Experts advise hospitals to heed warning signs, leverage security to prepare against shootings
September 1, 2014
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Experts advise hospitals to heed warning signs, leverage security to prepare against shootings
Executive Summary
While hospital shootings are not commonplace, studies suggest they are happening with increasing frequency, and that EDs are particularly vulnerable to this type of violence. Researchers report that roughly a third of all hospital shootings occur in the emergency setting. Experts say such incidents are typically targeted events, not random acts. Consequently, effective security programs should emphasize preventive steps to defuse potentially volatile situations and prevent weapons from entering the facility.
Hospital security departments should be equipped to provide training to employees throughout the facility so that employees know how to respond if an active shooter is identified.
• Researchers report that between 2000 and 2012 there were 154 shootings in American hospitals, and that the frequency of these events increased markedly in the later years of the study.
• Experts say hospital shootings may involve disgruntled patients, dementia patients, or psychiatric patients, but the most common perpetrators are prisoners who are brought into the hospital for treatment under guard.
• Security experts say effective safety plans should focus on identifying threatening language or other signs of agitation early on so that interventions can be employed. They also advise hospitals to install gun lockers at every entrance point so that lawful weapons can be stored before owners enter the facility.
• Liberalized gun laws in some regions are making security more difficult at public hospitals. Also, hospitals need to be careful with surveillance activities that could raise privacy concerns.
Some surveillance methods raise privacy concerns, but to avoid liability hospitals need to plan and prepare
In the early afternoon of July 24, a patient and a case worker entered the office of a psychiatrist at Mercy Fitzgerald Hospital, a community hospital in Darby, PA. Witnesses say they heard heated language and then gunfire. Later, it was learned that the patient opened fire, grazing the physician’s head. The physician then returned fire, using his own weapon. The patient was severely injured in the skirmish, and the case worker was killed.
While the details of this incident are chilling, experts maintain that hospital shootings do not happen often. Researchers report that between 2000 and 2012, there were 154 shootings in American hospitals.1 However, this same study shows that shooting events occurred with much greater frequency in the later years of the study. During the first six years of the study period, a mean of nine shootings occurred on hospital grounds per year. During the second six months, a mean of 17 shootings occurred. (Also see: "Survey: Incidents of violence on the increase in hospitals, better metrics, assessment tools needed," p. 101.)
Further, even though other types of violence occur much more frequently than shootings in hospital settings, hospital staff members are rightly fearful of the deadly impact that an active shooter can have in a matter of seconds. The incident at Mercy Fitzgerald Hospital illustrates this reality, but there are many other examples.
In September of 2010, a man who was upset about his mother’s prognosis at Johns Hopkins Hospital in Baltimore, MD, shot and wounded an orthopedic surgeon before killing his mother and himself. This prompted researchers at Johns Hopkins to take a closer look at hospital shootings, resulting in the 2012 study (mentioned above) and a day-long symposium this past spring on what steps hospitals can take to be prepared and respond to such incidents.
Identify vulnerabilities
One thing is clear: emergency workers are particularly vulnerable to this type of threat. Researchers report that roughly a third of all hospital shootings occur in an ED. However, Marilyn Hollier, the director of Hospital and Health Center Security Services at the University of Michigan Hospitals and Health Centers (UMHHC) in Ann Arbor, MI, and president of the International Association for Healthcare Security and Safety (IAHSS), explains that shootings are almost always targeted events.
"This not random violence," she says. "It’s [typically] a disgruntled patient, a dementia patient, or a psychiatric patient. And then there are the forensic or prisoner-patients who come into the hospital, take their correctional officer’s gun, and try to escape. That has probably been the most common [shooting event in hospitals]."
Recognizing the genesis of most gun violence events can help hospitals get on the front end of potentially volatile situations. "My program is emphasized on early intervention," explains Hollier. "If there is a disgruntled patient who is not happy with his doctor, or blames the doctor for whatever long-term disability he might have, usually there are warning signs out there."
For example, staff may be getting phone calls from the upset patient. Hollier’s approach is to train staff to report such incidents so that security can get a team together to evaluate the threat. "Depending on the threat, we can try to get these people counseling or other help," she says. "We can get risk management involved to see if there are other ways we can resolve their issues."
In most of these cases, patients or family members are just upset, stressed, or anxious, notes Hollier. "They or a loved one may be very sick and they may say things they don’t mean, so it is a matter of assessing these situations to find that one time where the person really [intends to carry out his threat], he has the means to do it, and there is a strong potential that he will do it," she explains.
The key is intervening at an early stage — ideally when a person has acted out or used threatening language for the first time, says Hollier. "We try to work with them, their family, their doctors, and social worker. There is a team of people, not just security, working to find a peaceful resolution," she says. "The last resort is that we may have to discharge them from practice and say we can’t treat them anymore."
Getting staff to notify security about patients or family members they are concerned about is a continuing challenge, explains Hollier. "A lot of times, staff members make their own decision that a person didn’t really mean [a threat that he or she voiced], so we know nothing about it. Then it happens again and again," says Hollier. "Then they will call us and say that this is the fourth time a person has been verbally abusive and threatening."
By this time, the patient feels empowered to make threats, and it is much more difficult for security to deescalate the situation, get the person to comply with hospital rules and regulations, and be the kind of person the hospital wants to serve, says Hollier. "It is easier to stop that behavior when it first starts. This is equally true with potentially violent employees. They don’t wake up one day and get that way," she observes.
While any threats need to be taken seriously, it is important to understand that a hospital visit is often a time of crisis for patients and their families. "It’s a stressful environment. You just have to balance that," says Hollier, noting that people are not at their best when they have a very sick child or parent. "They’re emotionally distraught and anxious. They’re not their normal selves, and nothing is wrong with that. It is not against the law to be a little crazy. It is just [a matter of] determining whether that behavior can escalate to violence or is just harmless."
It is a gray world, says Hollier. "You can’t just arrest a patient when he or she acts out. That is not the viable first-step answer because they need help," she says. "This is especially true for psychiatric patients who are not on their medications for whatever reason. It is a challenging environment some times."
Develop a dangerous weapons policy
The other aspect of prevention involves trying to keep weapons from entering the hospital. This is difficult because even hospitals that have metal detectors can’t place them at every entrance point. "You could address the ED [with metal detectors] as long as you address all access points — not just the front door," says Hollier. However, she stresses that administrators need to be cognizant of the fact that there are usually other ways to get inside.
Also, administrators need to consider the financial implications. "It is very expensive to run metal detectors because you have to have places to store the property and you have to have a definite armed presence," says Hollier. "I don’t recommend that hospitals put in a metal detector and then use unarmed security staff to run it."
Hollier suggests that the way airports handle metal detectors is best, but it may be impractical for hospitals. "They have unarmed staff running the metal detectors, but then at a distance away are armed people observing the whole check-in and check-out process," she explains. "That makes sense because the people running the metal detectors are up close and personal with the people [coming through], and weapon retention is always an issue. People grab guns from holsters."
Liberalized gun laws are making security more difficult at public hospitals, says Hollier. She recommends that hospitals install gun lockers at key entrance points, such as the ED. "If someone comes in and they are licensed to carry a gun, they can safely store their weapon," she says.
Also, gun lockers should always be posted outside locked-down psychiatric units, stresses Hollier. "Guns should not be going into lockdown units," she says. "Even on-duty police should be storing their weapons."
Hospitals should take particular care in how they deal with prisoners who enter the hospital for treatment under the guard of armed correctional officers, says Hollier. She advises hospital administrators to develop a dangerous weapons policy that specifically addresses this type of situation. "Any correctional officer that comes in [UMHHC] guarding a prisoner has to get clearance from security, and then we check on them to make sure they are following our rules," she explains. "If a correctional officer is found to be too close to a patient, or doing anything that renders the environment unsafe, we follow up with his or her supervisor."
Hollier also always requires that two correctional officers accompany a prisoner who is entering the hospital for treatment. "This way if one correctional officer gets his weapon taken away, the other correctional officer should be in a position to resolve the situation immediately without collateral damage," she says.
However, even with two guards, hospitals need to be hyper vigilant in these situations. Sheila Wilson, RN, MPH, co-founder of StopHealthcareViolence.org, a web-based resource for health care professionals, points to one recent incident at the Massachusetts Eye and Ear Infirmary, a specialty hospital in Boston, MA. "A prisoner had an appointment in the ED, and [after he arrived with two guards] he started to wrestle with one of them," she explains. Reports on the incident say that when the prisoner tried to get the guard’s gun, the gun went off, injuring the guard. The other guard then opened fire, severely injuring the prisoner.
"The prisoner’s arms and legs were both shackled, but he planned to escape that day," says Wilson. She adds that hospital security was on the scene quickly, but some of the nurses still recall the horror of that incident.
Wilson says it is up to hospital leaders to make sure that all hospital employees get any help they need following a violent incident of this nature. "Most hospitals have employee assistant programs. Some employees like them and some don’t like them at all," she says. "Right away, social workers should be sitting down with these people and talking with them about what they saw and how they are feeling. And if the employees aren’t ready to share at that point, then [the social workers] need to come back."
Provide training
The threat of an active shooter is getting more attention from accrediting agencies such as The Joint Commission, based in Oak Brook, IL. "Hospitals are figuring out that they’ve got to be planning and prepared for these types of events," explains James Hodge, Jr, JD, LLM, director of the public health law and policy program at Arizona State University in Tempe, AZ. (Also see, "Privacy, liability need to be considered when developing hospital security plans, p. XX.)
One common approach is to develop a communication program to alert hospital personnel to proceed as if an active shooter is on the premises. These may be given a disguised name so it can be used over hospital public address systems ("code silver" or "code black"). "The coding language can be problematic because people don’t always understand what it means, but it is an approach that is favored by accrediting agencies," says Hodge.
To keep hospital staff abreast of what to do in the event that such a code is called, it is important to provide regular training, advises Hollier. "The first thing we tell everyone is if it is safe to evacuate, then try to evacuate," she says.
If evacuation is not possible, then staff should try to hide or barricade in place, says Hollier, and she adds that part of her training program is focused on identifying "safe rooms" that would be good choices in specific areas of the hospital if staff need to elect this option. "If you can move the patient out of their bed and into a chair, then you can move the bed in front of the door so [a potential shooter] cannot get in," she explains.
As a last resort, staff may have to defend themselves, but Hollier only advises this approach in cases where evacuation or barricading in place is not possible.
Effective training programs typically leverage internal resources to make sure that hospital staff have the knowledge and skills to respond to potentially violent situations, says Hollier. "First and foremost, hospitals need to have good, comprehensive security departments that specialize in [health care] because there are a lot of unique challenges in a hospital environment," she says.
The IAHSS offers multiple resources that can help hospitals put good security programs in place, including officer training and advanced officer training programs, professional certifications, and guidelines, says Hollier. Well-trained security staff members can then take charge of making sure that personnel throughout the hospital are in a position to effectively respond to threats and other crises.
For example, at UMHHC, security staff members regularly provide violent crisis intervention training to frontline health care personnel. "We teach them how to use empathy skills to deescalate [potentially violent encounters], and how to recognize when nothing they say is going to deescalate someone," says Hollier. "They need to know when to call security to get us involved."
Security staff members also provide orientation sessions around the hospital to educate employees about the importance of having critical response plans, and how they can help the security department keep the community safe.
Wilson believes that hospital administrators need to do a better job of keeping the lines of communication open with their own employees about the issue of violence. "Entry-level workers such as housekeepers and nutrition people often have important input they can share because many of them come from the community," she says.
For instance, Wilson recalls learning how men in the community would wear their trousers in a distinctive way to hide their guns. "If you knew this was the type of attire they wore, then you would know the person had a gun," she says. "Community workers are your greatest asset. Learn to work with them and with the local branches of the police."
Editor’s note: The Emergency Nurses Association (ENA) offers a free online course on workplace violence that participants can take at their own pace. "Workplace Violence Prevention: Know Your Way Out," offers information on how to recognize and respond to workplace violence risk factors, and how to implement organizational prevention strategies. Also available from the ENA is a Workplace Violence Toolkit, containing templates and other tools particularly geared to the needs of the emergency setting. More information and links are available at www.ena.org.
The Centers for Disease Control and Prevention in Atlanta, GA also offers resources on violence prevention in health care settings. You can find more information here: http://www.cdc.gov/niosh/topics/violence/training_nurses.html.
Reference
- Kelen G, Catlett C, Kubit J, Hsieh Y. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine 2012;60:790-798.
- James Hodge, Jr, JD, LLM, Director, Public Health Law and Policy Program, Arizona State University in Tempe, AZ. E-mail: [email protected].
- Marilyn Hollier, Director, Hospital and Health Center Security Services, University of Michigan Hospitals and Health Centers, Ann Arbor, MI, and President, International Association for Healthcare Security and Safety. E-mail: [email protected].
- Sheila Wilson, RN, MPH, Co-founder, StopHealthcareViolence.org. E-mail: [email protected].
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