Active Shooter Preparedness for Health Care Facilities

Although COVID-19 was the primary focus for hospital emergency managers throughout 2020–21, recent active-shooter incidents, including the killing of 4 people at a Tulsa, Oklahoma medical facility in June, underscore that the familiar threat of mass shootings remains. As EMS providers and their public safety colleagues prepare for these, they must recognize COVID as one of the many secondary complications to be aware of when responding to active-shooter incidents in health care facilities.

Responders to hospital disasters must adapt to critically changing situations and understand the diverse hazards and complications they can face. A previous article discussed the basic emergency management concepts to enhance hospital preparedness and first responders’ engagement before, during, and after armed-intruder incidents. This article will amplify advanced tactics and strategies used to provide optimal emergency management and security for health care facilities.

Incident Command Training

Although Incident Command System (ICS) courses can be very dry, they are the backbone of a major response and crucial for health care representatives and first responders to implement efficiently. Many local and state ordinances throughout the United States require firefighters, EMS providers, and law enforcement officers to take basic ICS classes such as IS-100, -200, -700, and -800. Requiring this for your public safety representatives and leadership officials (including elected officials) will enhance their understanding of disaster management operations.

In health care there are very few hospitals or medical institutions that require physicians, nurses, and other first receivers to have basic and advanced incident command training. This can be extremely dangerous during mass-casualty events and surge incidents such as active-shooter responses. Such individuals and departments may engage in tasks without using proper command channels, which will disrupt coordination and communications.

Security officers in hospitals may have some incident command training through law enforcement or military backgrounds. However, this should also be standardized because security officers play a crucial role when responding to health care armed-intruder incidents by helping law enforcement set perimeters, provide crowd control, and evacuate personnel.

Requiring hospital leadership as well as clinicians, security, and other critical response staff to take basic incident command courses will solidify their understanding of large-scale disaster responses. This will also provide educational benefits throughout many diverse hospital departments.

ICS classes are free through the Department of Homeland Security’s Emergency Management Institute. Once these courses are completed, emergency managers must monitor and track certifications to assess the educational needs of the institution and set further training goals.

Drone Imagery Operations

Many fire departments and law enforcement agencies have begun to use drones.

Previously in my hospital emergency management experience, I partnered with the New York State Police and other law enforcement agencies to conduct joint drone imagery operations of all the health care facilities I managed, which included hospitals and primary care centers. These images provided extreme clarity and could be inserted into our hazard/vulnerability assessments to help leadership prioritize the needs of vulnerable areas. These images were also used in training presentations, disaster briefings/debriefings, and policy documentation.

Most important, these images amplify 2 different strategies to optimize emergency management. The first is to enhance preplanning for active-shooter incidents, which includes the mapping of potential staging areas, casualty collection points, evacuation routes, alternative care sites, emergency operations centers, family reunification centers, and other necessary outposts.

Once the drone imagery operations are completed, our hospital emergency management department, in conjunction with the police, will disseminate the images to other responders. These images also provide excellent visual awareness for other disasters. Drone imagery operations should be conducted annually due to physical alterations in your facility, structural changes, and changes to the surrounding environment.

The second major strength of this operation is that it provides integration between agencies before the crisis occurs. The health care facility benefits because it receives clear images from various aerial angles to assist preplanning. Police and firefighters benefit by increasing training experience for their personnel and familiarity with the facility and health care personnel.

Secondary Devices and WMD

Active-shooter situations may also incorporate secondary devices or weapons of mass destruction. Therefore, it is important for hospital staff to undergo awareness-level training that provides guidance for suspicious activities and devices. The New York Police Department and many other law enforcement agencies provide officers with radiological and hazardous-materials detection devices on their tactical belts. This tactic can be used in health care to detect secondary weapons. Security officers, patient transport personnel, engineering, and environmental service staff are constantly on the move throughout hospitals; providing them with basic training and detection devices can assist in monitoring for threats within the facility.

EMS and RTF Implementation

The 1999 active shooter incident at Columbine High in Aurora, Colorado emphasized the importance of getting emergency medical services, fire, and law enforcement officers into shooting scenes as soon as possible to eliminate the threat and begin rapid medical treatment/transportation. The initial protocols for this jurisdiction were to stage until the SWAT team arrived. As a result students and faculty in the school had to wait approximately 40 minutes for that team to arrive on scene.

Protocols like this were immediately revisited throughout the United States, and within the past decade many communities have been approaching responses to armed intruders through the rescue task force (RTF) methodology. This methodology incorporates initial law enforcement officers to immediately enter the structure or area with a group of fire-medics to provide medical treatment. This provides a quick response while assuring the protection of unarmed fire-medics entering the warm zone.

Hospital staff must understand that the initial priority is eliminating the threat, then aiding the wounded. During this operation there will be initial law enforcement teams entering the hot zone while secondary teams enter as an RTF to engage in quick and efficient medical treatment.

Hospitals can benefit by providing security officers with certified first responder training, including tourniquet application. Training security officers to a basic level of RTF operations can benefit all responders because then they can effectively guide law enforcement through the facility, providing access to camera feeds and assisting with basic medical support and evacuation under the protection of law enforcement. This strategy requires personal protective equipment, interagency coordination, and basic medical training to work effectively. However, it will significantly increase the efficiency of responses to crisis situations.

Hospitals can mitigate the cost of this training by hiring security officers with current EMS experience and certifications.

Exercises and Communications

Health care facilities are among the most complicated institutions to execute full-scale exercises in due to the constant and critical operations they contain. Some of the most common areas for active-shooter incidents include the emergency department, parking areas, and critical care areas. Other areas to consider are the human resources department, administrative offices, and maternity units. After conducting a hazard/threat assessment and analyzing relevant trends, emergency managers must design full-scale exercises to provide real-world response experiences for health care representatives and first responders. These should be planned in stages that include an awareness presentation followed by tabletop and functional exercises. Once these smaller exercises are complete, the emergency manager should hold a full-scale exercise. Full-scale exercises generally take a minimum of 12 months to plan and should be designed with both internal and external partnerships in mind.

To maintain operations I recommend emergency managers utilize areas of the hospital that are vacant or have minimal activity. Also work with municipal partners to find vacant locations or even construct replicas of hospital floors to provide an alternative method to enhance training. In previous simulations I have used actors with public safety backgrounds or even local drama groups to assist. During full-scale exercises your facility must include staging areas as well as other incident command facilities, such as a public information/media center, family reunification center, and other command areas.

After conducting these exercises, it is important to debrief to see what went well and what can be improved. It is almost guaranteed that communications will need improvement, policy will need to be updated, and certain tactical procedures will require strengthening. Applying these strategies will drastically enhance your community’s health care facilities and the preparedness and response of first responders when managing active-shooter situations.

Patrick LaBuff, MS, is emergency manager at Hartford Hospital in Connecticut, as well as a former Congressional homeland security and emergency management advisor.