Active-Shooter Incidents: Basic Strategies for Hospitals

In recent years the United States has witnessed a surge of active-shooter incidents. Incidents such as the Columbine high school and Aurora theater shootings in Colorado have shown the complexities that can stress emergency management and public safety personnel. The shooters in these incidents have used multiple and diverse firearms as well as weapons of mass destruction such as incendiary devices and improvised explosive devices. 

Many of these shooters are extremely young and have intensely studied firearms and explosives. The Aurora shooter, for instance, used secondary devices to booby-trap his apartment. These complex incidents clearly illustrate that first responders, emergency managers, and counterterrorism representatives must always be prepared to adapt their strategies. Coordinating strategies and tactics before, during, and after incidents will help protect first responders and first receivers. 

Active-shooter incidents have targeted all forms of soft and hard targets. Among soft targets, hospitals are among the hardest to defend against armed-intruder incidents. Unlike most other soft-target facilities, hospitals have lifesaving operations that cannot stop. Most have operating rooms, maternity wards, and critical care units where lifesaving or life-stabilizing activities are continual. Alternatively, you may have emergency departments, critical care units, or ancillary/satellite facilities like nursing homes with patients/residents who lack vision, hearing, mobility, or have extreme issues with basic life support functions. This makes it nearly impossible for such facilities to effectively evacuate during active-shooter incidents. 

Hospital leadership and personnel must employ effective conflict-resolution strategies before, during, and after times of crisis. Leaders such as fire chiefs, police chiefs, emergency managers, EMS coordinators, and local health directors also play a large role in the preparedness/response to these incidents. This article offers strategies to guide hospital emergency managers and other healthcare personnel to combat active-shooter situations effectively. 

Coalitions

Creating and maintaining external coalitions, such as a local emergency planning committee, works like a hospital emergency management committee expanded to include additional governmental and private organizations. These can facilitate coordination among responding agencies and promote effective communication. 

Communication is always a top issue in active-shooter situations and many other disasters. Meeting with community chiefs quarterly will dramatically expand awareness of community and regional problems, increase training opportunities, strengthen mutual aid relationships, and even improve access to grants. Hospital leadership should reach out to surrounding fire and EMS departments, law enforcement, county and state emergency/disaster offices, health departments, the Red Cross and similar private organizations, elected officials, and neighboring hospital emergency managers. The goal is to have a diverse membership of chiefs and specialists that mirrors the framework of the internal emergency management committee but promotes the same objectives on a larger scale. 

Partnering with the FBI or attending its weapons of mass destruction community work group meetings can enhance your awareness of trending issues in terrorism and criminal activity. Healthcare representatives can also act as specialists to provide specialized knowledge and intelligence to law enforcement. Topics such as potential threats, vulnerabilities, and case studies are shared at these quarterly meetings. 

Threat/Vulnerability Assessments

Threat assessments are extremely important for healthcare facilities. When conducting hazard/vulnerability assessments, it is important to synthesize the complexities of the healthcare sector. Prioritize departments by their vulnerabilities.

These assessments will expose weaknesses and strengths. Take this information and apply it to preplanning, grant research, policy reform, and emergency response. Be sure to incorporate all satellite offices or related facilities. Ideally you should conduct an assessment for each facility for optimal security for your patients, employees, and visitors. 

For example, say several surgeries are taking place in the operating wing of your healthcare facility, and an active shooter occurs in the cafeteria. It is important your surgical staff know the proper protocols. Many hospitals will continue to perform the surgery while locking down and isolating the room. 

After the hazard/vulnerability assessment, you realize this is a complex issue for emergency managers to solve. Moving forward you should increase training and exercises for this situation, incorporating external public safety agencies. Many chiefs may not have thought about this problem. Law enforcement and other leaders can work with the hospital emergency manager to provide secondary or tertiary task forces to engage in defensive operations for these critical units. These task forces should consist of law enforcement, firefighters, EMT/paramedics, and potentially facility security officers. The latter can assist law enforcement with navigation, unlocking doors, access to the surveillance and communication systems, and access to critical infrastructure areas like mechanical rooms. Law enforcement and emergency management can also send strike teams to protect these critical units while surgeries, deliveries, and other vulnerable operations continue. 

Remember, this can only occur with efficient resources and effective planning. If your hospital is in an area that’s not extremely populated, you may lack additional resources and personnel, because the first priority of law enforcement will be to neutralize the shooter(s). Conflict-resolution strategies all begin with identifying the problem area(s) and matching resources to goals to combat these issues.

Security Architecture

To improve the security architecture of your facility, you must either have budget funds or grant funding. Once your threat assessments are complete, the hospital’s emergency management team must prioritize security architecture needs. Maybe it’s most prudent to add bollards near entry points that are vulnerable to threats such as vehicle ramming. Maybe you should increase the number of cameras throughout the hospital or allow law enforcement wireless access to video feeds, allowing them to trace the shooter as an incident develops. Some critical areas could implement ballistic-resistant glass. All these measures can be costly, so it is important to conduct efficient research and provide data to your executive team to illustrate their importance. 

Each facility has different budget hurdles as well as different threats/vulnerabilities, which makes it important to engage in a thorough assessment and discuss emergency management priorities before adding security architecture. Some improvements are not necessarily costly, such as numbering the outsides of patient/resident windows for emergency responders. This allows law enforcement and fire service personnel to identify room locations from the outside of the structure for a swift and safe extrication of victims.

Communications

Lack of effective communications is often one of the largest problems in emergency incidents. From a hospital perspective, the focus should be improving interdepartmental and interagency communications. 

Many hospitals or healthcare facilities use emergency code systems—for example, a “code pink” could be a child abduction, or a “code silver” an active-shooter situation. Initially hospitals began using color code systems because they did not want to cause panic. However, when teaching active-shooter training courses, I always tell hospital staff to put themselves in the visitor’s shoes: If you were waiting in a hospital waiting room or lobby for a family member receiving treatment, most likely you would want to hear a direct verbal communication that there was an active shooter and their location so you could effectively flee or shelter in place. “Code silver in the PACU” would leave you with no idea what to do. 

Another problem with color code systems occurs when multiple agencies work a major incident together. Those from outside the hospital system—EMTs/paramedics, firefighters, and police officers—may not understand unique notifications. Emergency color code systems are not standardized throughout the United States, and some personnel may work for multiple institutions. Promoting common terminology limited to the threat and its location will combat these issues. 

Conclusion

Emergency managers must remain adaptable. Threats such as active shooters always evolve in response to our defenses and preparations. Following these approaches will promote the fundamental first phase of combating active-shooter situations for hospitals and healthcare facilities.  

Patrick LaBuff, MA, is emergency management director at Hartford (Conn.) Hospital. A former homeland security and emergency management advisor to the U.S. Congress, he has dual master’s degrees in homeland security and emergency and disaster management from American Military University. He is a doctoral candidate in emergency management and a member of Connecticut USAR Task Force 1.