Hospital shooting rates bump up need for active shooter drills
Nurses learn how to respond to open gunfire situations
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By Heather Stringer
EDITOR'S NOTE: Heather Stringer is a freelance writer.
The incident was just 500 yards from Nadworny’s hospital, Beth Israel Deaconess Medical Center. The son walked into the hospital and asked to see the surgeon. The man believed a post-operative drug prescribed by the doctor had killed his 78-year-old mother. “A lot of risk mitigation can happen ahead of time, and part of preparation is doing drills,” said Nadworny, clinical director of operations for ED and urgent at Beth Israel Deaconess Medical Center. “And it does not have to be large-scale events with hundreds of volunteers. It can be a group of people talking through a scenario from start to finish.” Statistics suggest the increase in hospital-based shootings mirrors the national trend. The Federal Bureau of Investigation recorded a total of 160 active shooter incidents between 2000 and 2013, with 6.4 incidents per year during the first six years and 16.4 per year during the second six years. In the hospital setting, rates increased from 9 per year from 2000 to 2005 to 17 per year from 2006 to 2011, according to a study published in 2012 in the Annals of Emergency Medicine.
“Know the quickest routes out of the building, and if the front door isn’t an option, is there a back way or stairwell?” he said. Nurses can hide behind badged doors or barricade themselves inside a room using a heavy hospital bed with the brakes on. He recommends turning off the lights to prevent a shooter from seeing inside. Medication and staff locker rooms also may serve as hiding places. Practice alerting others that there is an active shooter in the building, Nadworny said. The ENA advocates for the use of plain language such as “active shooter in the building” rather than acronyms or codes because patients and visitors need to understand what is happening. “Try not to engage the active shooter, but as an absolute last resort, nurses can throw items like a fire extinguisher at an assailant,” Nadworny said. Another element of preparedness is planning for an emergency department closure if the shooter is in the department. Emergency management leaders at TriHealth Bethesda Butler Hospital in Hamilton, Ohio, recruited 25 volunteers that included hospital staff, local law enforcement officers and community members to execute a full-scale exercise in February. To avoid disruptions to patient care, the exercise took place in a building outside of the emergency department. During the exercise, the team simulated an angry patient in the emergency department who began shooting at people in the waiting room.
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“Know the quickest routes out of the building, and if the front door isn’t an option, is there a back way or stairwell?”
— David Vialpando
Run, hide, fight
The hospital security officers subdued the shooter, and several minutes later emergency medical services and police entered the building. In the simulation, people in the waiting room were injured and the shooter died. “We simulated taking patients to other EDs because ours had closed,” said Michelle Ping, BSN, CEN, co-chair of the emergency management committee that organized the exercise. “They also learned how to preserve forensic evidence.” If a bullet creates a hole in a victim’s clothing, nurses practiced leaving the hole intact to preserve evidence rather than cutting the shirt off the victim, Ping said. Workers also practiced wrapping the shooter’s hands with paper bags rather than plastic bags — which can expedite the growth of bacteria and interfere with evidence of gun residue.  While preparing for the exercise, Ping also discovered a 911 call would alert emergency medical services and police from two different jurisdictions because the hospital is situated within two boundaries. She contacted first responders from both areas to participate in the event. It was also important for hospital staff to be exposed to the sights, sounds and screams from victims and witnesses.  “Nurses didn’t realize how scary it felt until they were in the situation,” Ping said. “It’s also instinctive for nurses to take care of everyone else, but we instructed them to run, hide or fight so they could take care of others when it was over.”
Active shooter incidents in hospitals are on the rise, yet it’s easy for nurses — and the general public — to assume they will never be confronted with this type of situation. But nurses on the front lines of emergency management agree preparing for such incidents can ultimately save lives.
Although nurses should strive to protect themselves, decisions about whether to put themselves at risk to protect patients during an active shooter incident can vary from nurse to nurse, said Martha Sexton, PhD, RN, an associate professor and chair of the department of adult, family and population health nursing at the University of Toledo in Ohio.

Nursing students in the college participate in a two-hour active shooter training with students from other health science disciplines, and the groups discuss ethical decision making in these scenarios. “They are very uncomfortable with the fact that there is no right or wrong way to handle these ethically complex decisions,” Sexton said. A nurse with young children at home may make a different decision about protecting patients than a more seasoned nurse whose children are adults, she said. In 2016, leaders at Hartford Healthcare in Connecticut decided that active shooter training should be a higher priority, and 150 employees completed the training to become certified instructors for ALICE, an acronym for Alert, Lockdown, Inform, Counter, Evacuate. Now units throughout the healthcare system are expected to watch a 45-minute e-learning module on ALICE training.
RNs have tough decisions to make
The certified instructors follow up to help each unit plan for an incident by discussing details like the locations of the nearest exits and places to hide, said Dawn Filippa, MSN, MHA, RN, RRT, EMT-P, an ALICE instructor and EMS operations manager in Hartford Hospital’s Center for Education, Simulation and Innovation. Sexton recently conducted a study to explore how nurses would respond in active shooter situations. She found students who had watched an ALICE training video were more likely to run than stay with a patient. More experienced nurses, however, shared they would be more likely to stay to protect patients, which may be because they’ve spent years in the field caring for others on a daily basis, Sexton said.   The training is critical because hospital staff often will be the first responders in these incidents, Filippa said. “It’s also important for nurses to be aware of their surroundings,” she said. Now Filippa looks for the closest exits whenever she’s at work, in a restaurant or a movie theater and she tries to face the door to see who is entering a room. “My passion is to train as many people as possible to be aware and avoid freezing if they are ever faced with an active shooter situation.” OnCourse Learning will host a webinar on July 25 for nurses interested in learning how to develop a mindset of action and survival during an active shooter incident.
The importance of developing an active shooter response plan became all too clear in 2015 to Daniel Nadworny, DNP, RN, a member of the Emergency Nurses Association’s Emergency Preparedness Committee. That year, the son of a former patient at Brigham and Women’s Hospital in Boston shot and killed a cardiac surgeon there.
Preparing to respond starts with assessing a workplace to identify options to run or hide, said David Vialpando, a former law enforcement officer and director of gaming programs at OnCourse Learning.
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