ACTIVE SHOOTER IN THE HEALTHCARE SYSTEM? ??Section I. Introduction: Describe the topic or problem.? You will include an epidemiological description of the impact

COMMENTARY–INVITED

“Run, Hide, Fight,” or “Secure, Preserve, Fight”: How Should Health Care Professionals and Facilities Respond to Active Shooter Incidents?

The Federal Bureau of Investigation (FBI) definesan active shooter as “an individual actively engaged in killing or attempting to kill people in a confined and populated area.”1 A study of newspaper articles and press releases identified 154 active shooter incidents (ASIs) in hospitals in the United States in the 12-year period 2000 through 2011.2 ASIs were more common in larger hospitals, with 29% taking place in the emergency department (ED) and 19% in patient rooms. In 50% of the ASIs in an ED, the per- petrator used a security officer’s gun.2

Current federal law enforcement guidelines recom- mend “Run, Hide, Fight” as a stepwise response to ASIs.3 A 2014 report issued jointly by the U.S. Departments of Health and Human Services, Home- land Security, and Justice; the FBI; and the Federal Emergency Management Agency explicitly endorses the “run, hide, fight” model for health care facilities.4

According to this strategy, one should first “run,” that is, rapidly leave the area under attack and keep mov- ing until one is in a safe location. If one cannot run away, the next best option is to “hide” in as safe a place as one can. This may include locking and barri- cading doors and windows and remaining silent. In the event one cannot run or hide, one should “fight” when confronted, that is use force to disrupt or inca- pacitate the shooter. Law enforcement agencies endorse the “run, hide,

fight” strategy because research shows that it is the most effective sequence of responses to protect individ- uals during ASIs.5 Self-protection is certainly an understandable and permissible reason for choosing a

particular action, but it is only one among a variety of actions and reasons. Should the value of self-protec- tion persuade health care facilities and individual health care professionals to implement the “run, hide, fight” response to ASIs? In a 2018 article in the New England Journal of

Medicine, Inaba et al.6 agree that health care profes- sionals, staff, patients, and visitors should follow the “run, hide, fight” strategy in ASIs, provided that all are able to take those actions. In other situations, how- ever, these authors propose that health care facilities and professionals consider a different response to ASIs that they refer to as “secure, preserve, fight.” They describe these specific health care situations and their proposed response as follows: “for professionals providing essential medical care to patients who can- not run, hide, or fight owing to their medical condi- tion or ongoing life-sustaining therapy, a different set of responses should be considered—secure the loca- tion immediately, preserve the life of the patient and oneself [by continuing care that is required to preserve life], and fight only if necessary.”6

Inaba et al. offer several reasons for their proposed alternative response to ASIs. They point out that most U.S. hospitals are designed vertically, with heavy reli- ance on elevators and often narrow stairwells for inter- nal movement. These architectural features are likely to impede access to escape routes when an active shoo- ter is present and so interfere with the primary instruc- tion to run away. They also point out that many hospital units caring for incapacitated patients, most notably EDs and intensive care units (ICUs), typically

The authors have no relevant financial information or potential conflicts of interest to disclose.

252 ISSN 1553-2712 © 2019 by the Society for Academic Emergency Medicine

doi: 10.1111/acem.13912

have open designs that maximize visibility, but greatly limit the ability of patients and staff to hide from a shooter. Finally, they assert, without further elabora- tion, that “health-care professionals have a moral and ethical duty not to abandon their patients, which directly conflict with the primary directive to run.”6

Do Inaba et al. provide morally compelling reasons for adoption of the “secure, preserve, fight” strategy they propose? The strength of their proposal depends heavily on assessment of the scope and limits of the moral responsibilities of health care professionals and facilities to their patients. Health care professionals have widely recognized, central responsibilities to bene- fit their patients and to protect them from harm.7

They carry out these responsibilities primarily by pro- viding medical care to prevent and treat illness and injury, but also by keeping patients safe during their stays in health care facilities. Prominent professional codes of ethics assert that patient welfare is a primary responsibility, and this implies that professionals have a duty to accept risks to themselves to care for their patients.8–10 Codes and commentators also, however, recognize that the duty to benefit patients is not abso- lute.11,12 It is, for example, limited by the availability of resources and by legitimate professional interests in personal integrity, autonomy, and self-protection. How, then, does the basic responsibility to benefit

patients bear on the health care professional and facil- ity response(s) to ASIs? Recent discussion of care for patients who present to health care facilities with sus- pected Ebola virus disease (EVD) offers an instructive, if not perfect, analogy here. Patients with EVD are highly infectious, and they rapidly develop critical ill- ness. They require intensive treatment to survive, and many, if not most, will succumb to the disease even if that treatment is provided.13 Must health care profes- sionals at these facilities treat these patients, or may they decline to do so? With other commentators, we contend that health care professionals have a responsi- bility to accept significant, but not disproportionate, risk in their efforts to benefit their patients.14,15 There is no single, bright-line border between these two cate- gories of risk, but services that expose professionals to highly infectious and lethal diseases often require sacri- fice of the professionals’ life or health, and that risk seems clearly disproportionate. In the case of EVD, therefore, asserting a duty of care requires that risks to caregivers can be and are reduced to an acceptable level. Risk mitigation is typically beyond the capacity of individual professionals; it requires that facilities

implement effective control measures. For care of patients with EVD, necessary measures include provi- sion of adequate personal protective equipment to caregivers and the development, training, and imple- mentation of proven infection control protocols, including infectious waste disposal systems.16

Health care professional and facility responses to ASIs are similar to care for patients with EVD in several morally significant ways. Without substantial measures to protect themselves and their patients, professionals’ attempts to shield vulnerable patients from active shoot- ers are very likely to be ineffective and self-sacrificial. Recognition of a professional duty to protect patients from active shooters, therefore, depends on a reciprocal duty of health care facilities to develop and implement reasonable measures to help professionals keep patients and themselves safe from such attacks. Inaba et al. rec- ognize that this is a joint responsibility, and they then identify multiple actions that facilities can take to maxi- mize protection from active shooters. Among the mea- sures they describe are:

1. Security screening, including metal detectors, at facility entrances;

2. Development and dissemination of an active shoo- ter response plan;

3. Internally activated locking systems to secure the doors to hospital units with vulnerable patients, including EDs, ICUs, operating suites, and labor and delivery units;

4. Active shooter alert systems for immediate notifica- tion to all staff of ASIs; and

5. Initial and periodic training for staff on their roles in ASIs.6

Implementation of measures like these can bolster the confidence and resolve of staff and help counteract the fear they are likely to feel in these dangerous situa- tions.17 In addition to the above preventive and pro- tective measures, Inaba et al. recommend several other response strategies, including staff training in hemor- rhage control measures for gunshot victims and psy- chological first aid for patients, visitors, and caregivers who experience an ASI. There is no foolproof technique to prevent a deter-

mined shooter from targeting a health care facility, but a combination of the above measures can significantly reduce the risks to patients who cannot run or hide and to the professionals who remain with those patients to protect them and to provide continuing life-sustaining treatment for them. Facilities that

ACADEMIC EMERGENCY MEDICINE • March 2020, Vol. 27, No. 3 • www.aemj.org 253

implement these measures can ask their medical and clinical staff members to carry out the “secure, pre- serve, fight” option to protect their most vulnerable patients in ASIs. When health care facilities embrace their responsibility to provide effective protection against active shooters, health care professionals can also fulfill their fundamental responsibility to act for the benefit of their patients.

Al O. Giwa, MD, MBA1

([email protected]) Andrew Milsten, MD, MS2

Dorice L. Vieira, MLS, MA, MPH3

Chinwe Ogedegbe, MD, MPH4

Kristen M. Kelly, MD1

Abraham P. Schwab, PhD5

John C. Moskop, PhD6 1Department of Emergency Medicine

Icahn School of Medicine at Mount Sinai, New York, NY

2Department of Emergency Medicine University of Massachusetts Medical School

UMass Memorial Medical Center, Worcester, MA 3NYU Health Sciences Library

NYU School of Medicine, New York, NY

4Emergency Medicine, Hackensack Meridian School of Medicine @ Seton Hall

University, Hackensack University Medical Center Emergency and Trauma Center

Hackensack, NJ 5Purdue University Fort Wayne

Fort Wayne, IN 6Wallace and Mona Wu Chair in Biomedical Ethics

Wake Forest University School of Medicine Winston-Salem, NC

Supervising Editor: Zachary F. Meisel, MD, MPH, MSc

References

1. Federal Bureau of Investigation. Active Shooter Resources. Available at: https://www.fbi.gov/about/partnerships/office- of-partner-engagement/active-shooter-resources. Accessed December 5, 2019.

2. Kelen GD, Catlett CL, Kubit JG, Hsieh YH. Hospital- based shootings in the United States: 2000 to 2011. Ann Emerg Med 2012;60:790–8.

3. Interagency Security Committee. Planning and Response to an Active Shooter: An Interagency Security Committee Policy and Best Practices Guide. November 2015. Avail- able at: https://www.dhs.gov/publication/isc-planning-and- response-active-shooter-guide#. Accessed December 5, 2019.

4. U.S. Department of Health and Human Services, U.S. Department of Homeland Security, U.S. Department of Justice, Federal Bureau of Investigation, Federal Emergency Management Agency. Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans. 2014. Available at: https://www.phe. gov/Preparedness/planning/Documents/active-shooter- planning-eop2014.pdf. Accessed December 5, 2019.

5. Blair JP, Nichols T, Burns D, Curnutt JR. Active Shooter Events and Response. Boca Raton, FL: CRC Press, Taylor and Francis Group, 2013.

6. Inaba K, Eastman AL, Jacobs LM, Mattox KL. Active- shooter response at a health care facility. N Engl J Med 2018;379:583–6.

7. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. New York: Oxford University Press, 2019.

8. ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:243–6.

9. Principles of medical ethics. In: Code of Ethics of the American Medical Association. Chicago, IL: American Medical Association, 2017, 1–2.

10. American College of Emergency Physicians. Code of Ethics for Emergency Physicians. 2017. Available at: https://www.acep.org/globalassets/new-pdfs/policy-stateme nts/code-of-ethics-for-emergency-physicians.pdf?_t_id=&_t_ q=Code%20of%20Ethics%20for%20Emergency%20Physic ians.pdf&_t_tags=andquerymatch,language:en| language:7 D2DA0A9FC754533B091FA6886A51C0D,siteid:3f8e28e 9-ff05-45b3-977a-68a85dcc834a| siteid:84BFAF5C52A349 A0BC61A9FFB6983A66&_t_ip=&_t_hit.id=ACP_Websi te_Application_Models_Media_DocumentMedia/_bea229 49-bb55-4462-83d0-7a56dbb9c623&_t_hit.pos=0. Accessed December 5, 2019.

11. Moskop JC. Methods of health care ethics. In: Moskop JC, editor. Ethics and Health Care: An Introduction. Cam- bridge, UK: Cambridge University Press, 2016, pp 30–52.

12. Rybak EA. Hippocratic ideal, Faustian bargain, and Damocles’ sword: erosion of patient autonomy in obstet- rics. J Perinatol 2009;29:721–5.

13. Mulangu S, Dodd LE, Davey RT Jr, et al. A randomized, controlled trial of Ebola virus disease therapeutics. N Engl J Med 2019;381:2293–303.

14. Fins JJ. Distinguishing professionalism and heroism when disaster strikes. Cambr Quart Healthcare Ethics 2015;24: 373–84.

254 Giwa et al. • ETHICAL OBLIGATIONS ANALYSIS AND HOSPITAL-BASED ASIS

15. Moskop JC. Law and ethics in health care. In: Moskop JC, editor. Ethics and Health Care: An Introduction. Cambridge, UK: Cambridge University Press, 2016, pp 53–62.

16. Centers for Disease Control and Prevention. Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation (PUIs) or with Confirmed Ebola

Virus Disease (EVD): A Framework for a Tiered Approach. Available at: https://www.cdc.gov/vhf/ebola/ healthcare-us/preparing/hospitals.html. Accessed Decem- ber 7, 2019.

17. Iserson KV, Heine CE, Larkin GL, et al. Fight or flight: the ethics of emergency physician disaster response. Ann Emerg Med 2008;51:345–53.

ACADEMIC EMERGENCY MEDICINE • March 2020, Vol. 27, No. 3 • www.aemj.org 255

Briefings on The Joint Commission May 2015

8 HCPRO.COM © 2015 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

Continuing Education Objectives After reading this article, you will be able to:

• Identify the five missions an organization has during an ac-

tive shooter event

• Describe considerations when building a plan for an active

shooter scenario

• Discuss statistics that staff can be educated about to iden-

tify potential active shooter situations

• Discuss the concept of Run, Hide, Fight

Editor’s note: Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, is a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor. Special thanks to Brad Keyes, CHSP, for his assistance with clarifying emergency management requirements in this article.

It feels as if not a day goes by without talking about the need for active shooter planning in pub- lic spaces, including hospitals. This plays into the ongoing need for hospitals to address Emergency Management, Environment of Care, and other safety- related standards and regulations. But where do we look for advice on preparing for what we hope is an incident we will never have to deal with? The Federal Emergency Management Agency (FEMA) and the Assistant Secretary for Preparedness and Response,

Active shooter preparation Training for before, during, and after an emerging event

in conjunction with the FBI and the departments of Health and Human Services, Homeland Security, and Justice, released a report in December 2014 address- ing just that, titled “Incorporating Active Shooter Incident Planning into Healthcare Facility Emergency Operations Plans.”

Active shooter incidents are defined as those in which an individual is “actively engaged in killing or attempting to kill people in a confined and populated area,” according to the Department of Homeland Security.

Healthcare facilities “are faced with planning for emergencies of all kinds, ranging from active shoot- ers, hostage situations, and other similar security challenges, as well as treats from fires, tornadoes, floods, hurricanes, earthquakes, and pandemics of infectious diseases,” the report states. “Many of these emergencies occur with little to no warning; therefore, it is critical for healthcare facilities to plan in advance to help secure the safety, security, and general welfare of all members of the healthcare community.”

So while active shooter incidents can be pooled under the same category as other dramatic incidents of dan- ger, they have their own unique challenges that need to be anticipated (as do all disaster issues). Hospitals need to have plans and procedures for these events, and those plans must be living documents: They must

behavioral health disorder,” says Cooke. “So we know that, at least minimally, a third of the patients we’re treating have a comorbidity.”

In the end, care providers are not just treating a person with diabetes whose eyesight has begun to be affected, or whose legs are in pain. Providers must focus on the emotional and behavioral aspects of care as well as the physical characteristics.

“How do we shift the culture? Through a lot of educa- tion,” says Cooke. “It also takes a serious effort to con- vince politicians that we need to bring back behavioral

health resources and provide improved parity.” Some organizations are starting to establish inte-

grated care models that work to manage both the physical and behavioral needs of the patient. They surely will have better outcomes in the long run.

“We need to get over the denial, ignorance, stigma that surrounds substance abuse and behavioral health disorders,” says Cooke. “We as healthcare providers need to understand and accept the immensity of this issu

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.