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

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.

Preparedness for Mass Casualty Incidents: The Effectiveness of Current Training Model

The importance of MCI organization and training was highlighted by the events of September 11, 2001. Training focuses on the management of physical injuries caused by a single traumatic event over a well-defined, relatively short timeframe. MCI management is integrated into surgical and trauma training, with disaster management training involving the emergency services, law enforcement, and state infrastructure agencies. The COVID-19 pandemic revealed gaps in the preparedness of nation states and global partners in disaster management. The questions that arose include 'has training really prepared us for an actual emergency,' 'what changes need to be made to training to make it more effective,' and 'who else should training be extended to?' This article focuses on the importance of involving multiple sectors in mass casualty training and asks whether greater involvement of non-medical agencies and the public, in operational drills might improve preparedness for global events such as the COVID-19 pandemic.

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.

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.

The Calm Before the Storm: Using In Situ Simulation to Evaluate for Preparedness of an Alternative Care Hospital During the COVID-19 Pandemic

Objectives:

Coronavirus disease (COVID-19) has been identified as an acute respiratory illness leading to severe acute respiratory distress syndrome. As the disease spread, demands on health care systems increased, specifically the need to expand hospital capacity. Alternative care hospitals (ACHs) have been used to mitigate these issues; however, establishing an ACH has many challenges. The goal of this session was to perform systems testing, using a simulation-based evaluation to identify areas in need of improvement.

Methods:

Four simulation cases were designed to depict common and high acuity situations encountered in the ACH, using a high technology simulator and standardized patient. A multidisciplinary observer group was given debriefing forms listing the objectives, critical actions, and specific areas to focus their attention. These forms were compiled for data collection.

Results:

Logistical, operational, and patient safety issues were identified during the simulation and compiled into a simulation event report. Proposed solutions and protocol changes were made in response to the identified issues.

Conclusion:

Simulation was successfully used for systems testing, supporting efforts to maximize patient care and provider safety in a rapidly developed ACH. The simulation event report identified operational deficiencies and safety concerns directly resulting in equipment modifications and protocol changes.

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.

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.

Use of tabletop exercises for healthcare education: a scoping review protocol

INTRODUCTION

There is a growing interest in developing interprofessional education (IPE) in the community of healthcare educators. Tabletop exercises (TTX) have been proposed as a mean to cultivate collaborative practice. A TTX simulates an emergent situation in an informal environment. Healthcare professionals need to take charge of this situation as a team through a discussion-based approach. As TTX are gaining in popularity, performing a review about their uses could guide educators and researchers. The aim of this scoping review is to map the uses of TTX in healthcare.

METHODS AND ANALYSIS

A search of the literature will be conducted using medical subject heading terms and keywords in PubMed, Medline, EBM Reviews (Evidence-Based Medicine Reviews), CINAHL (Cumulative Index of Nursing and Allied Health Literature), Embase and ERIC (Education Resources Information Center), along with a search of the grey literature. The search will be performed after the publication of this protocol (estimated to be January 1st 2020) and will be repeated 1 month prior to the submission for publication of the final review (estimated to be June 1st 2020). Studies reporting on TTX in healthcare and published in English or French will be included. Two reviewers will screen the articles and extract the data. The quality of the included articles will be assessed by two reviewers. To better map their uses, the varying TTX activities will be classified as performed in the context of disaster health or not, for IPE or not and using a board game or not. Moreover, following the same mapping objective, outcomes of TTX will be reported according to the Kirkpatrick model of outcomes of educational programs.

ETHICS AND DISSEMINATION

No institutional review board approval is required for this review. Results will be submitted for publication in a peer-reviewed journal. The findings of this review will inform future efforts to TTX into the training of healthcare professionals.

The 2015 Amtrak Philadelphia Train Derailment: After-Action Review of the Emergency Radiology Response at Temple University Health System

PURPOSE

The aim of this article is to assess a large tertiary care medical center's emergency radiology response after the 2015 Amtrak Philadelphia train derailment.

METHODS AND MATERIALS

A total of 55 patients with 308 total CTs and radiographs ordered within 12 hours of arrival to Temple University Health System (combining Temple University Hospital and Episcopal Hospital) emergency departments on May 12 to 13, 2015, were included in this study. A retrospective PACS and electronic medical record chart review of emergency department imaging turnaround times (TAT) during this event was completed and compared with emergency department radiology operations for the same 12-hour period throughout the preceding year. Wilcoxon's rank-sum test analysis was performed.

RESULTS

A total of 308 CTs and radiographs were performed, and 91 radiologically evident injuries were observed in a total of 30 patients, with fractures (n = 51) as the most common type of injury. There were no significant differences in time from patient arrival to beginning of radiological examination (26 min; interquartile range [IQR], 11-58 min) compared with annual median (28 min; IQR, 10-131 min; P = .232). Examination completion TATs were significantly increased (35 min; IQR, 17-112 min) compared with annual median (10 min; IQR, 5-15 min; P < .001), and time required from viewing of the examination by the radiologist to the examination being marked as read was significantly decreased (17 min; IQR, 6-45 min) compared with annual median (248 min; IQR, 126-441 min; P < .001).

CONCLUSIONS

The analysis highlights areas of efficiency in our response but also indicates areas for process improvement in future potential mass casualty events.

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)