Hospital-based shootings in the United States: 2000 to 2011

Violence in the healthcare workplace

PURPOSE OF REVIEW

Healthcare workers experience a disproportionate frequency of workplace violence. Identifying commonalities among incidents of workplace violence provides an opportunity for change to prevent and mitigate future violence.

RECENT FINDINGS

Despite a continued decline in overall workplace violence, the rate of violence in the healthcare sector is steadily rising. While healthcare workers make up 13% of the workforce, they experience 60% of all workplace assaults. Environmental, structural, and staffing issues may all contribute to the increased rates of workplace violence affecting healthcare workers.

SUMMARY

Comprehensive proactive workplace violence prevention programs can significantly reduce the frequency of violence and the negative impact on employees and institutions. Analyzing the factors that contribute to violence in the healthcare workplace provides the potential to mitigate these risks and reduce episodes of violence.

Firearm Policy in the Hospital Setting-Recognizing Health Care as a "Sensitive Place"

Importance

Hospitals are hot zones of the US gun injury epidemic. To shelter these facilities from the dangers of gun violence, state legislatures have enacted laws to reduce the carrying of firearms on hospital premises. However, these efforts currently face serious Second Amendment challenges in federal courts. The ongoing legal battles, which have wide-ranging implications for patient and clinician safety as well as public health generally, are setting the stage for a Supreme Court case that may decide the fate of firearm regulations in US hospitals. A permissible pathway for advancing sensible gun regulation in hospitals is urgently needed.

Observations

Since the Supreme Court established a new constitutional test for firearm laws in New York State Rifle & Pistol Association v Bruen (2022), states now face unprecedentedly high barriers to enacting health-protecting legislation regarding firearms. Post-Bruen, the Supreme Court requires that laws be consistent with "this Nation's historical tradition of firearms regulation." This means that states hoping to enact laws barring public carry of firearms in hospitals must demonstrate that hospitals are a "sensitive place" as a historical matter (ie, analogous to a location where firearms were traditionally restricted). By reasoning from analogy, it is clear several historical comparators exist for regulating firearms in hospitals. Although the hospital (as understood today) did not exist in the 1700s, it is sufficiently analogous to asylums and schools, to name a few examples. These settings all share a common denominator with the modern-day hospital: serving vulnerable populations or individuals who may be at heightened risk of misusing firearms.

Conclusions and Relevance

The Supreme Court's interpretation of the Second Amendment right to bear arms is threatening democratically enacted laws seeking to shelter hospitals from firearm violence. However, it is clear that hospitals and other health care settings are a sensitive place with compelling historical analogies. Policymakers' strategic deployment of the sensitive places designation, along with its rightful judicial recognition in the hospital setting, are critical to upholding laws that protect health care facilities, patients, and professionals from firearm violence-a conclusion consistent with the US Constitution, history, medical ethics, and common sense.

Impact of Implementation of a New Weapons Screening at an Urban Emergency Department

BACKGROUND

Violence in the emergency department (ED) setting is well documented in medical literature. Weapons can be used to cause significant injury or mortality, although there is a paucity of literature on weapons and weapons screening in the ED.

OBJECTIVES

The purpose of this study was to assess the impact of initiating a weapons screening process on the identification and removal of weapons.

METHODS

Multiple aspects of a weapons screening program were evaluated at 2 and 6 months prior to and after a weapons screening protocol was initiated at an urban ED. In the Pre-Screen periods, only patients primarily seeking care for mental health were screened prior to entry. In the Post-Screen periods, all patients and visitors were screened with walk-through magnetometers or wand metal detectors, and additional screening checks were initiated. The number of individuals screened and numbers of weapons found were measured. Descriptive statistics comparing Pre- and Post-Screen periods were performed.

RESULTS

Prior to the new screening process, 511 and 1701 patients primarily seeking care for mental health were screened, with 15 and 103 weapons confiscated at 2 and 6 months, respectively. After the screening process was initiated, 13,149 and 43,321 ED patients and visitors were screened, with 194 and 567 weapons confiscated at 2 and 6 months, respectively. Persons screened increased by 25-fold at both 2 and 6 months after implementing the screening process. Weapons confiscated increased approximately 13-fold and sixfold at the respective 2- and 6-month Pre- and Post-Screen periods, respectively.

CONCLUSION

Implementation of weapons screening significantly increased the number of weapons identified and confiscated prior to entry in the ED by patients and visitors.

Police Violence in Health Care Settings in US Media Coverage

Importance

Hospitals do not collect or share data tracking their policing and security activities despite their reliance on police and security personnel, including armed officers. Thus, little is known about how hospital security is associated with patient and staff safety.

Objective

To examine the harms exerted by health care-affiliated police and security personnel.

Design, Setting, and Participants

For this qualitative study, data were collected using a systematic Media Cloud search for US news media coverage from January 2011 to May 2022. A total of 18 987 articles on policing and hospitals were screened and a content and thematic analysis of articles that met the search criteria was conducted, which involved incidents that revealed harm to patients, patients' families, and staff. Data were analyzed from October 2022 to April 2023.

Main Outcomes and Measures

Incident year, incident location (hospital name, city, state), survivor and victim characteristics (race and ethnicity, presence of mental illness), and a narrative description of the incident focusing on outcomes of harm exerted by police and security personnel in the health care setting.

Results

A total of 48 unique stories across 25 US states were included. The median (range) year published was 2017 (2009-2022). Harms reported to have been perpetuated by health care-affiliated police and security personnel were identified within 5 domains from 48 unique incidents: (1) patients shot by police or security personnel (17 patients); (2) patients subject to excessive use of force (17 patients); (3) patients arrested (7 patients); (4) patients subject to sexual assault (2 patients); and (5) hospital personnel or those considered collateral damage shot, injured, or arrested (5 individuals). Most survivors and victims were Black, although the race and/or ethnicity of involved individuals was not routinely reported across the news stories. Mental illness was the most documented medical condition among patients injured or killed by health care-affiliated police and security personnel.

Conclusions and Relevance

This qualitative study of US news media found that police and security personnel in hospitals were reported to have perpetuated harm via excessive force, sexual assaults, injuring patients and health care workers, and fatal shootings. Compounded by a lack of transparency and accountability mechanisms, this may represent an underrecognized manifestation of structural racism at the organizational level. Policy suggestions include introducing accountability measures, deescalation techniques, and removing arms from hospital security personnel to reduce harm and fulfill health care's healing mission.

Health Effects of Policing in Hospitals: a Narrative Review

IMPORTANCE

Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals.

OBSERVATIONS

Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being.

CONCLUSIONS AND RELEVANCE

Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.

"Code Green Active" Curriculum: Implementation of an Educational Initiative to Increase Awareness of Active Shooter Protocols Among Emergency Department Staff

BACKGROUND

There has been an increase in violent acts against hospital employees, including active shooter events. Emergency department (ED) staff must be able to respond to these events efficiently to ensure the safest possible outcome. However, few in our ED were aware of our hospital's active shooter protocol. We aimed to increase staff knowledge of and confidence in these guidelines.

METHODS

We developed and implemented a 7-week spiral curriculum using the Kern model of curriculum development. Each week, a segment of the hospital active shooter protocol was featured. Multimodal instructional methods including posters, instruction at daily team huddles, descriptions in the weekly division newsletter, and email summaries were used.A 10-question assessment was administered to ED staff both before and after the implementation of our curriculum. During both assessments, staff were asked to rate their confidence in both knowledge of and ability to follow hospital active shooter guidelines.

RESULTS

There were 95 and 102 participants in the preintervention and postintervention periods, respectively.The median proportion of correct answers on the knowledge assessment increased when comparing preintervention with postintervention performances (P < 0.05).Staff confidence in both knowledge of and ability to follow active shooter protocols increased after the implementation of our curriculum (P < 0.05).

CONCLUSIONS

Our 7-week curriculum resulted in improved knowledge of and confidence in hospital active shooter protocols among ED staff. Given that our sample was an unpaired convenience sample, inferences from our analysis were limited. Tabletop simulations are currently underway to further reinforce and clarify concepts.

Assessment of Emergency Department Staff Awareness of Policy and Expert Opinion Protocol Regarding Active Shooter Events

OBJECTIVE

Active shooter incidents (ASI) have continued to increase over the years, with the majority of attacks occurring in the workplace. Workplace violence in the hospital setting is a growing concern in the emergency department (ED). While ASI are inherently unpredictable by nature, it is prudent to be prepared for these scenarios in the hospital to prevent fatalities. The goal of this study is to access the level of familiarity of emergency department staff with ASI hospital policy and response protocol.

METHODS

A survey of ED employees was distributed using the Qualtrics® platform via an electronic link. The study was approved by the University of Central Florida College of Medicine's IRB.

RESULTS

Only 10% had participated in an ASI drill in the past year. Personnel who answered "no" to the question, To your knowledge, is there a hospital-based emergency action plan in the event of ASI?, were significantly more likely to feel unprepared for an ASI (P < 0.0001). Those who did not receive training for a hospital-based emergency action plan were similarly less likely to feel prepared (P = 0.0002).

CONCLUSION

Most ED providers in the survey reported feeling unprepared to handle an ASI in the emergency department. This study underscores the need to implement regular training on ASIs for ED staff.

Active Shooter Preparedness: Is Your OR Ready?

Active shooter events, including those in health care facilities, are expected to increase in incidence. Perioperative personnel may be underprepared for such an event. Understanding how to make the best decision regarding whether to escape, hide, or fight, and being aware of the communication channels during these types of events are crucial to adequate preparation. Health care facilities and critical areas such as the OR should be prepared for an active shooter event. This article briefly describes a firsthand shooting event experience at Johns Hopkins Hospital and includes a review of the literature on active shooter events in health care settings to determine the most practical application of event preparedness for staff members working in the OR. It also discusses the highly relevant concept of patient abandonment.

Quantitative content analysis of physician-involved work-related firearm violence in the United States, 2008-2017

BACKGROUND

The frequency with which physicians are injured or killed in acute care hospital shootings has more than tripled during the past two decades. Moreover, physicians may be exposed to firearm violence outside of hospital settings.

OBJECTIVE

To characterize physician-involved workplace-related firearms violence to inform risk identification and mitigation strategies.

METHODS

Quantitative content analysis of physician-involved workplace-related firearm violence resulting in injury or death. Two investigators independently abstracted web-based reports for each year from 2008-2017 with differences resolved by consensus. Data were summarized using descriptive statistics, and analyzed using chi-square, Fisher exact, or Kruskal Wallis test, as appropriate.

RESULTS

Twenty-six incidents, 10 (38.5%) perpetrated by physicians and 16 (61.5%) perpetrated by nonphysicians, resulted in 83 casualties. All physician-perpetrated shootings represented either type III or IV violence motivated by grudges. Significantly more crimes perpetrated by nonphysicians were type II violence (11/16, 68.8%), P < .001, most representing grudges related to medical or surgical outcomes (7/16, 43.8%), P = .003. Physician perpetrated shootings occurred significantly more often in the victim's home (5/11, 45.4%), compared to nonphysician perpetrated attacks which more often occurred at a hospital or physician office (14/16, 87.5%), P = .03. Urologists (4/26, 15.4%) were disproportionately targeted.

CONCLUSIONS

These data may inform practical education and training to identify potential perpetrators before a work-related attack occurs by or on a physician.

The Effect of Abuse and Mistreatment on Healthcare Providers (TEAM): A Survey Assessing the Prevalence of Aggression From Patients and Their Families and Its Impact

OBJECTIVE

Aggression from patients and families on health care providers (HCP) is common yet understudied. We measured its prevalence and impact on HCPs in inpatient and outpatient settings.

METHODS

Four thousand six hundred seven HCPs employed by a community teaching hospital received an anonymous survey with results analyzed.

RESULTS

Of 1609 HCPs (35%) completing the survey, 88% of inpatient staff reported experiencing different types of aggression compared to 82% in outpatient setting. Almost half did not report it to their supervisor. Younger staff were more likely to report abuse. Negative impacts on productivity and patient care were reported. A third of all responders' indicated negative effects on mental health.

CONCLUSIONS

Despite negative impacts on staff wellbeing and productivity, patient/family aggression toward HCPs is highly prevalent and underreported. Our healthcare system needs measures to address staff security and wellness.

Hospitals as disaster victims: Lessons not learned?

OBJECTIVE

Hospitals are a key component to disaster response but are susceptible to the effects of disasters as well, including infrastructure damage that disrupts patient care. These events offer an opportunity for evaluation and improvement of preparedness and response efforts when hospitals are affected directly by a disaster. The objective of this structured review was to evaluate the existing literature on hospitals as disaster victims.

METHODS

A structured and scoping review of peer-reviewed literature, gray literature, and news reports related to hospitals as disaster victims was completed to identify and analyze themes and lessons observed from disasters in which hospitals are victims, to aid in future emergency operations planning and disaster response.

RESULTS

The literature search and secondary search of referenes identified 366 records in English. A variety of common barriers to successful disaster response include loss of power, water, heating and ventilation, communications, health information technology, staffing, supplies, safety and security, and structural and non-structural damage.

CONCLUSIONS

There are common weaknesses in disaster preparedness that we can learn from and account for in future planning with the aim of improving resilience in the face of future disasters.

Multimodal Active Shooter Training for Emergency Department Personnel: An Initiative for Knowledge, Comfort, and Retention

BACKGROUND

While hospital-related shootings are not common, recent years have demonstrated an increasing trend, especially involving the emergency department (ED). Despite this increase, there remains a lack of effective training for providers for active shooter events. Existing trainings commonly lack active participation, departmental-specific plans, or feasibility.

METHODS

Sixty-six emergency medicine physicians, nurses, and technicians participated in a two-phased multimodal active shooter training aimed to increase response knowledge and comfort. The initial training phase included a lecture on "Run-Hide-Fight" principles with departmental adaptations, followed by scenario-based discussion, and then safety walkthrough. Months later in the second phase, participants completed an active shooter simulation. An identical knowledge survey was collected before and after each phase along with descriptive analysis. Surveys were compared using paired t-test. Comfort levels were reported on a Likert scale and compared by paired t-test.

RESULTS

Paired t-tests confirmed a statistically significant difference in both active shooter knowledge and comfort levels. Participants showed retention of response knowledge and comfort with implementing response behaviors. Further descriptive analysis demonstrated effective fleeing and barricading, suggesting a real-life gain of knowledge and comfort.

CONCLUSION

A two-phased, multimodal training design for active shooter response was successful in increasing ED provider active shooter knowledge, comfort, retention, and effective response behaviors.

Preventing and Mitigating Radiology System Failures: A Guide to Disaster Planning

Disaster planning is a core facet of modern health care practice. Owing to complex infrastructure requirements, radiology departments are vulnerable to system failures that may occur in isolation or during a disaster event when the urgency for and volume of imaging examinations increases. Planning for systems failures helps ensure continuity of service provision and patient care during an adverse event. Hazards to which a radiology department is vulnerable can be identified by applying a systematic approach with recognized tools such as the Hazard, Risk, and Vulnerability Analysis. Potential critical weaknesses within the department are highlighted by the Failure Mode and Effects Analysis tool. Recognizing the potential latent conditions and active failures that may impact systems allows implementation of strategies to prevent failure or to build resilience and mitigate the effects if they happen. Inherent system resilience to an adverse event can be estimated, and the ability of a department to operate during a disaster and the subsequent recovery can be predicted. The main systems at risk in a radiology department are staff, structure, stuff (supplies and/or equipment), and software, although individual issues and solutions within these are department specific. When medical imaging or examination interpretation needs cannot be met in the radiology department, the use of portable imaging modalities and teleradiology can augment the disaster response. All phases of disaster response planning should consider both sustaining operations and the transition back to normal function. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

The Code Silver Exercise: a low-cost simulation alternative to prepare hospitals for an active shooter event

Mass-shooting incidents have been increasing in recent years and Code Silver—the hospital response to a person with a weapon such as an active shooter in many Provinces or States in North America—is quickly shifting from a theoretical safety measure to a realistic scenario for which hospitals must prepare their staff. A Code Silver Exercise (CSE) involving an independent mental practice exercise with written responses to scenarios and questions, followed by a facilitated debrief with all participants, was conceptualized and trialled for feasibility and efficacy. The CSE was piloted as a quality improvement and emergency preparedness initiative in three different settings including in situ within a hospital Emergency Department or Intensive Care Unit, offsite in a large conference room workshop, and online via virtual platform. These sessions took place in 4 different cities in Canada and included 3 academic teaching hospitals. Participants of the in situ and virtual CSE completed pre- and post-simulation surveys which showed improved understanding of Code Silver protocols following participation.

The CSE is a reproducible simulation alternative, designed to operationalize a Code Silver policy at a large healthcare institution in a sustainable way. This training model can be administered in multiple settings in-person (in situ or offsite), and virtually, making it versatile and easily accessible for participants. This exercise enables participants to mentally rehearse practical responses to an active shooter in their unique work environments and to discuss ethical and medical-legal implications of their responses during a facilitated debrief with fellow healthcare providers. Implementation of a CSE for training in hospitals may help staff to create a mental schema prior to an active shooter event, and thus indirectly improve the chances of survivability in the event of a real active shooter situation.

Emergency physician risk of occupational mortality: A scoping review

BACKGROUND

Occupational hazards for emergency physicians are widely known, but the risk of work-related mortality is not clear. The COVID-19 pandemic generated new concerns about the risk of occupational mortality, particularly in the setting of inadequate personal protective equipment. The perception of increased risk generated ethical concerns regarding emergency physicians' duty to treat and employers' duty to protect their employees. We performed this scoping review to define prepandemic emergency physician occupational mortality.

METHODS

We performed a scoping review of peer-reviewed publications from PubMed, EMBASE, and Cochrane databases in September 2020.

RESULTS

Of the 747 unique articles identified in the 3 databases, 1 article met inclusion criteria and was included in the final analysis.

CONCLUSION

The baseline risk of occupational mortality for emergency physicians is not established in the scientific literature. Further study is needed to quantify risk, as this information would be useful to shape policy and ethical considerations.

When disasters strike the emergency department: a case series and narrative review

INTRODUCTION

Emergency departments (EDs) are reasonably well prepared for external disasters, such as natural disasters, mass casualty incidents, and terrorist attacks. However, crises and disasters that emerge and unfold within hospitals appear to be more common than external events. EDs are often affected. Internal hospital crises and disasters (IHCDs) have the potential to endanger patients, staff, and visitors, and to undermine the integrity of the facility as a steward of public health and safety. Furthermore, ED patient safety and logistics may be seriously hampered.

METHODS

Case series of 3 disasters within EDs. Narrative overview of the current IHCD-related literature retrieved from searches of PubMed databases, hand searches, and authoritative texts.

DISCUSSION

The causes of IHCDs are multifaceted and an internal disaster is often the result of a cascade of events. They may or may not be associated with a community-wide event. Examples include fires, floods, power outages, structural damage, information and communication technology (ICT) failures, and cyberattacks. EDs are particularly at-risk. While acute-onset disasters have immediate consequences for acute care services, epidemics and pandemics are threats that can have long-term sequelae.

CONCLUSIONS

Hospitals and their EDs are at-risk for crises and their potential escalation to hospital disasters. Emerging risks due to climate-related emergencies, infectious disease outbreaks, terrorism, and cyberattacks pose particular threats. If a hospital is not prepared for IHCDs, it undermines the capacity of administration and staff to safeguard the safety of patients. Therefore, hospitals and their EDs must check and where necessary enhance their preparedness for these contingencies.

Perceptions of the Moral Obligations of Pediatric Nurses During an Active Shooter Event in a Children's Hospital

PURPOSE

To explore and compare the perceptions of nurses and parent/family advisors regarding pediatric nurses' moral obligations to children and families during an active shooter event in a children's hospital.

DESIGN AND METHODS

This was a descriptive, exploratory study using survey methodology. A convenience sample of all licensed nurses and parent/family advisors from four children's hospitals across the United States were recruited. Surveys consisted of five primary domains including Appropriateness of National Guidelines, Personal Preparedness, Moral Accountability, Professional/Legal Concerns, and Personal Risk Expectations. Frequency counts and percentages were calculated for each survey item.

RESULTS

Data from 874 pediatric nurses and 81 parent/family advisors were analyzed. Most respondents believed the Run-Hide-Fight campaign should be changed to Secure-Preserve-Fight. Only 30% of nurses felt mentally prepared to respond to an active shooter event. Most respondents agreed that nurses have a professional duty to protect their patients, but agreed that it was a personal choice, not a moral obligation, to accept potentially fatal risks. Hospital setting and patient vulnerability often influenced nurses' perceived obligations to patients. Most respondents reported they would not leave their patient/child during an active shooter event.

CONCLUSIONS

Nurses feel morally obligated to patients, but must balance their own personal risk tolerance level against the need to protect patients and families.

PRACTICE IMPLICATIONS

Hospitals need in-depth active shooter training for both nurses and parents as well as safety plans that address both evacuation protocols and measures to secure in place to protect the lives of patients, families, and staff.

An armed assailant in our hospital: Are we prepared?

While armed assailant attacks are rare in the hospital setting, they pose a potential risk to healthcare staff, patients, visitors and the infrastructure. Singapore hospitals have well-developed disaster plans to respond to a mass casualty incident occurring outside the hospital. However, lack of an armed assailant incident response plan can significantly reduce the hospital's ability to appropriately respond to such an incident. The authors describe various strategies that can be adopted in the development of an armed assailant incident response plan. Regular staff training will increase staff resilience and capability to respond to a potential threat in the future. The aim of this article is to highlight the need for the emergency preparedness units of all hospitals to work together with various stakeholders to develop an armed assailant incident response plan. This will be of great benefit for keeping healthcare facilities safe, both for staff as well as for the community.

The Power of an Active Shooter Simulation: Changing Ethical Beliefs

Introduction

During a hospital-based active shooter (AS) event, clinicians may be forced to choose between saving themselves or their patients. The Hartford Consensus survey of clinicians and the public demonstrated mixed feelings on the role of doctors and nurses in these situations. Our objective was to evaluate the effect of simulation on ethical dilemmas during a hospital-based AS simulation. The objective was to determine whether a hospital-based AS event simulation and debrief would impact the ethical beliefs of emergency physicians relating to personal duty and risk.

Methods

Forty-eight emergency physicians and physicians-in-training participated in this cohort study based in an urban academic hospital. Simulation scenarios presented ethical dilemmas for participants (eg, they decided between running a code or hiding from a shooter). Surveys based upon the Hartford Consensus were completed before and after the simulation. Questions focused on preparedness and ethical duties of physicians to their patients during an AS incident. We evaluated differences using a chi-squared test.

Results

Preparedness for an AS event significantly improved after the simulation (P = 0.0001). Pre-simulation, 56% of participants felt that doctors/nurses have a special duty like police to protect patients who cannot hide/run, and 20% reported that a provider should accept a very high/high level of personal risk to protect patients who cannot hide/run. This was similar to the findings of the Hartford Consensus. Interestingly, post-simulation, percentages decreased to 25% (P = 0.008) and 5% (P = 0.041), respectively.

Conclusion

Simulation training influenced ethical beliefs relating to the duty of emergency physicians during a hospital-based AS incident. In addition to traditional learning objectives, ethics should be another important design consideration for planning future simulations in this domain.

An Active Shooter in Your Hospital: A Novel Method to Develop a Response Policy Using In Situ Simulation and Video Framework Analysis

Hospital shootings (Code Silver) are events that pose extreme risk to staff, patients, and visitors. Hospitals are faced with unique challenges to train staff and develop protocols to manage these high-risk events. In situ simulation is an innovative technique that can evaluate institutional responses to emergent situations. This study highlights the design of an active shooter in situ simulation conducted at a Canadian level-1 trauma center to test a Code Silver active shooter protocol response. We further apply a modified framework analysis to extract latent safety threats (LSTs) from the simulation using ethnographic observation of the response by law enforcement, hospital security, logistics, and medical personnel.The video-based framework analysis identified 110 LSTs, which were assigned hazard scores, highlighting 3 high-risk LSTs that did not have effective control measures or were not easily discoverable. These included lack of security during patient transport, inadequate situational awareness outside the clinical area, and poor coordination of critical tasks among interprofessional team members. In situ simulation is a novel approach to support the design and implementation of similar events at other institutions. Findings from ethnographic observations and a video-based analysis form a structured framework to address safety, logistical, and medical response considerations.

Emergency Providers' Familiarity with Firearms: A National Survey

BACKGROUND

Emergency providers (EPs) are uniquely placed to advocate for firearm safety and have been shown to be at risk of exposure to firearms in the emergency department (ED). We sought to characterize EPs' knowledge of firearms, frequency of encountering firearms in the ED and level of confidence with safely removing firearms from patient care settings.

METHODS

This was a survey study of EPs representing medical centers in 22 states. A 15-item questionnaire was e-mailed to all EPs at all included institutions. Questions pertained to EPs' knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions with p-values and conducted association analyses among survey items.

RESULTS

Of 2,192 survey recipients, 1,074 (49.0%) completed the survey. A total of 635 (59.1%) reported encountering firearms in the ED or its immediate environment at least once per year, and 582 (54.2%) were not confident in their ability to safely handle a firearm found in a patient's possession. Frequency of handling firearms was significantly higher in states in the top quartile for firearm ownership, with 21.5% of respondents reporting handling firearms daily or weekly, compared to 10.9% in bottom-quartile states. Level of firearms training also differed significantly: 42.1% of respondents in top-quartile states reported formal training compared to 33.0% in bottom-quartile states. Increased regional firearm ownership rates were associated with decreased rates of feeling unsafe at work.

CONCLUSIONS

The majority of surveyed EPs reported little experience with handling firearms. Firearm experience was associated with comfort with managing firearms found in patients' possession. Regional differences were found regarding personal firearm experience and perceptions of workplace safety, both of which were associated with regional variations in firearm ownership. Despite this, no regional differences were found in encountering firearms in or around the ED. EPs may benefit from training on safely handling firearms.

U.S. acute care hospital shootings, 2012-2016: A content analysis study

BACKGROUND

Healthcare workers experience a disproportionately high frequency of workplace assaults. Incidents involving firearms are of particular concern.

OBJECTIVE

To provide detailed characterizations of recent hospital shootings to better inform prevention and mitigation strategies.

METHODS

Quantitative content analysis of reports involving hospital shootings resulting in casualties derived from web searches for each year from 2012-2016. Data were abstracted independently by two investigators, with differences resolved by consensus. Data were compared between subgroups by chi-square test, Fisher's exact test, or Kruskal-Wallis test, as appropriate.

RESULTS

Eighty-eight shootings occurred in 86 hospitals resulting in 121 firearms-related casualties, including 54 victims and 67 perpetrators. Case fatality rates were 55.6% (n = 30) and 70.1% (n = 47), respectively. The most frequent sites involved were the emergency department, (n = 27, 30.3%), patient room (n = 19, 21.3%), and parking lot (n = 13, 14.6%). Grudge (n = 17, 19.3%), suicide (n = 14, 15.9%), and mental instability (n = 13, 14.8%) were the most common explanations for these shootings. Four inadvertent discharges occurred and were more likely to involve a female perpetrator (p = 0.03). Shootings were most frequent during summer (p = 0.03) and winter (p = 0.04).

CONCLUSIONS

Out study findings on location and seasonal patterns can guide the development or improvement of prevention and mitigations strategies for hospital shootings.

Hospital Security Programs and Policies Related to Guns and Other Weapons

EXECUTIVE SUMMARY

Workplace violence in healthcare is a health and safety problem that can have a significant impact on the mission and effectiveness of organizations. To ascertain hospital approaches to address violence and experiences with guns and other weapons, we conducted a survey of International Association for Healthcare Security & Safety members. Although many hospitals have enhanced their security programs, many challenges persist. We found that armed security appears to be increasingly prevalent in hospitals, and the use of Tasers appears to be increasing the most in comparison to other weapons. Most of our survey respondents did not perceive officers losing control of their weapons during altercations in their healthcare facility as a real risk. In addition, roughly half of the respondents reported that portable metal detectors (including wands) were not used in their facilities. The disposition of weapons confiscated by security also raised concerns about how legally owned firearms can be safely returned to their owners while they are still on hospital property.

[Orientation for emergency and law enforcement personnel in internal threat situations in hospitals : Are guidance and orientation systems needed for hospitals?]

BACKGROUND

Emergency exit and escape routes in public buildings, such as schools, hospitals and administrative offices are controlled by legal rules and regulations. Thereby escape from the building is very well organized in cases of internal threats (e.g. fire, active shooter and hostage situations). Complex buildings with numerous rooms are a special challenge to emergency and law enforcement personnel. Without additional means of orientation a targeted localization of the incident is not possible in many cases.

MATERIAL AND METHODS

An extended literature search for guidance and building orientation systems, which enable an intuitive orientation and guidance for emergency personnel was performed.

RESULTS

Only three German systems were identified that enable orientation and reliable guidance of emergency personnel within buildings. All three systems, i.e. uniform orientation system schools (EOS), color guidance system (FLS) and the Gütersloh model (GM) were derived from shooting incidents in schools in 2009. Based on a systematic labeling of all rooms, stairways, exits and entrances, ad hoc orientation and guidance of law enforcement and emergency personnel is possible.

CONCLUSION

For targeted localization of an internal incident there only seem to be three German systems worldwide that enable an intuitive and immediate orientation and guidance within buildings. An increasing threat of worldwide terrorism and the fact that hospitals are seen as crucial infrastructures for attacks by terrorists make the implementation of guidance and orientation systems in hospitals urgently necessary. This is the first review dealing with this topic.

Workplace Violence: Experiences of Internal Medicine Trainees at an Academic Medical Center

OBJECTIVES

Healthcare professionals are at higher risk for workplace violence (WPV) than workers in other sectors. This elevated risk exists despite the vast underreporting of WPV in the medical setting. The challenge of responding to this risk is compounded by limited empirical research on medical training environments. Understanding trainees' experience and educating them on workplace safety, WPV reporting, and awareness of resources are shared goals of educational and institutional leadership. In our setting, clear understanding and education were urgent after the enactment of a statewide "constitutional carry" law affording individuals a right to carry concealed firearms in all state-owned universities and hospitals, beginning in July 2017. We sought to examine the incidence of WPV affecting Internal Medicine trainees to understand the types of violence encountered, reporting rates, and the factors that influence reporting.

METHODS

We conducted a cross-sectional online survey of Internal Medicine residents and fellows in practice for the previous 12 months. Survey items included both forced choice and open-ended questions. Descriptive statistics were calculated and used to summarize the study variables. χ² tests were performed to examine whether sex differences existed for each of the survey questions. Qualitative responses were content analyzed and organized thematically.

RESULTS

Of 186 trainees, 88 completed the survey. Forty-seven percent of respondents experienced WPV, with >90% of cases involving a patient, a patient's family member, or a patient's friend. Verbal assault was the most common type of incident encountered. Trainees formally reported fewer than half of the violent incidents disclosed in the survey. Major factors that influenced reporting included the severity of the incident, condition of the patient, and clarity of the reporting mechanism.

CONCLUSIONS

Previous research indicates similar amounts and types of WPV. Likewise, a large percentage of the incidents are not reported. Addressing the key factors related to why physicians underreport can inform institutions on how to make systematic changes to reduce WPV and its negative impact. Future research is needed to examine whether specific interventions can be implemented to improve reporting and reduce the incidence of WPV.

Hospital Planning and Response to an Active Shooter Incident: Preparing for the n = 1

Changing patterns of violence in the United States and around the world are increasingly manifest as acts of mass violence and acts of terrorism. Preventing such attacks, reducing harms, and maintaining operations following such events requires the bolstering of key infrastructure facilities, such as hospitals, and developing response plans capable of detecting and withstanding such attacks. Attacks occurring in a hospital or clinic present unique challenges that differ from workplaces or schools. This article provides an overview of active shooter incidents occurring within health care facilities, and the fundamental knowledge on how to respond and manage these challenging situations.

Emergency Physicians' Familiarity with the Safe Handling of Firearms

Introduction

Emergency physicians (EP) experience high rates of workplace violence, the risks of which increase with the presence of weapons. Up to 25% of trauma patients brought to the emergency department (ED) have been found to carry weapons. Given these risks, we conducted an educational needs assessment to characterize EPs’ knowledge of firearms, frequency of encountering firearms in the ED, and level of confidence with safely removing firearms from patient care settings.

Methods

This was a survey study of attending and resident EPs at two academic and four community hospitals in the Midwest and Northeast. A 26-item questionnaire was emailed to all EPs at the six institutions. Questions pertained to EPs’ knowledge of firearms, experience with handling firearms, and exposure to firearms while at work. We calculated response proportions and p-values.

Results

Of 243 recipients who received the survey, 149 (61.3%) completed it. Thirty-three respondents (22.0%) reported encountering firearms in the workplace, 91 (60.7%) reported never handling firearms, and 25 (16.7%) reported handling firearms at least once per year. Thirty-six respondents (24.0%) reported formal firearms training, and 63 (42.3%) reported no firearms training. There were no significant regional differences regarding firearms training or exposure. Residents from the Northeast were more likely to be moderately confident that they could safely handle a firearm prior to law enforcement involvement (p=0.043), while residents from the Midwest were more likely to be not at all confident (p=0.018).

Conclusion

The majority of surveyed attending and resident EPs reported little experience with handling firearms. Among resident EPs, there was a regional difference in confidence in handling firearms prior to law enforcement involvement. Given the realities of workplace violence and the frequency with which firearms are encountered in the ED, further investigation is needed to evaluate provider competence in safely handling them. EPs may benefit from training on this topic.

Active Shooter Training in the Emergency Department: A Safety Initiative

PROBLEM

Active shooter incidents are becoming more common, and although they are still rare compared with other shooting sites, incidents have increased in health care facilities. Agencies such as the Federal Bureau of Investigation, The Joint Commission, and the Emergency Nurses Association have emphasized that an action plan and training are essential for hospital preparedness.

METHODS

Planning an active shooter simulation for the emergency department was a complex project and involved collaboration between the hospital's Emergency Management team, simulation staff, security, and ED leadership, which included the educators and clinical nurse specialist. Decisions were made related to appropriate location, equipment, and needs for the functional exercises. Scenarios also were developed with roles for the ED population and actors.

RESULTS

A total of 204 staff members participated in the simulations between August and December of 2016. A survey was distributed to staff who attended the simulation. Ninety-two percent of staff felt more prepared to respond to an active shooter event and reported a 70% improvement in knowledge and preparation. Attendees reported their first response would be to flee the scene (66%), protect patients (15%), hide (7%), fight (6%), and call 911 (4%).

IMPLICATIONS FOR PRACTICE

The active shooter education included a didactic portion, a pre- and postsurvey, and the simulation event. The presentation focused on statistics of active shooters, possible threats, and the concepts of RUN, HIDE, and FIGHT. A Critical Incident Stress Management team member was present to ensure the emotional and psychological health of the participants. The debriefing was a crucial part of the simulation experience so staff could talk about their experience and express their concerns.

Utilizing compassion and collaboration to reduce violence in healthcare settings

Violence in healthcare settings is a global problem and violent acts are more likely to occur in emergency departments (EDs). Significant barriers to reporting workplace violence persist among healthcare workers. This, and lack of shared definitions and metrics, increase the difficulty of assessing its prevalence, understanding its causes, and comparing the impact of interventions to reduce its frequency. While risk factors for violence in EDs have been articulated, less is known about how the perspectives of patients and accompanying persons, and their interactions with ED staff may contribute to violence.

We discuss the nature and social context of ED violence and some approaches used to address this problem in the U.S. We argue that perpetrators of violence as well as healthcare staff who experience ED violence suffer when it occurs. While securing safety is paramount, compassionate practices to address this suffering and the social context from which it emerges should be developed and provided for all involved. Collaboration among stakeholders, including patients and family members, may lead to effective approaches to address this problem.

The effect of an active shooter response intervention on hospital employees' response knowledge, perceived program usefulness, and perceived organizational preparedness

Active shooter events occur frequently across the United States in a variety of locations, including health care facilities. Hospital health care worker response to an active shooter event may mean the difference in life or death for self or others. There is little research on how hospitals prepare nonmanagers to respond to active shooter events. We conducted a study to explore differences in knowledge, perceived organizational preparedness, and program utility following participation in an active shooter response program. Self-efficacy, personal characteristics, and professional characteristics were also explored. Program evaluation was conducted via a one-group pretest/posttest design. There was a significant increase in knowledge and perceived organizational preparedness postintervention. Trait-level self-efficacy did not have a significant effect on retained knowledge and perceived organizational preparedness. The current study is the first known to evaluate the efficacy of an active shooter response program for nonmanagers within an inpatient health care facility. Findings from this study may inform risk managers on how to educate employees on what to expect and how to react should an active shooter event occur.

Security, Violent Events, and Anticipated Surge Capabilities of Emergency Departments in Washington State

INTRODUCTION

Over the past 15 years, violent threats and acts against hospital patients, staff, and providers have increased and escalated. The leading area for violence is the emergency department (ED) given its 24/7 operations, role in patient care, admissions gateway, and center for influxes during acute surge events. This investigation had three objectives: to assess the current security of Washington State EDs; to estimate the prevalence of and response to threats and violence in Washington State EDs; and to appraise the Washington State ED security capability to respond to acute influxes of patients, bystanders, and media during acute surge events.

METHODS

A voluntary, blinded, 28-question Web-based survey developed by emergency physicians was electronically delivered to all 87 Washington State ED directors in January 2013. We evaluated responses by descriptive statistical analyses.

RESULTS

Analyses occurred after 90% (78/87) of ED directors responded. Annual censuses of the EDs ranged from < 20,000 to 100,000 patients and represented the entire spectrum of practice environments, including critical access hospitals and a regional quaternary referral medical center. Thirty-four of 75 (45%) reported the current level of security was inadequate, based on the general consensus of their ED staff. Nearly two-thirds (63%) of EDs had 24-hour security personnel coverage, while 28% reported no assigned security personnel. Security personnel training was provided by 45% of hospitals or healthcare systems. Sixty-nine of 78 (88%) respondents witnessed or heard about violent threats or acts occurring in their ED. Of these, 93% were directed towards nursing staff, 90% towards physicians, 74% towards security personnel, and 51% towards administrative personnel. Nearly half (48%) noted incidents directed towards another patient, and 50% towards a patient's family or friend. These events were variably reported to the hospital administration. After an acute surge event, 35% believed the initial additional security response would not be adequate, with 26% reporting no additional security would be available within 15 minutes.

CONCLUSION

Our study reveals the variability of ED security staffing and a heterogeneity of capabilities throughout Washington State. These deficiencies and vulnerabilities highlight the need for other EDs and regional emergency preparedness planners to conduct their own readiness assessments.

The New Age of Bullying and Violence in Health Care: Part 2: Advancing Professional Education, Practice Culture, and Advocacy

PURPOSE AND OBJECTIVES

This article will discuss new regulations and professional guidance addressing bullying and workplace violence including addressing recent organizational initiatives to support the health care workforce; reviewing how professional education has historically contributed to a culture of bullying across health care; and exploring how academia is shifting the culture of professional practice through innovative education programming.

PRIMARY PRACTICE SETTINGS(S)

Applicable to all health care sectors where case management is practiced.

FINDINGS/CONCLUSION

This article is the second of two on this topic. Part 2 focuses on how traditional professional education has been cited as a contributing factor to bullying within and across disciplines. Changes to educational programming will impact the practice culture by enhancing collaboration and meaningful interactions across the workforce. Attention is also given to the latest regulations, professional guidelines, and organizational initiatives.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Workplace bullying and violence have contributed to health care become the most dangerous workplace sector. This is a concerning issue that warrants serious attention by all industry stakeholders.Traditional professional education models have created a practice culture that promotes more than hinders workplace bullying and violence in the industry. Changes to both academic coursework and curricula have shifted these antiquated practice paradigms across disciplines. New care delivery modes and models have fostered innovative care and treatment perspectives. Case management is poised to facilitate the implementation of these perspectives and further efforts to promote a safe health care workplace for patients and practitioners alike.

Lessons Learned From an Active Shooter Full-Scale Functional Exercise In a Newly Constructed Emergency Department

OBJECTIVE

The primary objective of this exercise was to conduct a full-scale functional exercise utilizing an active-shooter-based scenario to test and evaluate hospital response and coordination with local law enforcement.

METHODS

A multidisciplinary group, including community partners, formulated objectives in accordance with the Homeland Security Exercise and Evaluation Program and defined a scenario. A date to conduct the exercise was chosen on the basis of the expected completion of a large section of the new emergency department but prior to its opening for patient care.

RESULTS

The exercise highlighted several strengths, but more importantly, illuminated areas for improvement that might otherwise have been missed in tabletop exercises and smaller-scale drills. Educational opportunities to improve functional skills and protocol were recognized.

CONCLUSION

Conducting a full-scale functional exercise of an active shooter in a newly constructed emergency department prior to opening for patient care provided valuable insight into areas for improvement while minimizing the impact such an exercise can have on daily operations. Should a similar opportunity arise as a result of new facilities being developed or renovations and maintenance requiring temporary closure, we advise hospitals to consider planning an exercise in the area prior to reopening for patient care. (Disaster Med Public Health Preparedness. 2017;11:522-525).

Workplace Violence in Health Care-It's Not "Part of the Job"

IMPORTANCE

While health care workers comprise just 13% of the US workforce, they experience 60% of all workplace assaults. This violence is the second leading cause of fatal occupational injury. Women comprise 45% of the US labor force but 80% of health care workers, the highest proportion of females in any industry.

OBJECTIVE

The purpose was to describe the prevalence, forms, and consequences of health care workplace violence (WPV). The role and components of prevention programs for avoiding or mitigating violence are discussed, including opportunities for participation by obstetrician-gynecologists.

EVIDENCE ACQUISITION

A search of PubMed from 1990 to February 1, 2016, identified relevant manuscripts. Additional studies were found by reviewing the manuscripts' references. Government Web sites were visited for relevant data, publications, and resources.

RESULTS

Health care WPV continues to rise despite an overall decrease in US WPV. While workers are most likely to be assaulted by clients or patients, they are most frequently bullied and threatened by coworkers. All incidents are markedly underreported in the absence of physical injury or lost work time. Sequelae include physical and psychological trauma, adverse patient outcomes, and perceived lower quality of care.

CONCLUSIONS

The human, societal, and economic costs of health care WPV are enormous and unacceptable. Comprehensive prevention, planning, and intervention offer the best means of mitigating risks. As women's health physicians and health care workers, obstetrician-gynecologists should be encouraged to participate in such efforts.