Active-Shooter Preparedness Requires Operating-Room Provisions

By Will Boggs MD

November 12, 2019

NEW YORK (Reuters Health) - Active-shooter response plans need provisions that specifically address what happens in operating rooms.

"Hospital shootings and active-shooter events are increasingly common," said Dr. John T. Leppert of Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System, in California.

"These events and active-shooter 'false alarms' may occur during an operation," he told Reuters Health by email. "Surgeons should consider ahead of these events how to best coordinate responses at their hospital. These steps are needed to ensure the safety of themselves, the operating-room team, and the patient."

Dr. Leppert and colleagues describe their dilemma after notification of an active-shooter event one hour into a robotic partial nephrectomy for a patient with renal-cell carcinoma. The decision as to whether to continue or abort the case was left to the operating-room team, which ultimately decided to abort the case. It was later determined that the two reports of shots fired were erroneous.

In response to this alert, the authors note, each operating room had to make a decision of whether to proceed with their cases. Moreover, intensive-care-unit (ICU) team members also separately made response plans to try to safeguard staff and patients by transporting patients to the post-anesthesia-care unit (PACU) for shelter.

To overcome this lack of coordination, they say, there should be a coordinated response based on a prespecified centralized response plan, which would designate a single decision-maker for the operating room, PACU, ICU, emergency department (ED) and other critical-care areas.

The use of such an Incident Command System (ICS) could assure that critical decisions in the operating room are aligned with the broader facility-level decisions, the authors suggest in Surgery, online October 9.

Their own ICS and Incident Action Plans did not, in fact, address care delivery in the operating room during an active-shooter event. Moreover, they found no facility with an active-shooter Incident Action Plan that addressed the conduct of ongoing care delivery in the operating room and other critical care units among a selection of large urban trauma hospitals.

"When considering protocols specific to the operating room, and other key acute care areas of the hospital, input from clinicians caring for patients in these areas would be critical," Dr. Leppert said.

"When there is an immediate threat from an active shooter, each person will need the ability to make decisions for themselves," he said. "When the situation allows for coordinated responses, then decisions could be centralized to a single person (the Incident Commander). In the operating room, these decisions could consider the progress in the case (a case that is at a critical junction could continue, while a case just starting could be aborted as needed)."

Dr. Bryan Wexler from WellSpan, York Hospital, in York, Pennsylvania, who recently reviewed lessons from an active-shooter exercise in a newly constructed ED, told Reuters Health by email, "Active-threat situations are dynamic and unpredictable. Ultimately, the actual response of staff under direct and indirect threats will be based on situational awareness and judgment. A key point here though is to ensure clinicians have the right tools and training to make the best decisions possible under such circumstances."

"No matter which nomenclature is utilized, whether it is 'Run, Hide, Fight' or 'Secure, Preserve, Fight,' proper planning followed by realistic training and stress-inoculation techniques will help promote the desired reaction," he said.

"Depending on the situation, in an operating-room setting where there is potentially only one egress, barricading and sheltering in place may be a better option than blindly evacuating potentially into the line of fire," Dr. Wexler said. "However, it cannot be stressed enough that proper training is needed to help ensure good decisions, as what may be perceived as an indirect threat can quickly evolve into something more immediate."

Nicole McKenzie of the University of Toledo, in Ohio, who has written about active-shooter events, told Reuters Health by email, "Clinicians are accustomed to making split-second, life or death decisions, and they're already working quickly and efficiently as a team. With some additional training on how to effectively barricade and defend in place (and run, and evacuate their patient, etc.), they will have everything they need to make their decisions with as little chaos as possible. So, in essence, all of the decision making is left to the clinicians. We just need to give them the right tools to do it with confidence."

"Even if we can't prepare for every possible scenario, we should, at minimum, spend some time discussing appropriate responses that can save lives," she said. "Most importantly, the protocol can't stop after 'Fight.' The scene needs to be cleared, debriefing needs to occur, and mental-health support must be provided for all involved to reduce feelings of guilt, post-traumatic stress, and the stigma that can result after such complex ethical decisions have been carried out."

Dr. Matthew D. Sztajnkrycer of Mayo Clinic, in Rochester, Minnesota, who recently described a simulation-based training approach to active-shooter responses in the ED, told Reuters Health by email, "One thing not addressed in the decision-making process is the fact that the surgeons may actually be needed elsewhere. As such, even if the team felt they were safe, it might still be appropriate to abort the case in order to prepare for an influx of penetrating truncal trauma victims."

"Unfortunately, we live in a time where health care is no longer considered 'sacred,'" he said. "Increasing acts of violence impact health care providers on a daily basis. The authors have done a fantastic duty in highlighting their experience with the unthinkable. It behooves us to close our own practice gaps."


Surgery 2019.