Active Shooter Events Research Articles

Assessment of Emergency Department Staff Awareness of Policy and Expert Opinion Protocol Regarding Active Shooter Events.

Active shooter incidents (ASI) have continued to increase over the years, with the majority of attacks occurring in the workplace. Workplace violence in the hospital setting is a growing concern in the emergency department (ED). While ASI are inherently unpredictable by nature, it is prudent to be prepared for these scenarios in the hospital to prevent fatalities. The goal of this study is to access the level of familiarity of emergency department staff with ASI hospital policy and response protocol. A survey of ED employees was distributed using the Qualtrics® platform via an electronic link. The study was approved by the University of Central Florida College of Medicine's IRB. Only 10% had participated in an ASI drill in the past year. Personnel who answered "no" to the question, To your knowledge, is there a hospital-based emergency action plan in the event of ASI?, were significantly more likely to feel unprepared for an ASI (P < 0.0001). Those who did not receive training for a hospital-based emergency action plan were similarly less likely to feel prepared (P = 0.0002). Most ED providers in the survey reported feeling unprepared to handle an ASI in the emergency department. This study underscores the need to implement regular training on ASIs for ED staff.

Active Shooter Preparedness: Is Your OR Ready?

Active shooter events, including those in health care facilities, are expected to increase in incidence. Perioperative personnel may be underprepared for such an event. Understanding how to make the best decision regarding whether to escape, hide, or fight, and being aware of the communication channels during these types of events are crucial to adequate preparation. Health care facilities and critical areas such as the OR should be prepared for an active shooter event. This article briefly describes a firsthand shooting event experience at Johns Hopkins Hospital and includes a review of the literature on active shooter events in health care settings to determine the most practical application of event preparedness for staff members working in the OR. It also discusses the highly relevant concept of patient abandonment.

How police officers are shot and killed during active shooter events: Implications for response and training

Active shooter events have driven police to change how they respond to events where an attacker is actively engaged in killing civilians. This paper examines these changes through the lenses of Normal Accident Theory (NAT) and Resilience Engineering (RE). Our results show a police officer is shot in one out of every six active shooter events in the United States. We then apply RE to better understand how these shootings occur so that police can improve their ability to anticipate, monitor, and respond during these attacks. Implications for police training are discussed.

A Comparative Synthesis of American and Korean Parricidal Mass Murders

Contemporary studies of mass murder have examined attacks carried out by current or former students in educational settings or disgruntled employees at former places of work. Recently conceptualized as “active shooter events,” this type of public mass killing has eclipsed the most pervasive one throughout the twentieth century: mass killings within the family. The dearth of scholarly work on mass killings in the context of parricides in other national and cultural contexts is notable given the salience of family killings in the homicide literature. Using previously published findings on parricides in nineteenth-century America and twentieth-century Korea, this paper provides a comparative synthesis of parricidal mass murders—mass killings that occur during the course of parricides. Notable points of convergence and divergence are discussed relative to culture and offense characteristics.

Armed and considered capable? Law enforcement officers’ attitudes about armed teacher policies in the USA

Active shooter events, including those in K-12 schools in the USA, continue to occur. In an effort to protect students, faculty, and staff, several states have implemented policies allowing teachers to be armed while on school premises, with more expected to follow suit. While recent research surveys the general public, school administrators, and policing executives (from a single state) regarding their perceptions of armed teacher policies, there is a dearth of literature that examines the issue from the law enforcement community’s perspective. The present study utilizes a nationwide survey of law enforcement officers, collected in 2020, that encompass a wide variety of job duties, agency types/sizes, and types of communities served. We find widespread support for armed teacher policies; however, respondents expressed a desire for additional training for teachers to better prepare them to respond to an active shooter event. Additional implications for policymakers and school administrators considering this policy are offered.

Education, preparation, and moral obligation: An examination of hospital employee role in active shooter training response

As active shooter and armed intruder events continue to increase, hospitals have recently begun using the Department of Homeland Security-endorsed “Run Hide Fight” procedures to train employees on how to respond to violent situations. This study uses survey data collected from 333 staff in various employee roles at a Midwest hospital. Employees responded to questions related to “Run Hide Fight” policy education, feelings of preparedness for an active shooter event, and perceptions of moral obligation related to remaining with patients during a potentially fatal encounter. Results indicate variations in education and preparedness response among administration, clinical staff, and non-clinical staff.

Active shooter mitigation techniques.

This paper looks at current active shooter mitigation techniques employed by schools throughout the country in an attempt to mitigate casualties during an active shooter event. The researchers modified an existing Columbine High School agent-based model created by Jae Lee, MS, to examine if the introduction of a school resource officer (SRO), concealed carry weapon (CCW) holder, or both would change the outcome of the previous research. RUN.HIDE.FIGHT® scenarios were modeled with the same parameters of the previous work, but now included armed first responders during the incident to assess whether their presence decreased casualties through a reduction in response time. The researchers determined that the addition of either an SRO, CCW holder, or both significantly reduced casualty rates during an active shooter scenario.

Software library for agent-based modeling and simulation of active shooter events.

Software libraries have been used for decades to produce code in a quick and cost-effective manner. The use of well-designed libraries permits software developers and other professionals to create applications due in part to code reusability. Also, good libraries grant lesser skilled developers the opportunity to make high-quality applications they otherwise could not produce. In the field of active shooting incident (ASI) research, various tools have been used for years that give researchers the ability to conduct exploratory research. However, as good as these tools might be, there has been little thought about reusability of these models and associated code. This has hindered the proper advancement of the research field given that researchers must often start from nothing when building a new model. Constant repetition of the same basic tasks has not enabled researchers to expand model fidelity and has limited time to dedicate toward the problem set. This paper proposes the creation of a new agent-based ASI library, made for the AnyLogic® system. The library assists researchers in quickly creating models using a well-defined application programming interface. It also abstracts away implementation details so that the library user does not get waylaid in development. The authors also recreated parts of a large and powerful AnyLogic model to observe the resultant library employment. It was determined that a significant amount of time can be saved building new models, even with the initial version of the library implementation.

"Code Green Active" Curriculum: Implementation of an Educational Initiative to Increase Awareness of Active Shooter Protocols Among Emergency Department Staff.

There has been an increase in violent acts against hospital employees, including active shooter events. Emergency department (ED) staff must be able to respond to these events efficiently to ensure the safest possible outcome. However, few in our ED were aware of our hospital's active shooter protocol. We aimed to increase staff knowledge of and confidence in these guidelines. We developed and implemented a 7-week spiral curriculum using the Kern model of curriculum development. Each week, a segment of the hospital active shooter protocol was featured. Multimodal instructional methods including posters, instruction at daily team huddles, descriptions in the weekly division newsletter, and email summaries were used.A 10-question assessment was administered to ED staff both before and after the implementation of our curriculum. During both assessments, staff were asked to rate their confidence in both knowledge of and ability to follow hospital active shooter guidelines. There were 95 and 102 participants in the preintervention and postintervention periods, respectively.The median proportion of correct answers on the knowledge assessment increased when comparing preintervention with postintervention performances (P < 0.05).Staff confidence in both knowledge of and ability to follow active shooter protocols increased after the implementation of our curriculum (P < 0.05). Our 7-week curriculum resulted in improved knowledge of and confidence in hospital active shooter protocols among ED staff. Given that our sample was an unpaired convenience sample, inferences from our analysis were limited. Tabletop simulations are currently underway to further reinforce and clarify concepts.

Educating and Empowering Inner-City High School Students in Bleeding Control

IntroductionUnintentional bleeding is the leading cause of death in people 1–44 years of age in the United States. The Stop the Bleed (STB) campaign is a nationwide course that teaches the public to ensure their own safety, call 911, find the bleeding injury, and achieve temporary hemorrhage control by several techniques. Although the national campaign for the training course was inspired by active shooter events, the training can be applied to motor vehicle accidents and small-scale penetrating and gunshot wounds. Extending the audience to inner-city high school students in a violence-prone neighborhood has the potential to save lives if they are first on the scene.ObjectivesWe hypothesized that students would have a greater degree of comfort, willingness, and preparedness to intervene in acute bleeding after taking the course.MethodsThis was a prospective, interventional pilot study in one inner-city high school in Brooklyn, New York. Students were given the option to participate in the STB course with pre- and post-surveys. We recruited 286 students from physical education or health education class to take a 50-minute bleeding control training course. Mean age was 15.7 years old. Students were divided into groups of 20–25 and taught by 2–3 emergency medicine, pediatric, or trauma surgery STB instructors. Each course included 2–3 skills stations for placing a tourniquet, wound packing, and pressure control.ResultsPrior to the course, only 43.8% of the students reported being somewhat likely or very likely to help an injured person who was bleeding. After the course, this increased to 80.8% of students even if no bleeding control kit was available. Additionally, there were significant improvements in self-rated comfort level from pre- to post-course 45.4% to 76.5%, and in self-rated preparedness from 25.1% to 83.8%. All three measures showed statistically significant improvement, P <.0001.ConclusionTeaching the STB course to high school students from a community with high levels of violence resulted in increased comfort level, willingness, and preparedness to act to control bleeding. If these opinions translate into action, students’ willingness to act could decrease pre-hospital blood loss and empower youth to perform life-saving interventions.

An Ethical Framework for Conducting Active-Shooter Simulation in the Healthcare Environment.

Active shooter events, although rare, are increasing in frequency in the United States, and healthcare settings are not immune to such events. Of the 277 active shooter events that took place in the United States between 2000 and 2019, 15 (4.5%) took place in healthcare facilities. Healthcare workers (HCWs) must be (1) well trained to respond to an active shooter event and (2) trained to respond to active shooter casualties. Educational activities related to active shooter events require a clear focus on goals and objectives, balanced to assure the physical and psychological safety of all participants. This article outlines how the recommendations of the National Association of School Psychologists might be adapted to conduct active shooter drills in the healthcare setting. This approach provides a framework for managing some of the ethical considerations in active shooter simulations.

Immersive virtual reality training module for active shooter events

Active shooter events are not emergencies that can be reasonably anticipated. However, these events do occur more than we think, and there is a dire need for an effective evacuation plan that can increase the likelihood of saving lives and reducing casualties in the event of an active shooting incident. This has raised a major concern about the lack of tools that would allow robust predictions of realistic human movements and the lack of understanding about the interaction in designated environments. Clearly, it is impractical to carry out live experiments where thousands of people are evacuated from buildings designed for every possible emergency condition. There has been progress in understanding human movement, human motion synthesis, crowd dynamics, indoor environments and their relationships with active shooter events, but challenges remain. This paper presents an immersive virtual reality (VR) experimental setup for conducting evacuation experiments and virtual evacuation drills in response to extreme events that impact the actions of occupants. We have presented two ways for controlling crowd behavior. First, by defining rules for agents or NPCs (Non-Player Characters). Second, by providing controls to the users as avatars or PCs (Player characters) to navigate in the VR environment as autonomous agents with a keyboard/ joystick along with an immersive VR headset in real time.The results will enable scientists and engineers to develop more realistic models of the systems they are designing, and to obtain greater insights into their eventual behavior, without having to build costly prototypes.

Multimodal Active Shooter Training for Emergency Department Personnel: An Initiative for Knowledge, Comfort, and Retention.

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. 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. 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. 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.

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.

Community context and perceived risk: perceptions of active shooter risk in Pennsylvania

This study explored interconnections among perceived risk of an active shooter event occurring in the community, indicators of community vulnerability, and individual demographic traits. Individual-level data were obtained using an online survey of 668 adult Pennsylvania residents, selected to be representative of Pennsylvania demographics. Four subthemes of the Social Vulnerability Index (SVI) were used as proxy indicators of community vulnerability. Results indicated that higher levels of perceived risk were associated with lower income. There was limited evidence that Blacks and females had higher perceived risk than Whites and males, respectively. Community vulnerability was positively associated with perceived risk, most notably higher levels of community vulnerability related to minority population. Those with higher education had lower perceived risk than those with lower levels of education. Results support the minority threat hypothesis but differ somewhat from studies examining fear of crime more generally.

"Shots fired! We have many people down!": Common recommendations for managing high-casualty active shooter events in the USA

Active shooter events are disasters that continue to impact communities and people in the United States. Responses to active shooter events by first responder organizations have improved since the Columbine event; however, problems still exist in these responses. Using systems theory and the qualitative method known as thematic analysis, the purpose of the current study was to examine the recommendations provided in after-action reports of high-casualty active shooter events to identify improvements that can be made by first responder organizations to provide a more effective response to active shooter events. Three main themes were identified and are discussed.

Preparedness of senior centers for active shooter incidents.

The main objective was to evaluate the preparedness of senior centers (SCs) for active shooter (AS) events and test the hypothesis that most SCs were not organized to properly handle AS incidents. A cross-sectional study based on questionnaire with quantitative measures. A questionnaire-based multistate survey of SC Directors (SCDs) of public and private SCs. SCs were included upon receipt of answers from SCDs to questionnaire-based survey, resulting in 139 SCs from Ohio, Pennsylvania, Michigan, Maryland, Indiana, Illinois, New York, and West Virginia. SCs, SCDs, and SCs' staff preparedness and vulnerability to an AS event. Over half (56 percent) of SCDs replied that their center was not prepared for an AS event. A significant (p < 0.01) association was found between the SCD's perception of being prepared and the availability of a formal AS preventive policy. The lack of panic buttons and surveillance cameras was significantly (p < 0.01) associated with the feeling of inability by SCDs to respond effectively to an AS event. Those SCDs who were confident about their AS preparedness felt significantly (p < 0.01) better prepared to respond to an AS incident. Personal interviews with content experts agreed that all SCDs should take steps to develop an official AS preparedness policy, but its implementation should be the direct responsibility of local policymakers and legislators. Most SDCs and SCs are unprepared for AS incidents. SCDs should review or develop specific recommendations and implement plans for a better preparedness of SCs and SCDs for AS events. Considering the inherent high vulnerability of older adults, there is an urgent need to have such AS policy in place.

Perceptions of the Moral Obligations of Pediatric Nurses During an Active Shooter Event in a Children's Hospital

PurposeTo explore and compare the perceptions of nurses and parent/family advisors regarding pediatric nurses' moral obligations to children and families during an active shooter event in a children's hospital. Design and methodsThis was a descriptive, exploratory study using survey methodology. A convenience sample of all licensed nurses and parent/family advisors from four children's hospitals across the United States were recruited. Surveys consisted of five primary domains including Appropriateness of National Guidelines, Personal Preparedness, Moral Accountability, Professional/Legal Concerns, and Personal Risk Expectations. Frequency counts and percentages were calculated for each survey item. ResultsData from 874 pediatric nurses and 81 parent/family advisors were analyzed. Most respondents believed the Run-Hide-Fight campaign should be changed to Secure-Preserve-Fight. Only 30% of nurses felt mentally prepared to respond to an active shooter event. Most respondents agreed that nurses have a professional duty to protect their patients, but agreed that it was a personal choice, not a moral obligation, to accept potentially fatal risks. Hospital setting and patient vulnerability often influenced nurses' perceived obligations to patients. Most respondents reported they would not leave their patient/child during an active shooter event. ConclusionsNurses feel morally obligated to patients, but must balance their own personal risk tolerance level against the need to protect patients and families. Practice implicationsHospitals need in-depth active shooter training for both nurses and parents as well as safety plans that address both evacuation protocols and measures to secure in place to protect the lives of patients, families, and staff.

The Power of an Active Shooter Simulation: Changing Ethical Beliefs.

IntroductionDuring 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.MethodsForty-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.ResultsPreparedness 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.ConclusionSimulation 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.

Pennsylvania Workplace Safety: Employee Perceptions of Active Shooter Preparedness.

This study investigated the role of workplace preparedness actions in employee perceptions of workplace risk, workplace preparedness, and personal self-efficacy in an active shooter event. Data were drawn from an online, state representative survey of 668 Pennsylvania residents in 2019. Nearly 40% of employees reported their workplaces had not taken any preparedness actions. Having a workplace take a greater number of preparedness actions was associated with increased self-efficacy and increased perceptions of workplace preparedness, but also an increase in perceived risk. Males and gun owners perceived lower levels of workplace risk and reported substantially higher self-efficacy. However, associations between workplace efforts and self-efficacy differed from those for perceived workplace preparedness. Associations with firearm policy and the presence of security staff also differed for the two outcomes.