What Obligations Do Clinicians Have in Active-Shooter Scenarios?

Marcia Frellick

August 29, 2017

If shots are fired in a hospital, what is a healthcare provider's responsibility to patients?

A new survey finds a gap between how the public and providers would answer that question.

The survey was conducted by Lenworth M. Jacobs, MD, MPH, from the Department of Surgery, Hartford Hospital, Connecticut, and Karyl J. Burns, RN, PhD, from the Department of Academic Affairs at the hospital, as part of a new focus of the Hartford Consensus.

The Hartford Consensus resulted from the American College of Surgeons' Joint Committee to Create a National Policy to Increase Survivability in Intentional Mass Casualty and Active Shooter Events.

Now, the survey results, published online August 14 in the Journal of the American College of Surgeons, show that the public and providers differ in opinions on the likelihood of a hospital shooting, how prepared hospitals are for such a scenario, and the degrees of responsibility of physicians and nurses.

Providers See Hospitals at High Risk

When asked about the likelihood of an active-shooter scenario, a relatively low percentage of the public thought hospitals were at high or very high risk (18%) vs those who thought shopping centers (39%), airports (37%), and schools (35%) were at that level of risk.

In contrast, a larger proportion of providers said all four location types were at high or very high risk: shopping centers (53%), schools (50%), airports (50%), and hospitals (33%).

About three quarters (72%) of the public believe hospitals are prepared for such a disaster compared with just more than half (55%) of healthcare professionals.

Although 79% of the public feel strongly that physicians and nurses should put themselves at personal risk to help, only 63% of health professionals felt that way, according to the survey.

And although 40% of the public felt strongly that physicians and nurses should be required to save lives in such a situation, even if it means putting their own lives at risk, only 15% of professionals said that should be required.

Discussions, Plans Needed

The widely different answers are further proof that hospital staffs and administrators need to start discussions and set policies, which are likely to differ by room and by hospital, Dr Jacobs told Medscape Medical News.

There are different considerations on a floor, where patients can easily walk, vs in an intensive care unit, where patient mobility is limited, or an operating room, where the patient is unconscious, he notes.

Among the questions healthcare providers should ask themselves are: What would they want if they were the patient or if their parents or children were the patients?

What if the patient tells the provider it is OK to flee and the patient is then seriously injured?

"How will you feel about that afterward?" Dr Jacobs asks providers to consider.

These conversations are important because the number of active-shooter events in any type of location the United States is on the rise. The FBI defines an active shooter as "an individual actively engaged in killing or attempting to kill people in a populated area." The number of events that fit the FBI definition increased from an average of 6.4 events from 2000 through 2006 to 16.4 events per year from 2007 to 2013, the authors report. Of those, four (2.5%) occurred in healthcare facilities between 2000 and 2013.

If the definition is expanded to include any shooting event, however, there were 154 incidents on hospital properties in which at least one person was hurt between 2000 and 2011, the authors note.

"An examination of the steady increase in hospital-based shootings reveals that the attacks have become more complex, involve more weapons, and target more individuals," they write.

"Less Likely Than a Lightning Strike"

Gabor Kelen, MD, professor and chair of emergency medicine at Johns Hopkins Medicine in Baltimore, Maryland, told Medscape Medical News this study may give the impression that active-shooter scenarios in hospitals are more frequent than they actually are, and may cause people to fear that hospitals are not safe. In reality, he said, such events "are less likely than a lightning strike."

That said, his previous research in 2012 found that protecting against such events is a substantial challenge for hospitals because the shootings occur both inside the hospital and outside on the grounds or parking lots.

Also, rather than spraying a crowd with bullets, he said, hospital shooters are usually looking for a single person to punish.

If the shootings occur, they are usually in the emergency departments, said Dr Kelen, who also is director of Hopkins' Office of Critical Event Preparedness and Response. Hopkins is particularly alert to the issue because they had an active shooter incident in 2010, he said. A patient shot and killed his mother and himself after shooting and wounding an orthopedic surgeon, who has since returned to practice.

Hopkins providers are required to complete online training about active-shooter scenarios, he added.

"Those of us who plan for these kind of events worry that there's a natural tendency for staff to run toward a panic issue, because we do want to help. That's not necessarily the best thing to do. If you, as a doctor, are taken out by the next bullet, you're not going to be any help to anybody," he said.

He agrees that every hospital should have a plan, but the reality is that a large percentage of hospitals in the United States are small and do not have the staff for sophisticated security plans "for something that is not likely to happen in anybody's lifetime," he says.

"To plan a real in-life exercise is very disruptive to hospital care and astoundingly costly," he said.

Dr Kelen says it is a struggle for healthcare professionals to think about balancing the responsibility to save patients with their responsibility to their family at home.

That struggle may get even more complicated when the patients are children, he said.

He said he was not surprised about the findings in the survey that nearly 80% of the public expects healthcare providers to put themselves at personal risk in active-shooter scenario.

However, "The idea that a doctor or a nurse is trained like a CIA/Secret Service agent and is going to step in front of a bullet is completely unreal. In the case of an active shooter, we're going to be as scared as anybody," he said.

Kind of Risk Would Elicit Different Responses

Bryan Wexler, MD, MPH, medical director for Disaster Preparedness and Response at WellSpan Health in York, Pennsylvania, told Medscape Medical News that their staff was able to do an active shooter drill coordinated with law enforcement before their new emergency department opened for patients.

They have plans in place, offer classes, and do periodic drills throughout the year for a range of disasters.

He said there would likely be different answers in the survey if it delved into what kind of risk the public and professionals would expect providers to take.

For instance, it is different to take a risk of helping evacuate a patient off a floor than it is to try to tackle a shooter.

"There's a lot of room for interpretation as to what [the authors] mean when they say 'putting yourself at risk,' " he said. "Every day, providers put themselves at some risk."

The perception of duty of care is a longstanding discussion, he notes, and the debate that flared decades ago with the beginning of the AIDS epidemic and, more recently, with Ebola.

"This is a more current take on an issue that is becoming more and more common," he said.

He and the authors noted that the majority of the public and providers considered the level of risk to be a personal choice.

"That coincides with the ethical literature on this," he says.

Staff need to protect themselves first before they can help others. "In the immediate aftermath, when the threat is over, you're still going to need to have providers to take care of those patients and any casualties," he said.

Langer Research Associates acquired the data (for a fee) and contributed to the analysis and interpretation of the data. The authors, Dr Kelen, and Dr Wexler have disclosed no relevant financial relationships.

J Am Coll Surg. Published online August 28, 2017. Full text

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