The Hartford Consensus: Survey of the Public and Healthcare Professionals on Active Shooter Events in Hospitals

"You have to live with some risk, it's part of the profession". Specialist ambulance nurses' perceptions of assignments involving ongoing lethal violence

BACKGROUND

As a result of several violent terrorist incidents, authorities in Sweden have shifted from previous approaches of being certain that it is safe for the ambulance service to enter the scene, to a one where "safe enough" is sufficient, potentially making it possible to save more lives. The aim was therefore to describe specialist ambulance nurses' perceptions of the new approach to assignments involving incidents with ongoing lethal violence.

METHODS

This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg.

RESULTS

Five categories containing conceptual descriptions were developed from the analysis: Collaboration, Unsafe environments, Resources, Unequipped and Risk taking and self-protection.

CONCLUSIONS

The findings highlight the need to ensure that the ambulance service is a learning organisation, where clinicians with experience of an ongoing lethal violence event can pass on and share their knowledge with colleagues to prepare mentally for such an event. Potentially compromised security in the ambulance service when dispatched to ongoing lethal violence incidents needs to be addressed.

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.

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.

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.

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.

Should I Stay or Should I Go? A Bioethical Analysis of Healthcare Professionals' and Healthcare Institutions' Moral Obligations During Active Shooter Incidents in Hospitals - A Narrative Review of the Literature

Active shooter incidents (ASI) have unfortunately become a common occurrence the world over. There is no country, city, or venue that is safe from these tragedies, and healthcare institutions are no exception. Healthcare facilities have been the targets of active shooters over the last several decades, with increasing incidents occurring over the last decade. People who work in healthcare have a professional and moral obligation to help patients. As concerns about the possibility of such incidents increase, how should healthcare institutions and healthcare professionals understand their responsibilities in preparation for and during ASI?

Mass Casualty Shootings and Emergency Preparedness: A Multidisciplinary Approach for an Unpredictable Event

Mass casualty events (MCE) are an infrequent occurrence to most daily healthcare systems however these incidents are the causation for new hospital preparedness and the development of coordinated emergency services. The broad support and operational plans outside the hospital include emergency medical services, local law enforcement, government agencies, and city officials. Modern-day hospital disaster preparedness goals include scheduled training for healthcare personnel to ensure effective and accurate triage for a high-volume of injured patients. This MDT collaboration strengthens the emergency response to optimize the delivery of life-saving care during MCEs. This review identifies the clinical importance of the interdisciplinary team interactions and the lessons learned from past MCE experiences, strengthening healthcare system readiness for such critical incidents.

Tourniquet usage in prehospital care and resuscitation of pediatric trauma patients-Pediatric Trauma Society position statement

BACKGROUND

Recent mass casualty events in the United States have highlighted the need for public preparedness to prevent death from uncontrolled hemorrhage. The Pediatric Trauma Society (PTS) reviewed the literature regarding pediatric tourniquet usage with the aim to provide recommendations about the utility of this adjunct for hemorrhage control in children.

METHODS

Search terms "pediatric" and "tourniquet" were used to query the US National Library of Medicine National Institutes of Health for pertinent literature. Exclusion criteria include not involving children, not involving the use of an extremity tourniquet, primary outcomes not related to hemorrhage control, tourniquet use to prevent snake envenomation, single case reports, and only foreign language formats available. Bibliographies of remaining studies reviewed to identify additional pertinent research. Four physician members of the PTS Guidelines Committee reviewed identified studies.

RESULTS

One hundred thirty-four studies were identified. One hundred twenty-three studies were excluded. Seven additional studies were identified through bibliography review. Eighteen pertinent studies were reviewed. Seven articles evaluated physiologic response to tourniquet use in operating room settings. Six articles were generated from combat experience in conflicts in Afghanistan and Iraq. Four articles discussed technical details of tourniquet usage. One article evaluated the use of tourniquets during the Boston Marathon bombing in 2015.

CONCLUSION

Despite limited data of limited quality regarding their use, the PTS supports the usage of tourniquets in the prehospital setting and during the resuscitation of children suffering from exsanguinating hemorrhage from severe extremity trauma. Expedited, definitive care must be sought, and tourniquet pressure and time should be limited to the least amount possible. The Society supports the ACS "Stop the Bleed" campaign and encourages further investigation of tourniquet use in children.

LEVEL OF EVIDENCE

Guidelines/algorithm study, level IIIa.

Active Shooter: What Would Health Care Students Do While Caring for Their Patients? Run? Hide? Or Fight?

OBJECTIVE

The aim of this study was to explore the clinical decisions that health care students would make if faced with an active shooter event while providing patient care.

METHODS

A cross-sectional study design was used to survey 245 students from 6 different professional programs. Participants read 4 case-based scenarios, selected 1 of 4 actions in a multiple-choice format, and responded to an open-ended question. Demographic questions asked whether participants had been a victim of violence and whether they have taken a certified active shooter course. Statistical analysis included descriptive statistics and chi-square testing.

RESULTS

For each case, most students chose "patient-centric" versus "provider-centric" actions (range: 66%-94% and 4%-17%, respectively). The gender of the patient made no difference in actions. Those who attended a certified active shooter course tended to act with more "provider-centric" concerns than those who did not take such a course.

CONCLUSION

A significant majority of interprofessional health care students, when presented with specific case-scenarios, declared they would act to protect themselves and their patients during an active shooter event. This "patient-centric" attitude transcends the oversimplified "Run-Hide-Fight" axiom and must be addressed by all health care educational institutions.

An In Situ Simulation-Based Training Approach to Active Shooter Response in the Emergency Department

With an increased number of active shooter events in the United States, emergency departments are challenged to ensure preparedness for these low frequency but high stakes events. Engagement of all emergency department personnel can be very challenging due to a variety of barriers. This article describes the use of an in situ simulation training model as a component of active shooter education in one emergency department. The educational tool was intentionally developed to be multidisciplinary in planning and involvement, to avoid interference with patient care and to be completed in the true footprint of the work space of the participants. Feedback from the participants was overwhelmingly positive both in terms of added value and avoidance of creating secondary emotional or psychological stress. The specific barriers and methods to overcome implementation are outlined. Although the approach was used in only one department, the approach and lessons learned can be applied to other emergency departments in their planning and preparation. (Disaster Med Public Health Preparedness. 2019;13:345–352)

Public Perceptions About Nerve Injury From Hip Replacement Surgery

BACKGROUND

Nerve injury is a distressing complication for patients and surgeons that is difficult and frustrating to understand and treat. Whether the standard of care has been met when this complication occurs is a common question for both patients and surgeons but there is no information about how the public feels about nerve injury.

METHODS

The author surveyed 1409 individuals insured in a senior products health program using a 22-item questionnaire about nerve injury during hip replacement. Participants were given written descriptions of total hip arthroplasty, nerve injury, and the standard of care.

RESULTS

Seventeen percent of participants indicated that a direct nerve laceration is a standard of care violation. Respectively, 98%, 100%, 94%, and 97% of participants responded that the standard of care requires the surgeon to promptly identify the nerve injury, completely inform the patient about the nature and prognosis of the injury, and present options for treating the nerve injury. Eleven percent indicated that they lack trust in health care. Participants with distrust were more likely to find a standard of care violation than other participants. Women and non-white participants responded more commonly that a standard of care violation occurred with the nerve injury. Income level, age, prior surgery, and educational background were not differentiating factors as to whether participants found that a violation of the standard of care had occurred.

CONCLUSION

Most participants would accept the possibility of nerve injury during hip replacement but they would expect to be informed in advance that this complication is possible.