Preparing for the Worst: Active Shooter Events in Hospitals

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By Mary Anne Pazanowski

The June 30 shooting at the Bronx Lebanon Hospital Center in New York that left one doctor dead raises questions about how hospitals can avoid, or try to prepare for, such events.

Little can be done to prevent these incidents, which a recent study shows are increasing in frequency, but hospitals can improve their responsiveness by understanding that a shooting can occur anywhere, at any time, and preparing accordingly, experts who counsel hospitals in how to handle emergency situations told Bloomberg BNA.

David Jarrard, president and chief executive officer of Jarrard, Phillips, Cate & Hancock Inc. in Brentwood, Tenn., and Emily H. Wein, a shareholder at Baker Donelson in Baltimore, told Bloomberg BNA hospitals should start with training employees to recognize and respond to dangers and formulate a comprehensive crisis communications plan.

The two shared tips with Bloomberg BNA on how to address active shooter situations in hospitals—before, during, and after the event occurs.

‘Supremely Difficult’

Preventing an active shooter situation in a hospital is “supremely difficult,” Jarrard told Bloomberg BNA. Hospitals instead must be sensitive to the danger and be prepared to minimize it. Jarrard’s firm provides strategic communications support for health-care industry clients.

Gun-Related Incidents in Hospitals, 2017

The most important thing a hospital can do is to prepare appropriately in advance of any incident, Wein said. Joined by her police officer husband, Wein has given presentations on how to prepare for an active shooter situation in a hospital. She is a Bloomberg BNA advisory board member,

“Extremely difficult events happen” in hospitals every day, so they shouldn’t be surprised when a crisis like an active shooter situation occurs, Jarrard added.

Hospitals should prepare for an active shooter situation much in the same way they would prepare for any other type of emergency, from a communicable disease outbreak to a hurricane or earthquake, the commenters said.

Be Prepared

Personnel throughout a hospital always should be alert to the possibility a violent situation could occur. They should be trained to recognize “clues” leading up to an event, and how to respond appropriately should the situation escalate, Wein said.

Too many—or too shrill—warnings could dilute the sense of urgency, Wein warned. Employees, however, shouldn’t ever be allowed to become complacent. Uncontrollable events occur even in the face of the best-possible preparation, so it is important hospital personnel never adopt a “this won’t ever happen here” attitude, she said.

Jarrard told Bloomberg BNA hospitals’ crisis communications strategy should be in place well in advance of any outbreak of violence, so the hospital can get the story out calmly and in a way that will protect its reputation.

Recognizing the Threat

Preparation starts with recognizing the possible source of a threat.

Shooters often are disgruntled employees, Wein noted. In the Bronx Lebanon case, for example, the shooter was a doctor who formerly worked at the hospital but resigned after being accused of sexual harassment, according to newspaper reports.

Wein declined to address the particulars of the Bronx Lebanon case further, given the lack of details available, but said the situation highlights the need for human resources officers to take seriously any complaint or threat lodged by an employee.

Human resources personnel may be called on to evaluate the gravity and severity of a disgruntled employee’s threat, Wein said. They may be asked whether the person’s nature is such that they could see him or her carrying out the threat, she said.

The human resources and security departments, along with management, should be talking about these individuals. Wein suggested the agenda at management meetings regularly include discussions of potential security threats.

Disgruntled patients and family members of patients also should be on hospital officials’ radar, as they too could present a danger, Wein said. A man whose mother died after being treated at a Boston hospital shot and killed her doctor in 2015, for example.

Heading Off the Danger

The danger posed by “problematic people” may be averted by ensuring the employees who first come into contact with people entering the facility have a means of recognizing them, Wein said. A hospital, for example, could design a database containing information about people who have made tangible threats against the facility, a doctor, or another employee. Photographs and other identifying information could be included in the database, she said.

Wein acknowledged that it’s very difficult in a hospital setting to give the first contacts the information needed to stop a shooter from entering the facility, but it may be possible to provide them with enough data to recognize someone who presents a legitimate threat.

Employees who first come into contact with people entering the facility also should be trained to recognize the “characteristics of an armed person,” Wein said. Potential shooters could be identified by how they are dressed, how they move, or how they are acting.

Train employees to look for people who are dressed inappropriately for the weather, Wein suggested. A person dressed in an overcoat, long sleeves, and long pants during hot weather may be trying to conceal something. Someone walking stiffly, without swinging both arms, could be hiding a long gun or an assault rifle, she said.

Wein suggested that security personnel talk to people who look out of place. Just speaking to a suspicious-looking person could lead the individual to abandon his or her plans, she said.

Training Employees

All hospital employees should be trained in how to respond to an active shooter situation, Wein told Bloomberg BNA. For the most part, these are people who have dedicated their lives to helping others, so getting them on board with the idea that they need to help protect patients isn’t a problem, she said.

Teaching employees the best way to help those patients can be more difficult, and should be the focus of the training program. Law enforcement officers recommend a three-step approach in an active shooter situation, the now-familiar “run, hide, fight” protocol.

Hospital personnel should be trained to quickly get themselves and as many patients as possible as far out of the line of danger as they can, Wein said. If running away isn’t an option, then they should hide, and as a last resort use whatever is on hand to fight.

One of the few reported details from the Bronx Lebanon shooting suggests its employees knew what to do in response to the event. According to newspaper reports, hospital employees told patients to run or hit the floor when they heard the shots, then responded quickly to help the wounded.

First Responders

A good preparation plan also involves law enforcement, Wein said. She suggested engaging with the local police department prior to any emergency. Police officers can assist in teaching employees how to identify possible threats and how to react, Wein said. Police officers also can join hospital personnel in conducting active shooter drills

Hospital management should make certain officers have detailed maps of the facility’s campus showing exits, entrances, and places a shooter could hide, Wein said. Knowing in advance where the shooter is, and how to get there quickly, helps police officers greatly in planning their response.

Identifying one key person who will interact with police officers during the emergency also is important, Wein said. Having one decision maker cuts down on confusion and ensures everyone involved is on the same page, she said.

‘Heart of Community’

Jarrard told Bloomberg BNA a hospital is often the “heart of a community,” and its security concerns will reflect those of the area in which it is situated. How a hospital prepares and responds to a threat, therefore, often is “a civic conversation,” because it affects the whole community, he said. Crisis communications should be designed with the community in mind.

Hospitals should have “very structured” crisis communications protocols, Jarrard said. Put a plan in place that identifies who will say what, and when, in the event of an emergency. Hospitals should conduct “communications drills” to ensure the protocol is followed and works smoothly, he said.

The crisis communications protocol should address social media, Jarrard said. There is no way to control employees’ posts on social media platforms like Facebook and Twitter, Jarrard acknowledged, but most hospitals have social media policies—he pointed to the Mayo Clinic and the Cleveland Clinic as pacesetters in this area. A subset of that policy should address the use of social media during a crisis, he said.

Jarrard urged hospitals to “put on paper” the tone their response will take before an event occurs. The organization should identify whether it will respond in “lawyer-mode,” with a very limited, legally approved statement, or in a more transparent fashion. He favors the latter, arguing that the response should reflect the organization’s culture and personality.

Stick With Who You Are

Expect the hospital to be deluged with requests for information—from the community, the media, and patient and employees’ families—once an event occurs. The response needs to be consistent and “as transparent as reasonably possible,” Jarrard said. It should be delivered in a way that fits the hospital’s “style and fashion,” he added.

Any shift in the hospital’s “personality” could raise concerns, leading people to question the hospital’s response to the emergency, Jarrard said. Communicating in its typical fashion quickly restores “sanity and trust in the organization,” he said.

Sticking with the people who usually communicate the hospital’s messages can help in this endeavor, he said. For example, if the hospital normally uses doctors as spokespeople, it should do so in an extraordinary situation. “Stick with what you know,” Jarrard said.

Still, the organization should speak “with one authoritative voice,” he said. The idea is to instill confidence in all constituencies that the situation is under control. Consistency is key to the communications.

Jarrard also suggested hospitals use “micro-sites” to help get their message out. This can be a “black site” set up in advance and activated only in response to an emergency, or it could be a dark part of the hospital’s existing website. The micro-site would contain as much information about the event as the hospital is able to release, and should have areas where people can ask questions or leave tips. The site performs the role previously filled by hotlines, he said.

Can’t Control Message

Organizations must realize they can’t control the message fully, especially because so much information is delivered through social media, Jarrard said. They can, however, train employees to recognize their responsibility to protect the organization’s reputation before, during, and after an emergency event.

A hospital should address an event immediately after its occurrence, Jarrard said. In the weeks following an event, it should focus on the point that the provider is there for the community, just as it always has been, and that it is taking all steps necessary to protect its patients.

Hospitals should develop messages targeted to each of its constituencies, Jarrard suggested. For example, area doctors may be questioned by their patients about safety at the hospital. The hospital can help them formulate the best response.

Hospitalists, nurses, and other hospital employees will have their own questions about what the hospital is doing to protect them. Management must address their concerns adequately, Jarrard said. Employees will talk about the incident, as well as the steps the hospital is taking, when they go out into the community, he said.

Investigating the Incident

Post-event, hospitals should cooperate fully with law enforcement’s investigation, Jarrard added. Management also needs to “take a hard look” at its active shooter protocols. Some of these may require modification, or disciplinary action may be required.

Management also might need to formally review its hiring practices if the shooter was a disgruntled employee, he said. It should ensure relevant background checks and security procedures are performed for each person hired or granted privileges.

Outside experts could be brought in to review and consult with management and make recommendations for changes, Jarrard said. He suggested conducting a “participatory” process in which doctors, nurses, and other hospital personnel are consulted.

Relatively Few Incidents

Separate studies by Providence, R.I.’s Brown Univerisity and Johns Hopkins University in Baltimore, along with statistics compiled by the Bureau of Labor Statistics (BLS), have found that shooting incidents in hospitals are fairly rare.

Hopkins reported 154 hospital shootings occurred between 2001 and 2011, with 91 taking place inside the hospital and another 43 on the hospital grounds.

According to information the BLS released in 2015, 19 homicides occurred in health-care industry settings in that year, 16 of which involved guns. That was a 46 percent increase over 2014, when seven gun-related incidents were reported, the BLS said.

Brown’s study, however, suggested that homicides in hospitals are increasing. It reported that 241 fatalities occurred between 2000 and 2015. The majority of the incidents took place at hospitals in the southern U.S., it said. The study also found that most perpetrators were men, most killed themselves, and most incidents were spurred by grudges.

The Health and Human Services Department in 2014 released a document requiring health-care facilities to incorporate active shooter plans in their emergency preparedness plans.

To contact the reporter on this story: Mary Anne Pazanowski in Washington at mpazanowski@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com

For More Information

Wein's presentation on preparing for an active shooter situation is at https://www.bakerdonelson.com/emily-h-wein. The BLS's information is at https://www.bls.gov/iif/oshcfoi1.htm#2015. The Hopkins study is at http://src.bna.com/qCO. Brown's study is at http://src.bna.com/qCN. HHS's active shooter guidance is at http://src.bna.com/qCM.

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