Nov. 10, 2022

When you consider planning an active shooter exercise, it might be natural to think, "Well, we don't have time for that."

Deborah O. Teske, C.E.M., a senior emergency management coordinator at Mayo Clinic's campus in Rochester, Minnesota, says allotting time for exercises is imperative. Exercises are crucial to ensure your hospital staff knows what to do in an incident and feels comfortable with the procedures. Also, an annual exercise is a requirement of The Joint Commission.

"I appreciate the frustration of feeling like you don't have time for exercises, but it's critical your staff learn to respond appropriately in an incident," says Teske. "An exercise is the only way to know if your plans and staff are ready."

Teske indicates an active shooter, defined by the FBI as "an individual actively engaged in killing or attempting to kill people in a populated area," can appear anywhere, location notwithstanding. The circumstances prompting an individual to shoot a firearm at a hospital may occur in large cities or small towns. Shooters may range from disgruntled employees to individuals angry at a particular physician or patient. They also may be individuals suffering mental health crises.

"When faced with a new incident, it's a fight-or-flight or freeze reaction," says Teske. "If you freeze and someone's pointing a gun in your direction, potentially you're dead. So, it's critical employees are trained and prepared to respond."

Another reason for practicing active shooter incidents is that they are growing not only in incidence but also in their focus on soft targets such as hospitals and schools, says Daniel Stephens, M.D., a trauma surgeon at Mayo Clinic in Minnesota and chair of the multiple-mass casualty incident subcommittee at Mayo Clinic.

"Shooting incidents can happen anywhere," he says. "Without planning and training, you'll be underprepared. You can't learn for the first time when an incident actually happens at your facility."

He indicates that a common theme in national mass casualty incident (MCI) meetings he attends is how to avoid being unprepared. The MCI meetings involve individuals who have managed past incidents such as those in Las Vegas and Boston. Dr. Stephens indicates his committee coordinates Mayo Clinic MCI exercises — including active shooter exercises — and that the institution supports this preparation. He also mentions that although locations like Rochester, Minnesota, are relatively sheltered from the gang violence of a city such as Chicago, increasingly drugs and violence are affecting Minnesota. Mayo Clinic trauma centers see more penetrating trauma cases now compared with years ago.

He comments that smaller, rural hospitals may indicate they don't see much penetrating trauma. But Dr. Stephens says, "If you're not experiencing these incidents day to day, it's all the more important to practice handling an active shooter situation."

Preparing to train for active shooter incidents

If you conduct emergency response exercises, especially active shooter incidents, Teske strongly encourages careful planning and management. She indicates an exercise itself can cause trauma for staff. She is aware of a hospital that was sued because employees thought an active shooter exercise was real, and they suffered traumatic stress because of it.

"You don't know what people have in their pasts," says Teske. "An exercise can trigger some people, so make sure everyone knows that it is an exercise and not real."

Dr. Stephens agrees. "You have to rely on simulations and make it as realistic as possible without triggering PTSD," he explains.

Teske emphasizes that beyond ensuring staff knows an exercise is occurring, staff needs permission to not participate. Before starting the exercise, alert patients and visitors via signs, personal conversations or overhead announcements. She also suggests coordinating with relevant internal groups, such as security, during the planning for an active shooter exercise.

Before an exercise

A crucial tactic for employee training before an exercise is the "Run. Hide. Fight." method promoted by the FBI:

• Run away from the incident area if near an exit, to find help.
• If you can't run away, hide and turn off your cellphone. If you are in a patient room, move the patient away from windows and barricade the door.
• As a last option in mortal danger, fight against the shooter. Grab an object, and hurl it at the assailant.

Staff may be able to complete active shooter incident training online and even remotely with e-learning materials.

"Undergoing these steps will help your staff feel ready for an incident and solidify appropriate actions in given situations," says Teske. "Most active shooter incidents take six minutes or less, but that brief time period requires preparation to handle capably."

Tips for active shooter exercises

Dr. Stephens and Teske offer tips and suggestions for conducting manageable active shooter exercises at your hospital, such as:

• Preparation

  The majority of effort for an exercise lies in preparation, such as coordinating with security and the work area for the location of the exercise, and in communication. The first concern in an exercise is front-line personnel — the personnel most likely affected by a shooting incident — but everyone in the hospital should know the plan.

• Format

  Consider conducting discussion-based tabletop or drill exercises, with actions taken but limited in scope, which are less resource intensive than a full-scale exercise. Teske indicates that instead of a full exercise, you can conduct a "slow drill." A walk-around drill is efficient because it requires only one staff member to lead it and involves walking through what might occur and potential responses at each step. Some examples of steps include activating lockdowns, calling 911, determining a hiding spot, turning off cellphones and pagers, and identifying objects you could throw at an assailant, if needed.

• Input

  It is wise to ask your staff members about what scenarios they would like to drill. For example, if multiple active shooter incidents have occurred recently in the U.S., staff members may feel afraid and may benefit from learning to manage their own safety in this scenario.

  If work areas request training for specific scenarios, try to oblige.

• Assistance

  If your hospital is part of a system, contact security or emergency management at one of your larger organizations or another nearby hospital for assistance conducting an exercise.

  Contact your county emergency manager, whose role is to help with training and exercises.

  Seek tools for emergency exercises from your regional health care coalition.

• Coordination

  Consider coordinating the exercise with the local airport, SWAT and other local agencies that a shooting might impact.

  Connect with local law enforcement through your hospital's liaison. Request help holding an exercise, which is especially appropriate because The Joint Commission requires community engagement in an annual exercise. Ask officers to share with staff what they would do if called about a shooting incident. Provide life safety drawings and hospital lockdown entrance procedures.

• Frequency

  Determine the frequency of active shooter or other emergency exercises based on your risk, hazard and vulnerability assessment. For instance, if your facility is at significant risk for an IT outage, practice that scenario annually or biennially. If your hospital is near a prison, large city or frequent gang activity, practice active shooter or violent patient incidents more often. Hospitals especially need exercises in times of policy and procedure change, or changes in staff or campus location.

• Debriefing and report

  Hold a debriefing after the exercise, writing up an after-action report to learn from the exercise and comply with The Joint Commission requirements. The report should identify strengths and areas for improvement. Assign recommendations to staff members for follow-up.

  Help facilitate an opportunity for hospital leadership and other parties who would want a briefing about an active shooter incident to review this report.

• Other recommendations

  Do not exercise using actual weapons, as it "could go bad quickly," says Teske. She suggests using orange rubber guns or other items that are obviously not a threat.

  Identify the hospital's highest risk areas, such as the emergency department, behavioral health or large-volume outpatient areas, focusing on them first.

  Consider other downstream effects that may occur after the incident, including national media attention.

  Decide what will happen with other patient care areas close to a shooting incident.

Dr. Stephens says that options exist to conduct active shooter exercises without overstretching hospital resources.

"Yes, active shooter exercises can be costly and time-consuming — especially in human resources — but they don't have to be," says Dr. Stephens.

For more information

Active shooter safety resources. FBI.

Run. Hide. Fight. FBI video repository.

Refer a patient to Mayo Clinic.