Hospitals need to run active shooter drills, security experts say

Health systems should develop response plans, and they should make sure staff know what to do in an emergency.

About once a week, there’s an active shooter incident in America.

The FBI said 61 active shooter incidents took place in 2021, more than twice as many as in 2017. The FBI defines an active shooter as someone who is killing or trying to kill people in a populated area.

While it’s a chilling topic, security experts say hospitals and health systems need to train their staff in responding to active shooters.

Hospitals have seen too much violence, and doctors and nurses say attacks on staff are rising. A nurse and a social worker were fatally shot in Methodist Dallas Medical Center in October. Authorities said the suspect was beating his girlfriend, a patient who had just had a baby, and shot the social worker who tried to intervene and the nurse who responded after hearing the firearm.

Four people were killed in a shooting at a medical building on the campus of the Saint Francis Health System in Tulsa, Okla. in June. Authorities said the suspect was angry about postoperative pain. Two doctors, a receptionist and a patient were killed.

Staff need to know how to respond in such situations, said Paul Sarnese, assistant vice president for security at Virtua Health in New Jersey.

“Organizations have to have fire plans, you have to have a plan for surge … You also have to have an active shooter response plan,” said Sarnese, former president of the International Association of Healthcare Security Systems.

Sarnese and John Demming, director of operations at HSS, a healthcare security services firm, led an online discussion Nov. 4 on how hospitals should train and respond to active shooter incidents. The Johns Hopkins Medicine Alumni Association sponsored the discussion.

Here are some of the highlights on training and responding.

Developing plans

First, healthcare organizations need to develop their response plans. Organizations that have never held a training exercise for an active shooter shouldn’t start with a live drill, said Demming, who leads security at 30 hospitals in Texas.

Hospitals that have just developed their response plans but have never done an active shooter drill should start with a tabletop exercise, Demming said. If organizations run a live drill without having good response plans in order, Demming said, “It’s going to be, for lack of a better word, a calamity.”

“It’s good at scaring people and letting them know how unprepared they are, but I don’t think it’s an effective preparation tool,” Demming said.

Organizations that haven’t crafted such plans can reach out to the International Association of Healthcare Security Systems, which has developed active shooter response plans. They can also reach out to other health systems.

“Organizations are not by themselves here,” Sarnese said. “We all steal shamelessly from each other.”

Train regularly

Active shooter training shouldn’t be an annual exercise administered over an employees’ laptop. The drills should be simulations done regularly, so staff learn what they need to do in such an emergency.

“Muscle memory is only built by exercising muscle,” Sarnese said.

It’s vital to get staff to take the training seriously. Sometimes, doctors are the ones that “may not take it seriously as we’d like,” Sarnese said.

In Virtua’s drills, staff that don’t respond properly can receive cards that say this was an exercise, but they would likely have been hurt in a real incident, Sarnese said.

Organizations need to develop and train down to the department level, from the pediatric unit to the emergency department, the experts said.

Health systems should inform authorities about drills, and should consider having police and other emergency responders involved with the drill.

Staff and patients also need to be notified. At Virtua Health, patients receive notes with their meal trays to advise them that a drill will be taking place in the next day or so.

“If you’re going to do an exercise, it has to be announced,” he said.

Using plain language

Hospitals often use codes to describe certain threats, such as “code silver,” the experts said.

Some health systems are moving to using plain language in emergencies, Demming said. He thinks that’s a better solution, because hospitals need to make patients and visitors aware of an active shooter, not just the staff. Everyone in a certain section or office may need to leave.

When systems use plain language, Demming said, “It elicits a completely different response.”

Run, hide, fight

Organizations can develop different response plans, but if there’s an active shooter, systems need to get ambulatory patients out and staff need to run.

“As soon as you hear an active shooter, get out if you can,” Demming said.

Staff shouldn’t try to coax others who are hesitant to leave. “Do not stay to convince others to follow you,” Demming said. “Get yourself out.’

When officers arrive and advise staff to run, those nurses and doctors need to get out, Demming said, even if that means leaving someone behind who is injured.

“Do not stop to render care,” Demming said. “Listen to those officers and go on your way.”

It goes against the training of nurses and doctors to move away from someone who is hurt. But Demming and Sarnese said that is the correct response in an active shooter event, as painful as it may be to consider running away from an injured co-worker.

Healthcare leaders should stress to employees in training for such events, “We can’t take care of anyone in the future if we’re not safe ourselves,” Sarnese said. “We can’t provide care without you.”

If it’s not possible to get away, staff should seek shelter in any room that can be locked. If possible, put any obstacles that can block a door or slow down an intruder. If and when it’s safe to do so, call 911 and, quietly, relay any information about the shooter.

If it’s impossible to run or hide, fight back “only if your life is in imminent danger,” Demming said. If there’s no other recourse, grab whatever is available to use as a weapon, such as a fire extinguisher or even an IV pole, they said.

Some staff may be tempted to pull a fire alarm to help people evacuate, but Sarnese and Demming said that’s not recommended. In some scenarios, attackers have pulled the fire alarm so they would have more people to shoot, they said.

When staff have safely made it out of the building, they need to call 911 immediately.

Employees should offer as much information as possible, including a physical description of the shooter, the type of weapon being used, and the last known location of the attacker.

Convincing leadership

Health systems may be reluctant to develop response plans or run drills, because they don’t want to frighten staff. Demming argued that some staff would likely appreciate it if their system developed good response plans and helped educate their staff.

“An active shooter is not something people are unaware of,” Demming said. “They’re scared, they’re nervous about this.”

For those trying without success to convince leaders to move forward with response plans and exercises, Demming said it’s worth considering the impact of staff turnover. Some healthcare workers have said they don’t feel their organizations care about their safety, as indicated by employee engagement scores. Some nurses and doctors are leaving organizations where they don’t feel safe. Less than half of nurses surveyed (47%) said they think their employers value their safety and health, according to a report by the American Association of Critical-Care Nurses.

Developing such plans could stem turnover, or at least indicate that organizations care about the safety of their workers, Demming said.

Tying training to improved employee satisfaction and retention “will get them on board,” he said.