

According to national preparedness efforts, there are five mission areas in readying for a potential active shooter incident: • Prevention: The capabilities necessary to avoid,

deter, or stop an imminent threat. Prevention is the action healthcare facilities take to keep a threat or actual incident from occurring.

• Protection: The capabilities to secure healthcare facilities against acts of terrorism and manmade or natural disasters. Protection focuses on ongoing ac- tions that protect patients, staff, visitors, networks, and property from threats or hazards.

• Mitigation: The capabilities necessary to elimi- nate or reduce the loss of life and property damage by lessening the impact of an event or emergency. For our purposes in reviewing the FEMA report, we should also consider mitigation to mean re- ducing the likelihood that threats and hazards will happen.

• Response: The capabilities needed to stabilize an emergency once it has already happened, restore

and reestablish a safe and secure environment, save lives, prevent the destruction of property, and facil- itate the transition to recovery.

• Recovery: The capabilities needed to assist healthcare facilities experiencing an event or emer- gency in restoring the treatment or therapeutic en- vironment as soon as possible.

These missions align with three temporal frame- works: pre-incident, incident, and post-incident. Most prevention, protection, and mitigation happens before an incident, or consists of modifications made after an event has taken place.

So what are some of the challenges organizations face when preparing for active shooter scenarios? Geography, environment, governance, and population served all factor into this planning. As well, the size of the institution, its setting (e.g., urban, rural, suburban), and specific details about the organization itself (e.g., residential versus non-residential, academic, public, or private) all come into play. Each organization has its own unique environmental and cultural factors it must consider to fully develop its processes.

An effective plan for an active shooter incident includes: • Proactive steps, including training, that can be tak-

en by employees to identify individuals “who may be on a trajectory to commit a violent crime”

• A method for reporting active shooter incidents, such as informing everyone at the facility and any- one who may enter it

• An evacuation policy and procedure • Emergency escape procedures and route

assignments • Lockdown procedures (e.g., units, offices,

buildings) • Integration with the facility incident commander

and external incident commander • Available information about local emergency re-

sponse agencies and hospitals The planning team should consider the following:

• How to evacuate, shelter in place, or lock down pa- tients, visitors, and staff

• How and where to evacuate when the primary routes are unavailable

Briefings on The Joint Commission May 2015

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• How to select effective locations to shelter in place • Training staff in psychological first aid

In addition to the above considerations, healthcare organizations need a security management plan that accomplishes the following: • Provides indications of workplace violence and how

to take immediate remedial actions • Requires employees, medical staff, students, volun-

teers, and contractors to display identification • Creates a culture of vigilance and safety by empow-

ering employees to report unusual, dangerous, or suspicious activity

• Empowers employees who come into contact with individuals who seem lost or unfamiliar with their surroundings to offer assistance

• Provides safe rooms within the setting • Explains how communication occurs when there is

an active shooter in the facility, and when the situa- tion is all clear

• Develops an emergency notification system

Who is an active shooter? There is no singular definition of who fits the profile

of an active shooter. But there are signs and indications that staff can be trained to watch for. Let’s take a look at some key points on pre-attack behavior described in a report compiled by the U.S. Secret Service, the Department of Education, and the FBI titled “Campus Attacks: Targeted Violence Affecting Institutions of Higher Education,” which examined situations involv- ing lethal or attempted lethal attacks on U.S. universi- ties and colleges: • In 31% of cases, concerning behaviors were ob-

served by friends, family, colleagues, etc. These behaviors included paranoid ideas, delusional statements, changes in personality, suicidal ide- ation, “odd” behavior, and many more noticeable traits.

• In only 13% of cases were verbal or written threats made.

• In 19% of the cases examined, stalking or harassing behavior was reported prior to the attack.

• In only 10% of cases did the subject engage in phys- ically aggressive acts toward the targets (e.g., men- acing actions or physical assault).

The FBI has identified behavioral indicators that should be followed up with further investigation by the healthcare facility and by law enforcement. These include: • A developing personal grievance • Inappropriate acquisition of multiple weapons • Recent escalation of target practice or weapons

training • New interest in explosives • Intense interest in previous shootings or mass

attacks • Experience of a significant real or perceived per-

sonal loss leading up to the attack

Run, Hide, Fight Regardless of training or directions, human beings

will react as their instincts tell them to in most danger- ous situations. What hospitals can do, however, is help prepare staff better for an active shooter situation by providing training and letting staff know they should trust that the hospital will make the best decision they can at the time.

“There is no singular definition of who fits the profile of an active shooter. But there

are signs and indications that staff can be trained to watch for.”

—Elizabeth Di Giacomo-Geffers

One danger is that staff or patients will at first deny that an active shooter scenario is happening. This can lead to a delayed response. Train staff to overcome denial and respond immediately. Those who do will be able to call for assistance and lead others with slower reaction times to a safer environment.

Because active shooter incidents are unpredictable and change quickly, staff should be trained in more than one type of response in the Run, Hide, Fight continuum. The goal is maximum survival for all. Let’s take a look at recommendations for staff train- ing in all three of these potential responses to an active shooter.

• Run. Staff should be trained to: – Leave personal belongings behind – Visualize possible escape routes

Briefings on The Joint CommissionMay 2015

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– Avoid escalators and elevators – Take others with them, but don’t stay behind for the sake of others who are refusing to go

– Call 911 when it is safe to

• Hide: If running isn’t an option, staff should be trained to hide in a safe place with thicker walls and fewer windows. This may be the only option for patients lacking mobility, FEMA writes. The report includes the following additional recommended training:

– Barricade the doors with heavy furniture – Specialty care units should secure doors by any means necessary

– Close and lock windows and close blinds or cover windows

– Turn off lights – Silence electronic devices – Remain silent – Look for other avenues of escape – Identify ad-hoc weapons – Use strategies to silently communicate with first responders when it is safe to

– Hide along the wall closest to the exit but out of view of the hallway

– Remain in place until given the all clear by law enforcement

– Barricade areas where patients, visitors, or staff are located

– Transport patients in wheelchairs or stretchers to safe locations

– Identify locations before an incident occurs where patients and staff can be sheltered

The advice provided within the FEMA report does not mention special requirements for healthcare organizations that specifically prevent the locking of doors (standards actually dictate that the doors remain unlockable). When educating your staff, make sure not to simply import recommendations over from a non-healthcare checklist of suggestions— take into consideration specific rules for the health- care setting, particularly around barring or locking doors.

• Fight: Fighting should be a last resort in an active shooter situation. Research shows, according

to the FEMA report, that strength in numbers can be beneficial—studies have shown that potential victims themselves have disrupted 17 of 51 active shooter incidents before law enforcement arrived. That being said, attempting to engage the shooter is never rec- ommended. As the FEMA report states, “to be clear, confronting an active shooter should never be a requirement of any healthcare provider’s job; how each individual chooses to respond if directly confronted by an active shooter is up to him or her.”

Follow-up We have looked at both what to do before an active

shooter incident occurs and what the options are dur- ing such an event. Let’s take a moment to talk about what happens after the shooter is incapacitated and is no longer a threat. Post-event activities can include the following: • A head count to make sure no one is missing and

potentially injured • Working with responders to account for anyone not

evacuated • Determining the best method to inform families of

the event and any associated consequences • Making sure victims have the resources they

need, including care for mental health, following the incident (this includes those who have spe- cial needs, such as those with hearing or sight challenges)

• Planning and activating a family reunification plan and communicating this plan to staff and patients

• Identifying and addressing any key personnel or operational gaps resulting from the active shooter incident

• Determining when to resume full services

All of these items can and should be addressed in your Emergency Operations Plan. H

References: Adashi, E., Gao, H., & Cohen, J. “Hospital-Based Active Shooter Inci- dents: Sanctuary Under Fire.” Journal of the American Medical Associa- tion, Vol. 313, No. 12, March 2015.

Incorporating Active Shooter Incident Planning into Health Care Facil- ity Emergency Operations Plans, 2014. http://www.phe.gov/prepared- ness/planning/Documents/active-shooter-planning-eop2014.pdf

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