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 Experts Urge Health Care Centers to Plan for Shootings They Hope Will Never Happen

Fortunately, gun violence is rare in nursing centers and other health care communities. However, it happens.
Earlier this week, while administrators and others nationwide were participating in an “Active Shooter Preparedness Update” webinar, there was a shooting death at a hospital in New Hampshire. A man killed his mother who was in the Intensive Care Unit. More than one shot was fired, although no one else was injured. The son was later arrested.
“When we hear about another active shooter situation, we are saddened but no longer shocked,” said Steven Crimando, MA, BCETS, CHS-V, a nationally recognized expert on active shooter incidents, who spoke at the webinar supported by Everbridge, a security and communication firm based in California and Massachusetts.
Today, he noted, “There is a steady drumbeat of active shooter situations. The possibility of an active shooter incident is no longer a question of if, but rather when and where.”
Hospitals and other health care settings present unique challenges in shooter planning and response. Yet, planning, training, and having a staff that is confident about their abilities to function swiftly and effectively during such an emergency can mean the difference between life and death.
A shooting is shocking anywhere, but it is especially disturbing in a health care facility, which is supposed to be a place of warmth and caring. As these facilities are busy places, with staff, practitioners, family, vendors, and others coming and going constantly, a shooting incident could produce many casualties.
It is important to understand the difference between an active shooter and a shooting incident. An “active shooter,” said Crimando, generally “describes a situation in which a shooting is in progress, and an aspect of the crime may affect the protocols used in responding to and reacting at the scene of the incident.”
The U.S. Department of Homeland Security defines the person doing the shooting in these situations as “an individual actively engaged in killing or attempting to kill people in a confined and populated area.” The shooter is generally prepared to injure and kill as many people as possible, and he or she often has planned this for months or even years. Nearly three-quarters of these situations are over in five minutes or less, said Crimando, and 60 percent end before law enforcement arrives.
A shooting incident, on the other hand, tends to be unprepared and is often an opportunistic or angry reaction to a disagreement or other trigger. These shootings usually are directed at a specific person, such as a spouse, other family member, or a practitioner or staff member the shooter blames for a loved one’s death. However, this isn’t to say that others can’t get caught in the crossfire and injured or killed.
“There is no single method to respond to an incident, but prior planning will allow you and your staff to choose the best options—with the goal of maximizing lives saved,” said Crimando. “The best way to save lives is to remove potential targets from the shooter’s vicinity.”
He pointed to a recent study suggesting that many health care workers think doctors and nurses have a special obligation to protect patients, especially those who are vulnerable and nonambulatory, “even if it means endangering themselves.” However, he referred to a national survey showing that 76 percent of the public and 92 percent of health professionals thought that doctors and nurses should have a personal choice about whether to try and save patients’ lives in an active shooter situation.
The Occupational Safety Act of 1970 mandates that, in addition to compliance with hazard-specific standards, all employees have a “general duty” to provide employees with a workplace free from recognized hazards likely to cause death or serious physical harm. Then, late last year, the Occupational Safety & Health Administration (OSHA) published a request for information in support of a new standard on workplace violence in health care and social service organizations. Crimando said, “This may be OSHA’s first attempt at a workplace violence prevention law.”
In the meantime, he suggested, “From a litigation standpoint, in a shooting event, questions come up quickly: ‘Did you have plans? Were people trained? How?’ It’s important to have a strong, tested plan and to train people fully.”
Nursing centers and other long term care settings, Crimando said, tend to be targets of mercy or grudge killings or domestic violence. However, they still should be prepared for all types of shooting situations. All facilities are unique, so there is no cookie-cutter or one-size-fits-all plan.
imando suggested that facilities start with a fundamental knowledge of recommended response strategies such as Run>Hide>Fight. The question, he said, is when to run, when to fight, and when to hide. “A lot of hospitals have adopted a strategy that they should do everything possible to protect patients but also protect themselves,” said Crimando. He suggested the need for a more expansive model that addresses active shooter planning. He called this, “Stop the Killing, Stop the Dying, Stop the Crying
rimando noted that staff serve as first on-scene responders and need to be trained for this role. “We teach run, hide, or fight as a correct option but not in a linear, sequential way.” Generally, fight should be the last resort. However, Crimando said, “In certain scenarios, your best option might be to fight. People can and do stop shooters.”
Stop the Killing is whatever variant of run, hide, fight that is most effective in a particular circumstance, he said. The key is to train leadership and staff to give them the confidence to make decisions and act as quickly and as safely as possible.
Stop the Dying requires that staff and others have the training, skills, and knowledge to control bleeding and provide emergency care while waiting for first outside responders to arrive. Finally, Crimando said, “Stop the Crying doesn’t mean that you don’t cry. Of course, you should cry. But in the moment of terror, emotional reactions can make someone part of the problem instead of the solution—putting them and others at risk.”
Communication throughout is key, Crimando said. “There’s no better way to foil a shooter than to take away targets. One best way to do this is by rapid communication. You need to have communication templates, technology, and other tools at your fingertips. There will be no time for thinking or innovation when a shooting happens.”
He added, “Make sure your messages are customized, not created in a vacuum.” He suggested moving away from codes because nonemployees may not understand them. Finally, he said, “Verbal active shooter alerts should be provided by a voice of authority and pushed out everywhere you can.”
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