Active Shooter Training in the Emergency Department: A Safety Initiative

"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.

The impact of COVID-19 pandemic on temporal trends of workplace violence against healthcare workers in the emergency department

Background

It is known that there has been an increase over the years in attacks by patients admitted to the emergency department (ED) on healthcare workers; it is unclear what effect the COVID-19 pandemic has on these attacks.

Aim

to verify through a long-term time analysis the effect of COVID-19 on ED attacks on healthcare workers.

Mothods

a quasi-experimental interrupted time-series analysis on attacks on healthcare workers was performed from January 2017 to August 2021. The main outcome was the monthly rate of attacks on healthcare workers per 1000 general accesses. The pandemic outbreak was used as an intervention point.

Results

1002 attacks on healthcare workers in the ED were recorded. The rate of monthly attacks on total accesses increased from an average of 13.5 (SD 6.6) in the pre-COVID-19 era to 27.2 (SD 9.8) in the pandemic months, p < 0.001. The pandemic outbreak led to a significant increase in attacks on healthcare workers from 0.05/1000 attacks per month (p = 0.018), to 4.3/1000 attacks per month (p = 0.005).

Conclusions

The COVID-19 pandemic has led to a significant increase in attacks on healthcare workers in the ED. Trends compared to pre-pandemic months do not seem to indicate a return to normality. Health institutions and policymakers should develop strategies to improve the safety of the working environment in hospitals and EDs.

An Ethical Framework for Conducting Active-Shooter Simulation in the Healthcare Environment

SUMMARY STATEMENT

Active shooter events, although rare, are increasing in frequency in the United States, and healthcare settings are not immune to such events. Of the 277 active shooter events that took place in the United States between 2000 and 2019, 15 (4.5%) took place in healthcare facilities. Healthcare workers (HCWs) must be (1) well trained to respond to an active shooter event and (2) trained to respond to active shooter casualties. Educational activities related to active shooter events require a clear focus on goals and objectives, balanced to assure the physical and psychological safety of all participants. This article outlines how the recommendations of the National Association of School Psychologists might be adapted to conduct active shooter drills in the healthcare setting. This approach provides a framework for managing some of the ethical considerations in active shooter simulations.

A Simulation-Based Prospective Cohort Study on Teaching Best Practices in Firearms Safety

BACKGROUND

Gun violence in the United States is a significant public health concern. The high rate of weapons carriage by Americans places medical providers at risk for exposure to firearms in the workplace and provides an opportunity for patient safety counseling. Few curricular interventions have been published on teaching firearms safety principles to medical providers. Given the risk of encountering firearms in the workplace and the opportunity to engage patients in firearms safety counseling, providers may benefit from dedicated training on safely handling firearms.

METHODS

This was a prospective cohort pilot study of a simulation-based educational intervention for third- and fourth-year medical students enrolled in an emergency medicine subinternship and emergency medicine bootcamp elective. Before undergoing the educational intervention, students completed a preintervention simulation case during which they discovered a model firearm in the patient's belongings and were asked to remove it. Students then received the intervention that included a discussion and demonstration on how to safely remove a firearm in the clinical setting. Two weeks later, the students were presented with a model firearm in a different simulation case, which they needed to remove. During the preintervention and postintervention simulations, students were evaluated on their performance of the critical actions in firearm removal using an 8-item checklist. Students' scores on this checklist were compared.

RESULTS

Fifty-three students participated in the study, 25 of whom completed the postintervention assessment. The median number of correctly performed critical actions preintervention was 5 (interquartile range = 4-6) and postintervention was 7 (interquartile range = 6-8, P < 0.001). Students showed particular improvement in 4 steps: holding the firearm by the grip only, pointing the firearm in a safe direction at all times, removing the firearm from the immediate patient care area and placing it in a safe area, and ensuring that the firearm is monitored and untouched until police or security personnel arrive to secure it.

CONCLUSIONS

This educational intervention is the first to formally teach students about the safe handling of firearms found in the clinical care space. This low-cost pilot project is easily transferrable to other training centers for teaching principles of safe firearms handling.

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.

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.

Hospital-Based Simulation

This chapter discusses the current state of hospital-based simulation, including the unprecedented events of 2020's global COVID-19 pandemic. Hospital-based simulation training requires a new approach. The realities of social distancing and the operational demands of hospital staffing ratios warrant creative adaptations of traditional simulation training methods. Hospitals used simulation to improve patient outcomes by training healthcare staff and students through telesimulation, and tested systems and equipment using in situ simulation (ISS). Latent safety threats (LSTs) were identified and corrected to improve patient outcomes. Hospital-based simulation has been incorporated into newly licensed registered nurses (NLRNs) residency programs to prepare them for competent practice. Simulations are also used for preparing staff for low-incidence, high-risk medical emergencies or disasters, such as active shooter events. Hospital-based simulation training adds value to healthcare systems, but requires more evidence of its quantitative and qualitative impacts.

Work-based strategies/interventions to ameliorate stressors and foster coping for clinical staff working in emergency departments: a scoping review of the literature

BACKGROUND

Exposure to occupational stressors is an issue for staff working in emergency departments, managers and health services. The aim of this review was to identify, map, and synthesise the range and scope of current evidence for work-based strategies or interventions used in emergency departments to reduce occupational stressors and/or improve staff coping.

METHODS

The framework proposed by Arksey and O'Malley guided this review. A search of CINAHL, MEDLINE, Scopus, Cochrane and PsycINFO databases from January 2007 to June 2019 was applied. A total of thirty-one articles were included in this review. Quality appraisal was undertaken.

RESULTS

Exposure to or impact of occupational stress and workplace violence were common foci. A range of outcomes (such as burnout levels, stress levels and quality of life) were measured in the included studies. All studies demonstrated some improvement in outcomes measured although most were evaluated for relatively short duration. Quality of evidence varied.

CONCLUSION

Strategies ranging from mindfulness to organisational redesign have been trialed to diminish stress and enhance coping of emergency department staff. Understanding the effectiveness of strategies is an important early step in improving the working environment for emergency department clinicians in an evidence-informed manner. Such information may be of use to managers to inform decision making regarding the most appropriate strategy to implement in their emergency department.

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.

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.