Mock hostage crisis helps hospital prepare strategies for the real thing

Drill helps risk manager devise policy for future use

The risk manager at St. Edward Mercy Medical Center in Fort Smith, AR, watched as a police SWAT team stormed her facility to end the several hours of negotiation with the gunmen who had taken employees hostage. But after a lot of screaming, gunfire, and blood, she thanked the hostage-takers for doing such a good job.

The screaming and the appreciation were real, but the guns fired blanks and the blood was fake. The hospital had just completed a mock hostage drill, an unusual emergency exercise conceived by risk manager Eileen Kradel, RN, JD. (See p. 110 for the actual scenario.)

Even though everyone knew it was a drill, the scenario was graphic and left all the participants shaken, Kradel says. But that was part of the drill’s purpose — letting everyone know just what a hostage situation is like. "It was quite realistic. We had a lot of fun with it, but parts of the drill were extremely realistic and frightening for those involved," Kradel recalls. "We tried to make it a real learning experience by playing along just as if it were a real hostage situation. Everyone at the hospital played their roles just as they would in a real hostage situation, and since we’d never been in that scenario before, we learned a lot about what we should do."

The hostage drill was not prompted by any event at the hospital, but Kradel says she and other hospital leaders had become worried that the hospital could be a target for someone planning to take hostages or someone who becomes violent and takes hostages in a panic. That situation has occurred at other hospitals, and Kradel notes that health care facilities always are at risk of violence from people irate over their bills, a patient’s death, and family disagreements or from psychiatric patients and police prisoners.

No one wants to think about this frightening subject, but Kradel figured it was better to train for a hostage situation than just hope it never happens. Unlike in some other emergency situations, she and her staff had little idea what they would do in a hostage emergency. They would call the local police, of course, but what else?

To answer that question, Kradel contacted the Fort Smith Police Department to ask for help and found they were quite eager to put on a hostage drill at the hospital. A cooperative plan for the drill would allow the hospital to better prepare and would provide a realistic training opportunity for the local SWAT team.

"It was a great arrangement, because they have access to a lot of experts that we would never get access to," Kradel says. "They appreciated the opportunity to train in a very realistic way, and one of the big benefits of this whole thing was getting a better relationship with the local police department. We need them in so many situations, so it’s great to be on good terms with them."

Intensive planning went into the drill. In two sessions of two hours each, the head of the SWAT team and a police educator met with hospital security officials and several department heads to provide basic education about hostage situations and plan the actual drill.

Safeguarding patients, visitors

The team determined the best place to hold the drill was at the hospital’s cancer treatment center, which is in a building attached to the hospital. Because the cancer center was open for business only during the day, it would be clear of patients and visitors in the evening when the drill would take place. The rest of the hospital operates around the clock, but no services would be interrupted during the drill.

Hospital employees were recruited to play the hostages, but they were accepted only after they fully understood how stressful the experience might be. The police explained to them that the drill could go on for several hours, during which they would not be allowed to leave and might be quite uncomfortable. Physical force would be kept to a minimum, but they were warned that the mental stress might be severe.

Various officials of the hospital were alerted that they would be needed during the drill, but they did not know precisely when it would happen, and no one knew what the scenario would be. The hostage taker or takers would be played by undercover police officers and actors from a local theater group — all complete strangers to the hospital officials and volunteer hostages.

The hospital switchboard got a call at 7 one night reporting that someone with a gun had taken hostages in the cancer center. The hospital operator called hospital security and then 911 to summon police. The game was on.

Police cars, SWAT vans, fire trucks, and ambulances converged on the cancer center. SWAT leaders set up a command post and proceeded to start negotiating with the hostage takers inside. Over the next two hours, the police disconnected the cancer center’s phone system, then threw them a portable phone that provided the hostage takers a direct line with the police negotiator. "Everything was very realistic," Kradel says. "The police were in charge and deciding how things would go, but we were there providing the kind of assistance that we could."

For instance, hospital engineers and physical plant workers were on site with blueprints to help the SWAT team learn their way around the cancer center and disable the phone system. Kradel and other hospital leaders were there to help the SWAT team leaders make decisions about how to respond, though the final decisions always were made by the police.

The risk manager also worked closely with the hospital’s public relations staff to coordinate the simulated release of information to the press. Pastoral care representatives were present to counsel the hostages and their families. The hospital’s security staff was busy keeping people away from the scene and, in this case, informing worried onlookers that it was only a drill.

The scenario was so realistic that the police even had a pizza delivered to the scene, at the request of the hostage-takers. The chief of police participated in the drill, just as he would in a real hostage situation. One hostage and one police officer were "shot" during the scenario, and the hospital emergency department "treated" them as they were rescued.

"It was very similar to the typical disaster drills that hospitals participate in all the time, but the scenario was different," Kradel says. "Everyone was playing along as if it were real, and the tension levels could get quite high at times. It was an opportunity for a lot of hospital departments to test themselves."

The drill ended about 10 p.m., three hours after it began, when the SWAT team stormed the building to arrest the gunman and rescue the four hostages. When it was all over, the participants met for a debriefing in which they all discussed how they felt during the crisis and what they may have learned about responding to future events.

"We learned that the hostages developed very real feelings about the people holding them. It was a strong reaction," Kradel says. "The biggest thing we learned is that we are not the experts; the police know very specific things that work with hostages, and our role at that point is to support them. We primarily hold down the fort until police get here and take over."

The hospital’s security staff play an important role in helping secure the area and preventing other employees and bystanders from getting involved, but they do not try to rescue the hostages or arrest the hostage-takers. A hostage situation is a delicate one requiring police negotiators.

The cancer center suffered no damage in the drill and was ready for business the next morning. As a result of the experience, Kradel developed a "Code Command" policy for the hospital. It is similar to other emergency procedures found at most hospitals, such as "Code Red" or other codes for a fire in the facility. The policy lays out specific procedures to be followed when a hospital employee learns of a hostage situation in the facility, including the use of the term "Code Command" as the coded announcement to be used over the public address system. (See p. 112 for the Code Command policy.)

While the drill was useful in helping develop the new policy, Kradel says some questions were left unanswered. One drill will teach a lot of lessons, but it also will highlight questions you can’t answer right away, she says.

The hospital will conduct another hostage drill in the next few months in hopes of answering more questions about how it should respond. The risk manager concluded that staff could have done a better job of warning onlookers that the hospital was not actually under siege. Hospital employees had been warned the drill would take place, and an announcement was made over the public address system when the drill actually began for the benefit of visitors and patients. Security staff and others throughout the hospital also explained the drill to onlookers.

The weak point, Kradel discovered, was outside the facility. Visitors approaching the hospital, and people just driving by, were disturbed by what seemed to be a major police action. Kradel plans to develop ways to alert the public that everyone in the hospital is indeed safe.

"Visitors and people in the parking lot were very frightened by all the police cars, ambulances, and wounded people being taken to the emergency room," she says. "We learned that if we’re going to have a drill, we must have some method of funneling traffic away and making sure people know it’s a drill."

Readiness is in the details

These are some other questions that still need be addressed:

• Will the plan for housing the press in basement rooms work, or will they refuse to cooperate?

• Since the busy emergency department is one of the most likely spots for hostage-taking, do the drills and Code Command adequately address that department?

• How should traffic be directed outside the hospital? Should separate parking areas be established for emergency vehicles and others?

• What if patients must be evacuated? How can that be done safely without putting employees at risk?

Kradel says the hostage drill was immensely helpful in familiarizing the hospital staff with the kind of challenges they would face in such a crisis. But one drill and one draft of the Code Command policy are not enough, she says. The policy will evolve as she and her staff learn more.

"We’re now more aware of our ability to respond, and that makes us more comfortable about responding to a real emergency in the future," Kradel says. "I’ve never heard of anyone else doing a drill like this in the hospital, but this is one of the most positive things we’ve ever done in terms of educating people."