EXECUTIVE SUMMARY

Case managers can help their health systems prepare for the effects of mass shooting by taking several additional emergency preparedness steps.

  • Have a protocol that is specific to a mass shooting scenario.
  • Practice active shooter drills.
  • Address patients’ emotional health after such trauma.

Case managers are not the first healthcare professionals that come to mind when a mass shooting or terrorist event occurs, yet their roles can be essential.

Victims and their families might need the emotional support and knowledge of community resources that case managers can provide. Case managers also can fill in where needed and help staff deal with the aftermath of a traumatic event. They can also be go-betweens for media, families, and patients.

Case managers and others who have experienced this type of traumatic emergency offer the following suggestions for how to prepare and how case managers can be of benefit:

Have emergency preparedness plans in place. “If your hospital doesn’t have a protocol or some sort of plan, then go to the administration and talk about how a mass shooting event is a possibility because it doesn’t matter where you live anymore,” says Cathy Kearns, LCSW, case manager for the surgical ICU at Bay Medical Sacred Heart in Panama City, FL.

Active shooters have even targeted hospital staff, so hospitals need to be prepared for that as well, Kearns notes.

When seven spring break college students were shot in Panama City last year, there was concern that the shooter might follow victims to the hospital. It didn’t happen, but the hospital was prepared for it, she says.

“We have a tight security system and when we have something like the occurrence last year, we have a lot of police involvement, so they are monitoring the buildings and making sure there isn’t a second shooter involved,” Kearns says. “All hospitals have protocols for emergencies, and we have a silver code, meaning people should take cover because somebody is in the building with a gun or knife.”

Other codes for Bay Medical include yellow for a bomb threat and Adam for an infant abduction, she adds.

Active shooter drills should be part of emergency plans. When 17 people were shot at Umpqua Community College in the small community of Roseburg, OR, the local, 171-bed hospital’s 1,100 employees knew exactly what to do thanks to emergency preparedness planning, says Kevin Herskovitz, MS, safety and security manager of Mercy Medical Center in Roseburg.

“We received notice there was an active shooting event at the college campus, so we vetted it to make sure it wasn’t a training exercise or drill,” Herskovitz says. “When we realized it was a real event, we set up command and the ER began preparing to receive patients by clearing out a number of rooms to have space for victims.”

The hospital had teams, including clinicians and support staff, prepared to handle each person who came their way. The blood bank was ready, the operating room staff was on standby, and clergy were ready to assist with victims’ families as they also arrived at the hospital.

The hospital’s preparedness worked well, but there was one detail that posed an unanticipated problem: the influx of reporters and other media, Herskovitz notes.

“The media concerns were far and away the largest struggle for us to stay on top of over the next 10 days to two weeks,” he says.

General disaster preparedness works well, but health systems also need specific training for these active shooter or terrorist types of public disasters. “Ironically, we had penciled in to do our own active shooter drill sometime in the fall, and we had begun discussions on how to make that drill happen when the real event occurred off our campus,” Herskovitz says.

Pay attention to patients’ emotional well-being. When patients are injured from an active shooter event or another violent act, case managers can be of emotional help, says Geoffrey Brownell, BSN, RN, RN care manager at Mercy Medical Center.

“I talked with one of the shooting victims for a long time about what had happened,” Brownell recalled. “Later, there was an article written and she was interviewed and said that only one person had asked her about the incidents of the day, and that was me, sitting in there, talking with her and letting her talk.”

It’s important to resolve all of these trauma patients’ medical issues, but it’s also important to simply listen. Just grab a chair and sit near the patient, introduce yourself, and ask him or her how he or she doing and how the pain is, he suggests.

These questions can lead to a conversation that gives patients an opportunity to open up about their experience, Brownell says.

Help and work with families and patient gatekeepers. “I’ve had many families sit down in my office and cry,” Kearns says. “A lot of times, families are in shock and they want to tell their stories, especially if they know their loved one is not going to make it.”

So family members might pull out their phones to show pictures and talk about how their son or daughter was in law school or the president of the fraternity and was going to make something of him- or herself.

“We allow them to share; it’s what I call daily counseling,” Kearns says. “I’m licensed as a therapist and can talk with these individuals and family members and allow them to grieve.”

Their sadness is for children who died, as well as those who will never be the same when they leave the hospital, she says.

In other situations, family members might act as gatekeepers to healthcare staff accessing the patient. This requires case managers to hone their diplomatic skills.

“We have family dynamic issues with most of our patients, but with this mass shooting circumstance, it heightens it and makes it more challenging,” says Cindi Stephanos, BSN, RN, director of risk and quality/care management for Mercy Medical Center.

“You might have a mother who is trying to protect her child, but who might not always be rational about what she’s trying to accomplish,” Stephanos says. “You have to tread very lightly and be very careful because everyone is on edge.”

Family members might move into gatekeeper mode and try to keep hospital staff and others away from the victim when he or she is sleeping, and it’s true that patients need rest and a break. But that doesn’t always work, Brownell says.

“The police and FBI show up, and how do you work with these people while making sure the patient is getting rest?” he says. “The police are on a time schedule too, and it’s important they get information as soon as they can.”

Handle the media. When hospitals face a mass shooting or some other event that results in widespread media attention, some of the typical hospital dynamics change, case managers note.

For example, the Umpqua Community College shooting drew many reporters to the hospital as patients were being brought in, and their presence and attention was a threat to patient privacy, Brownell says.

“In a normal situation, I would call an ambulance when a patient has to be moved to another hospital, and have the ambulance by the main door, but in this circumstance, based on the attention the patient was receiving, we had to figure out how to get the ambulance to come to a side door to pick up a patient,” Brownell explains.

The media’s presence made logistics more challenging.

“Most media were ready and willing to play by the rules, but not all of them, and that was our biggest concern, to protect patients’ privacy,” Herskovitz says. “We wanted the patients and families who did not desire to have interactions with the media to remain physically private.”

This was most challenging when patients were discharged or transferred to another healthcare location. “The media literally was sitting in cars by the doors of the hospital, waiting to jump out and talk to people,” Herskovitz says.

In cases like this, hospitals should consider using a VIP plan in which victims of highly public tragedies receive the same attention to privacy, physical security, and protection as celebrities who are in a hospital, he adds.

This might even entail keeping patients in the hospital longer than medically warranted, Brownell says. “We had a situation where patients might have been medically able to be discharged, but because of the celebrity issue and other issues, they weren’t ready to actually leave the building — so we kept them in the hospital a little bit longer to make sure their exit plan was a safe and secure plan for them.”

Work with social workers and chaplains, and network with community resources. Families and patients will need additional help, particularly if the family is from out of town, Kearns says.

“Most families that come to our hospital from out of town are ill-prepared for staying long periods, especially if their loved one is intubated and might be that way for weeks to come,” Kearns says. “We have to sit down with them and talk about what’s going on and how we don’t know what the prognosis is, but the physician anticipates the patient will be here for another three to four weeks.”

Then case managers call hotels and, sometimes, even homeless shelters to find families a place to stay. When mass shootings or other traumatic events happen during spring break, most hotels are full or charging very high rates, making this option difficult for the families, she notes.

Also, there are some crime victims’ funds and assistance, and case managers can help patients and families obtain information about these, she says.