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by Steven M. Crimando, BCETS, CHS-V, Behavioral Science Applications | October 2017

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When You Hear Hoofbeats…

In the late 1940’s, Dr. Theodore Woodward, a professor at the University of Maryland

School of Medicine famously told interns, “When you hear hoofbeats, think horses, not

zebras.”i The message to his students was simply, when assessing a situation, consider

the more likely or common causes before exotic explanations. While horses are

common, at least in Maryland, zebras are not. As applied to the risk of violence in

hospital, healthcare and human service settings, most violence involves unarmed

patient-to-staff assaults. Regarding gun violence, what is more common than active

shooter situations, are shooting incidents. Active shooter events are the rarest, but most

devastating form of violence in hospitals. But in the moment a shot is fired, it is not

important to understand the shooter’s motives or which category of violence the attack

falls into; everyone must understand how to respond in the interest of survival. As such it

is important to be prepared for both the hoofbeats of horses (i.e. “shooting incidents”), as

well as zebras (i.e. “active shooter situations”), but to have an accurate understanding of

the realities of hospital shootings.

Recent incidents at

hospitals in Indiana, New

York, New Hampshire and

Florida are powerful

reminders of the special

challenges associated

with violence prevention

and active shooter

preparedness in hospital

and healthcare settings.

Any shooting incident in a

hospital or healthcare

setting is a nightmare

scenario. Active shooter

situations in hospitals are different from those in other environments in several critical

ways that should inform plans, procedures and exercises. The large number of patients,

visitors and medical staff on hand in hospitals means that a shooting incident may

produce multiple casualties. But in efforts to prevent, respond to, and recover from

hospital shootings, it is important to understand the distinction between an “active

shooter” situation and a “shooting incident.”

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The U.S. Department of Homeland Security defines an active shooter as, “an individual

actively engaged in killing or attempting to kill people in a confined and populated area.”ii

(DHS, 2013) In active shooter situations in non-hospital settings, the events are typically

planned long in advance of the attack, and are instances of “predatory” or cold-blooded

killing. In these situations target selection is usually random and the shooter usually has

no prior relationship with the victims, but rather has selected the venue because it

represents a “target rich” environment that will allow him (96% male) to kill as many

people as possible before he is stopped.iii The motives for such shootings are multiple

and complex. Many shots are fired; the attacker may be armed with multiple weapons,

and possibly explosives, and in some instances has been equipped in tactical gear.

Hospital shooting incidents tend to be acts of targeted violence and do not typically

involve random victim selection. In hospitals, the shooter (91% male) more likely has

specific targets in mind. Such instances usually arise from smoldering hostility and are

instances of “affective” or hot blooded killing. Many involved former staff or patients who

have been off the hospital’s radar for some time. The most common scenarios in

hospitals stem from a real or perceived grievance with current or former caregivers or

coworkers whom the perpetrator believes have wronged him or his loved ones in some

way. Some are instances of domestic violence that follow an employee from home to

work; others are mercy killings of a terminally ill loved one, often ending as a

murder/suicide.

Motives for Hospital Shooting Incidents:

• Grudge/Revenge (27%)

• Suicide (21%)

• Ending life of ill relative (14%)

• Escape attempt by prisoner (11%)

• Societal violence (9%)

• Mentally unstable patient (4%)

Many shooting incidents are spontaneous and emotionally driven. For example, in 23%

of shootings within the Emergency Department, the weapon was a security officer's gun

taken by the perpetrator when the opportunity presented itself. In hospital shooting

incidents, fewer rounds are fired, fewer weapons are involved, and the most common

victim is the perpetrator (45%).iv

True active shooter situations evolve quickly and about 70% of the cases end within 5

minutes.v The shooter, applying the principles of surprise, speed and violence of action,

seeks to create the highest casualty count possible before the police arrive. When the

shooter transitions from being the hunter to hunted, he loses his tactical advantage, and

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the incident ends one way or another quickly thereafter. Understandably, much attention

has been given to those five minutes of terror in the “response gap;” that time between

when the first shot is fired and when the first police arrive. This is a time when the action

of victims, witnesses and bystanders can be the difference between life and death, so

plans, training and exercises often focus exclusively on this narrow section of the overall

event timeline.

Sadly, we have learned

from experience the

psychological, social and

economic damage done

by a shooting can

continue to impact

individuals, families,

organizations and

communities for decades

after the incident. Much

less attention has been

given to understanding

and proactively planning

to manage the post-

incident consequences of an active shooter attack or shooting incident in the hospital or

healthcare setting. By understanding the critical challenges and action steps associated

with the post-shooting environment leaders and decision-makers can better map out the

road to recovery. As with other critical incidents it is helpful to apply a phase-specific

approach to identify the mile markers along that road to ensure a timely and effective

response to the complex post-shooting environment.

Planning Along the Event Timeline

As the first law enforcement personnel respond to 911 calls and reports of shots fired,

they will quickly take command and control of the tactical aspects the situation. It will be

necessary to proactively establish liaison between the organization’s leadership team,

the Hospital Incident Command Systems (HICS) and the law enforcement command

structure (Incident Command System). There will be information and support needed

from the organization to aid the police response. Floor plans and access to CCTV feeds

or files can greatly help tactical leaders gain a better understanding of the operating

environment, improve officer safety, and hasten the process of finding and stopping a

shooter. At the onset, there will necessarily be a high level of collaboration and

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coordination, but law enforcement officials are unlikely to give much direction about how

the organization should address the pressing post-shooting challenges beyond the

immediate response phase.

Immediate Post-Shooting Phase

The immediate post-shooting phase includes the first minutes to hours of the crisis. Life

safety and survival remain the top priorities even though the shooter has been stopped.

Within the scope of this paper, we will not address the issues of triage and emergency

casualty care, and all that those activities involve. We will rather make the assumptions

that medical personnel within the affected facility have planned and exercised casualty

care and the response phase of an internal mass casualty scenario. In the immediate

post-shooting, as the smoke begins to clear, there are a number of foreseeable

challenges that can be addressed through pre-planning. These include:

Assembly and Accountability of Evacuees

In the initial attack many people, including employees, visitors, vendors and anyone who

may have been onsite at the time of the incident, may have self-evacuated or followed

evacuation instructions given by the organization or responding police to evacuate.

Individuals in this group should be directed to predetermined assembly or muster points.

Such assembly points should not be in adjacent parking areas since it is possible the

attacker(s) may have also left

improvised explosive devices

(IEDs) in vehicles or in other

nearby positions for a secondary

attack on incoming responders.

Upon arrival at an assembly

point, evacuees should check in

to begin an accountability

process. It will be important for

the organization’s leaders to

quickly establish the

whereabouts of their personnel.

Any employees who were out of

the facility or at other locations at

the time of the shooting should be notified there is an emergency onsite and not to

return. Employees arriving at assembly points should also be asked and/or quickly

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looked over to make sure they have not been hurt. Endorphins, often associated with the

“runner’s high” sensation, are powerful neuro-hormones that activate the body's opiate

receptors, causing an analgesic effect. This means an injured person may not

necessarily realize they have been hurt. There are examples of this effect even with

gunshot wounds.

Non-evacuating employees must also be accounted for. There are likely to be

employees and others still inside a facility in the immediate wake of an attack. It will be

important to know who they are, where they are, and if there are any immediate medical

needs. Law enforcement officers employ a slow and meticulous clearing process to

search the facility after an attack. They are always cautious that there may be other

suspects and/or that the attacker(s) have carried other hazardous devices or substances

into the environment. Employees who may have taken refuge in offices, closets or

conference rooms should remain in place until informed by the responding officers that it

is safe to move. It will be important therefore, for the organization’s leaders to establish

some channel of communications with those barricaded employees since they are

unlikely to know the status of the event while in hiding. Informing the law enforcement

command team of the whereabouts and status of those hunkered down can help them

prioritize the discovery and release of those employees, and/or speed medical support to

them if someone has been injured.

Attend to basic needs, such as water and warmth or cooling, basic emotional support in

the form of Psychological First Aid, and connection to loved ones as early as possible.

Many individuals may also be witnesses, and as such, law enforcement officials may

wish to interview and take statements from them before they leave. Coordinate the

release of these employees with the law enforcement Incident Command structure.

Evacuating employees gathered in assembly points should also be instructed to redirect

any media questions to the Public Information Officer within the command system and

not to speak to the media themselves.

Family Reunification

The greatest source of anxiety in a crisis is separation from loved ones and the paucity

of information about their status. The organization’s plans should envision the need for a

Family Reunification Center (FRC) since loved ones of those in the targeted facility are

likely to begin arriving quickly after learning about an attack. FRCs are non-medical legal

operations, and are not coordinated by the local jurisdiction coroner/or medical examiner.

The role of the FRC is to provide family members of victims or potential victims with

information about status of the situation and of their loved ones. Planners should

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consider indoor venues or at least the ability to relocate to an indoor setting in inclement

weather.

Current models of Family Reunification Centers now assume the possibility of up to 8-10

friends and family members converging on the reunification point given how quickly and

widely information travels through new media channels and social media platforms. It

will be important to control incoming traffic from family members attempting to reach the

workplace and located loves ones. Having pre-printed signage (banners, placards, etc.)

identifying the various

functional areas (e.g.,

First Responder

Staging, Media, Family

Reunification, etc.) can

help speed initiating and

operating the

reunification center and

leaders should

anticipate operating

such a center for at least

24-hours post shooting.

It will be important to

identify the anticipated

needs in such an environment, train and prepare some employees to provide leadership

and support in those places, and/or develop relationships with community partners and

other providers of post-disaster support services to ensure successful operations of such

a complex and dynamic environment. EMS, emotional and spiritual support must be

made available for overwhelmed family members. Depending on the duration of family

support operations it is helpful to bring Employee Assistance Providers and more formal

sources of mental health support, as well as clergy members into the mix as

circumstances allow.

The initial phase of a crisis is characterized by information seeking. Communication with

family members as they assemble and await news of their loved ones is essential. A

representative of the organization, working in concert with the Incident Command

System’s designated Public Information Officer (PIO) must be ready with timely,

accurate, and relevant information to help alleviate the stress and frustration associated

with waiting, but can also help prevent the emotional escalation of the group as a whole.

Periodic updates from credible spokespersons and representatives must be made, even

if there is no significant new information available.

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In selecting a location for the FRC it is important to try to strike a reasonable balance

between being too close and too far from the affected facility. When families feel too far

removed they will often leave the FRC, believing that more news or better information

will be available closer to the impacted location. Of course, it is unlikely unauthorized

persons will be able to get near a working crime scene, and are therefore likely to

become even more frustrated, as well as potentially traumatized by the sights and

sounds of the emergency response. The ideal location for the FRC should be in a place

with low stimulation, reduced distractions and away from the media or a curious public.

Depending on scope and magnitude of the incident, the FRC may stay operational for

24-hours or more before transitioning to a jurisdictional Family Assistance Center (FAC)

in the days to follow. As such, basic creature comforts must be in place, and a schedule

to rotate the FAC staff should be established to avoid physical and emotional burnout.

Other considerations at the FAC include the availability of:

• Child care

• Language skills (including sign language interpreters)

• Psychological support providers with the ability to assist persons of all ages and

cultures

• Chaplains/Clergy

• Persons skilled in death notification and grief support

In some states it is also likely that therapy dogs may also have a role in the FAC

operation. For example, Connecticut lawmakers impressed with the effectiveness of

therapy dogs in calming and comforting Newtown students and staff after the Sandy

Hook Elementary School shooting passed legislation mandating the rapid response of

specially trained volunteer Critical Incident Response Canine Teams to violent and

traumatic events.vi

It is important to remember for individuals and families gathered at a FAC, the hours and

days ahead may be long and painful. Having a variety of different emotional support

resources in place will be important and necessary.

Media Management

Leaders should anticipate local, national and possibly international media to descend on

the location. Crisis communications is generally concerned with crafting the right

message for various stakeholder groups in the wake of critical incident, while media

management is focused on the logistics and interface with representatives of media

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outlets. Both functions are important since any shooting incident is likely to draw a

significant and immediate media response. While the Public Information Officer within

the law enforcement command staff will be coordinating the interface with the media in

terms of press conferences and the general release of information, it will still be critical

for communications professionals within the affected organization to be working in

concert with the PIO to coordinate both the message and logistics.

The media often prefer to

position camera teams

near the family

reunification site or in a

place near evacuating

employees to capture

dramatic footage, but by

negotiating with the PIO,

the organization may be

better able to protect the

dignity and privacy of

employees by limiting

movement of reporters

during and immediately following an incident. Coordinate with the Incident Command

Staff to limit helicopter news crew access to air space immediately above the workplace

can also be helpful. The organization’s communications team must be thoughtful as to

the backdrop for news cameras when selecting a Media Staging Area. Media often seek

backdrops of the organization’s facilities or distressed individuals and families if not

redirected. As a general rule, the media should also be kept separate from families and

staff while the emergency is ongoing and in the immediate post-crisis phase.

Coordination with local law enforcement agencies may also be necessary for families

who may experience intrusive media attention at their homes.

In the immediate phase, messaging from the organization must clearly communicate

care, concern, and compassion for the victims of the attack and those family members

affected. Later messages can transition to themes of restoring normal operations as

soon as possible and assuring employees the organization is a safe place for them to

continue to work. By working closely with the PIO the organization’s communicators will

have a better sense of timing and when to begin to shift the tone and content of

messages. It is critical for every leader to remember a shooting incident is a crime, that

there will be and investigation, and likely litigation, potentially both civil and criminal.

Legal counsel should be included in communications decisions as soon as reasonably

possible.

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Because information will need to be shared so quickly with concerned individuals and

groups, those in the organization tasked with communications should consider the

development of templates for different crisis events prior to actual events. Lessons

learned by way of the many mass shooting incidents that have occurred have helped

identify key messaging points, including:

• Empathy and concern for the victims of the attack

• Concern for affected family and friends

• Praise for dedicated and heroic responders and caregivers

• Information about the resumption/restoration or continuity of healthcare services

• Reassurance for staff and community members that the hospital is a safe and

secure place to work and receive care

• Updated information about the status of the event

IT and Communication Disruption

IT and telecommunication disruption is a critical area of concern and represents an

intersection with business continuity issues. There are several potential IT and

telecommunications challenges:

• Key IT and/or telecom equipment may have been damaged or disabled in the

attack.

• Access to data centers and server rooms, as well as other IT hubs may be

limited or denied for hours or days.

• Local cell towers may be inundated with volume.

It may be necessary to use automated information lines and the organization’s website to

provide updates, and to repurposing telephone call centers to help handle the flood of

inquiries about the incident or the status of staff and patients.

Crime Scene Management

Since hospitals and healthcare facilities cannot be completely shut down easily, it

becomes important to geographically contain the “footprint” of the crime scene. Hospital

leadership must quickly establish communication with those elements of the law

enforcement response involved in investigation and prosecution. It is most helpful if

representatives of those programs can be involved in discussion pre-event, during

planning and exercising, to help educate EMS and clinical staff members about the

preservation of evidence while rendering care.

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As early as possible investigators typically seek to photograph and/or videotape the

crime scene to help ensure continuity in the location and relationship of various pieces of

physical evidence, as well as the overall condition of the environment. Investigators also

seek to interview those who were victims and witnesses of violence, as well as those

with knowledge of the crime scene environment in its pre-attack condition.

While it is important for healthcare staff to understand the needs of investigators, it is

equally important that

investigators understand

the need to begin moving

patients within the

healthcare facility or to

another healthcare facility

to continue care. Law

enforcement leaders to

understand the complex

issue for sustaining life

during the response to a

critical incident. Law

enforcement responders

and investigators may also

require special instructions about operating in areas with specific risks, such as radiation

or MRI suites with powerful magnets that can interact with their weapons and equipment.

Early Recovery Phase

The early phase includes the next hours to days along the incident timeline. While each

active shooter situation or shooting incident is unique, there are commonalities in these

situations that allow leaders and planners to foresee several likely concerns in the

various phases. In the early phase, these include:

Family Assistance Center (FAC) Operations

Depending on the severity and scope of the attack, the law enforcement and emergency

management officials from the local jurisdiction may determine a Family Assistance

Center (FAC) is needed. The FAC is intended to be a one-stop service and support

center for those affected by the violent incident. They are not typically managing by the

hospital or healthcare organization, and are usually located in a place thought to be

accessible to the public, but not necessarily on or near hospital grounds. The operation

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tempo of the FAC also is different than the FRC. FRCs operations came seem like a

sprint, whereas FAC activities may need to adjust the pace for a potential marathon.

FACs can be operational for days and weeks post-incident, and in major attacks, much

longer.

Typical FAC functions include:

• Crime victim advocacy and support services

• Counseling and behavioral health services

• Collection of DNA samples for victim identification when necessary

• Ante mortem information collection

• Death notification, victims identification and temporary morgue operations

FACs often are operated under the auspices of the medical examiner or coroner, but a

strong support system is necessary. Credentialing and visitor management, donation

management, child care, food service, and a wide range of logistical support is critical to

the success of the FAC.

Return of Personal Effects

In the immediate phase, staff, ambulatory patients and visitors are likely to be running for

their lives. As per their training in Active Shooter Response they may have left many

important personal effects behind including car keys, purses or handbags, eyeglass,

medications, laptops, phones and other devices, all of which can prove to be disruptive

to daily life. Since the location will be designated a crime scene, investigators will need to

examine everything left

behind. They also will be

hesitant to allow

employees back into the

facility to retrieve their

belongings.

It will be important to work

with the Incident

Command staff and

investigators to determine

the timing and method of

returning personal

belongings to staff

members and others. It will be even more important to work out the return of personal

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effects to those who may have been injured, or to the families to those who were killed.

Law enforcement agencies, medical examiners/coroners, and crime victim assistance

workers are familiar with this delicate task and can help an organization’s leader facilitate

this process.

Supplemental Staff Support

It is foreseeable that many staff members may be unable or unwilling to return to work in

the days following a violent or traumatic event. Sadly, some may have been killed or

seriously wounded; others may be too frightened, grief stricken or traumatized to quickly

return. Some may take time off to attend funerals or memorials, thereby impacting

staffing levels and shifts.

Hospitals that may be part of larger healthcare systems may be able draw upon other

hospitals and healthcare facilities within their organizations for staffing. Others may find it

necessary to use medical staffing agencies to temporarily fill critical positions. This same

mutual aid concept between partner or intra-organizational facilities also may be

important in identifying alternate worksites for both clinical and non-clinical essential

functions if the crime scene footprint, or structural damage prevents a timely return to

normal operations. These arrangements may require written agreements prior to an

incident, and be exercised to ensure they are feasible during crisis conditions.

Behavioral Health Support

Behavioral health support will be necessary for nearly all exposed or affected

employees, and should be extended to their loved ones as well. Psychological First Aid

(PFA) is the intervention of choice in the 0-48 hours of the traumatic incident. PFA is an

every-person skill set, not reserved only for mental health workers. For a number of

reasons, Employee Assistance providers may not be able to access the scene or initiate

behavioral health support in the immediate aftermath of a violence event, therefore, it is

helpful to have a cadre of potential Psychological First Aid responders on staff to provide

peer support and rapid emotional aid for others who may have been the victims or

witnesses to violence.

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If the organization has a contracted Employee Assistance Program (EAP), that provider

may have the capability to provide onsite support in the form of one-on-one and group

sessions in the days that follow. The Incident Command staff from the emergency

response agencies may also have information and connections to the local disaster

mental health and crime victim assistance programs. If the organization has no formal

relationship mental health service providers, the National Disaster Distress Helpline can

be a viable resource. The helpline is operated by the federal Health and Human Services

(HHS)-Substance Abuse Mental Health Services Administration (SAMHSA) on a toll-

free, anonymous and

confidential basis,

24/7/365. The number is

800-985-5990, and for

those who would prefer

to communicate by text,

the phrase “TalkWithUs”

can be texted to 66746.

There is also a TTY line

at 800-846-8517.

In addition to onsite

behavioral health

support for affected

employees and their families, it will be important to remember that depending on the

severity of the attack, there may be spontaneous vigils, funerals and memorial services

at or near the affected facility in the early days after an attack, and it may be important to

provide emotional support at those gatherings as well.

Crime Victim Assistance

While Crime Victim/Witness Advocates from county, state and federal agencies offer an

array of important support services, a primary function is compensation to victims for

their out-of-pocket losses associated with the crime. This compensation is broad and

comprehensive, particularly in the area of long-term medical benefits, and can provide

some financial relief to victims who often suffer long-term financial losses in addition to

the physical and psychological harm caused by the crime itself.

In many instances, crime victims support personnel can initiate services within the first

several hours of an incident. Immediate financial support may be in the form of

assistance with funeral expenses, or helping relatives from outside of the area quickly

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travel to support their loved ones who may have been injured. Crime victims’ assistance

may begin in the early phase, but may continue through the long process of recovery

and aid in the many legal-justice challenges that victims can find overwhelming.

Business Continuity

There are a number of business continuity challenges specific to the early phase of

shooting incidents and active shooter situations. These include:

• Loss of workplace: (part or all) due to damage, crime scene concerns and/or the

psychological trauma of return to the scene of the crime

• Diminished workforce associated with deaths, injuries, acute grief, attendance to

funerals

• Loss of technology due to ballistic damage, water and smoke, other forces

• Loss of critical supplies and equipment

• Disruption of supply chain, both up and downstream

Depending on the scope of the crime scene and degree of damage to the facility,

alternate worksites may be necessary to sustain or help quickly resume essential

functions. Having a robust continuity plan in place prior to a violent event will help speed

the recovery process. The hospital’s business continuity professionals must play an

active role in planning and exercising for a wide range of potential impacts, including

blast damage from IEDs used in a violent attack.

Disaster Restoration/Crime Scene Clean Up

Once the physical location

of the attack is no longer

deemed a crime scene

and control is handed

back over to the hospital

or healthcare

organization, it will be

important to have all

damage and physical

evidence of the attack

repaired before bringing

the workforce back into

the environment. It is

strongly recommended an

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organization use a qualified and reputable disaster restoration or crime scene clean up

service to handle such tasks and not allow the organization’s own janitorial or custodial

staff to do the cleanup and repair. In addition to the potential biohazards involved in the

cleanup, it is potentially traumatizing to have employees who routinely have and will

need to continue to clean and maintain the affected facilities exposed to the graphic or

gruesome post-shooting environment. Spare employees that powerful experience and let

others from outside the organization who are properly equipped and emotionally

detached handle those tasks.

Human Resource Concerns

There are several likely human resource issues likely to emerge in the first days and

spilling into the first weeks following a shooting incident. Some of the HR concerns

naturally overlap with business continuity concerns, including:

Reduction of workforce: Injured, killed, traumatized, grieving, and otherwise unable or

unwilling to quickly return to work. Legal, moral and ethical challenges related to

continuing payroll, extending sick leaves, and continuing medical benefits will surface

soon after the attack. How will the organization handle absences due to emotional

trauma? Will employees be asked to use up their sick time or vacation time if they

require weeks or months before they are able to return to work? Will the organization

hold their jobs? There will be a number of difficult questions for Human Resource leaders

to tackle. These are just a few of what will likely be a long and complex list of HR issues.

There are no easy answers to such questions. Each organization must struggle to find

the right response based on their unique culture, vision and philosophies.

Time Off for Responders and Crisis Team Members

As the days become weeks, the operational tempo will shift and slow. Those involved

with the organization’s crisis management efforts will likely have been running a full

speed, with little rest and high levels of stress for an extended time. It is wise to consider

some down time and a period of decompression before returning to their normal duties.

Operational stress control will be an important consideration, and those operating at high

stress levels for days on end can begin to show signs of wear and tear, sometime

affecting judgement and performance. Leaders must be realistic in what is expected of

crisis team members.

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Management of Political Response

Mass violence is a social issue, as well as an organizational issue. Shooting incidents

often become politicized. Mayors, Governors, at times even Vice Presidents and

Presidents have visited the sites of mass shootings to make statements and support the

victims and survivors of such events. VIP visits from politicians and celebrities can be

highly disruptive. While some survivors may appreciate the show of support from a

powerful leader or well-known personality, others find it disrespectful, even shameful, as

attention may be turned away from the victims and survivor, and lights and cameras are

directed at the special guest. Such VIP visits are a possibility and require active

involvement by the organization’s leaders in concert with civic leaders and emergency

managers. VIP visits can be complicated and expensive, especially regarding increased

security needs.

Administrative Concerns

While not within the scope of this paper, regulators and accrediting bodies have several

levels of reporting and assessment of the incident that will require the attention of the

organization’s leadership. Note that when a facility has sustained damage as a result of

violence, a post-incident accreditation survey may be required.

Crisis Management, using both internal communications staff and perhaps external

public relations consultants may also be necessary to formulate and execute a strategy

to mitigate the impact on the organization’s brand, reputation and market position.

Executives will be drawn into many high-level strategic discussions, some requiring the

involvement of the Board of Directors.

Mid-Recovery Phase

The weeks to months following an active shooter attack or shooting incident can be

considered the mid-phase of recovery. The organization may have returned to normal

business operations, but there will still be many vivid reminders of the incident. Some of

the injured may still be hospitalized or in rehabilitation facilities. Others may not have

returned to work due to the powerful emotional effects. There are other likely milestones

in the recovery process that will represent challenges for individuals and for the

organization.

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Civil and/or Criminal Litigation

A realistic assumption in

any workplace shootings

is that every bullet comes

with a lawyer attached. If

the shooter surrendered

or survived the police

response, criminal

proceedings are likely to

begin in the weeks to

months after the attack.

Media coverage of the

trial or various processes

leading up to a trial can be

painful for victims and

survivors, and trigger a host of different reactions that can be uncomfortable and

disruptive at home and at work. Civil litigation in the form of negligence suits or wrongful

death cases can be expensive and time consuming. They can also affect employee

morale, recruitment and the organization’s brand or reputation.

It is also likely management and staff may be required to provide assistance in the

investigation and prosecution of a violent crime. Staff members may be called as

witnesses and participation in legal proceedings may bring back traumatic memories of

the incident, requiring additional psychological support. Media coverage concerning

related court cases can also stir up painful memories for many members of the staff and

surrounding community.

Ongoing Medical and Psychological Care

It will be important to actively support and coordinate ongoing support for victims’

families, survivors and witnesses, including medical and psychological care. Some

situations will evolve into worker’s compensation or disability cases. HR and legal must

be mindful of ADA issues related to employees with traumatic stress conditions and the

impact on job performance, attendance and other issues.

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After Action Reports

Done too quickly following a violent event, the fog of war can cloud memory, judgement

and decision-making, while waiting too long can result in important lessons fading from

memory. The weeks or early months after an active shooter incident are a reasonable

time frame to gather a

working group to create

an After Action Report

(AAR) to capture

important lessons learned

and develop a corrective

plan to make any needed

changes to the

organization’s violence

prevention/active shooter

response plans. This is an

important and sometimes

painful process, since it

means revisiting the

details of the incident and critiquing the response in a constructive manner. It is equally

important that any findings or recommendations be acted on quickly since failure to do

so can create additional legal risk.

It will be necessary to articulate and assign responsibility for completing any corrective or

improvement tasks to specific people, with deadlines for completion, and a feedback

mechanism to verify those tasks have been completed. Any changes made to the

emergency response plans that flow from the corrective process should be tested to

assure they are effective and understood by all concerned parties.

Anniversary Planning

The one-year anniversary of a violent attack can be an important milestone in individual

and organizational recovery, but it can also be complicated and emotional. As such, it

cannot be ignored, and any plans to commemorate the anniversary or to handle it in a

deliberate low-key manner must begin early on. Anniversary events or memorials should

be done with the staff and community, not to them. A violent attack represents a loss of

control and feelings of extreme powerlessness and vulnerability. Any activities to

commemorate the incident should involve a high-level of staff and community

involvement and empowerment.

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The anniversary represents an opportunity to take stock of the accomplishments of both

individuals and the organization; reassess the needs of the organization; enhance and

strengthen connections with stakeholders and continue creating partnerships that

promote resilience and create a legacy.

Forming a committee or

working group in the

months before the actual

anniversary will give the

group enough time to

gather feedback and

support for their plans.

Depending on the

magnitude and the

effects of the shooting on

the surrounding

community, it may be

important for the

planning team to

communicate and coordinate with civic leaders and others who may be planning

anniversary events separate from the healthcare organization. In some instances

coordination with state and federal partners will also be necessary and may require

sufficient lead time. There are also myriad logistical concerns associated with

anniversaries and memorials, including site security, vehicular and pedestrian traffic flow,

media coverage, and psychological support for both organizers and participants.

Long-Term Recovery Phase

Long-term recovery is typically considered the one-year anniversary and beyond. As

mentioned in the opening paragraphs of this paper, the physical and emotional impact of

an active shooter situation or shooting incident can linger for decades, and sometimes

an individual’s entire lifetime. It is important for leaders and decision-makers to

understand the long-term effects of violent and traumatic events. For example, the

prevalence of post-shooting diagnoses (predominantly PTSD) in studies ranges from

10% to 36%vii as compared with about 11%-15% of the affected population developing

such diagnoses after natural disasters.viii Compared with other types of critical incidents,

mass shootings represent the greatest risk for acute traumatic stress disorder:

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The rates of Acute Stress Disorder following traumatic incidents vary, with the highest

rates associated with human-caused trauma:

• Typhoon 7%

• Industrial accident 6%

• Mass shooting 33%

• Violent assault 19%

• MVA 14%

• Assault, burn, industrial accident. 13%ix

Lessons Learned

Among the many types of crises that can affect a hospital or healthcare organization,

gun violence in the form of shooting incidents and active shooter scenarios are some of

the most disruptive and devastating. While the attack may be a surprise, the necessary

action steps to effectively respond and recover from the incident are not. Proactive

leadership is required to anticipate and address the post-incident consequences in a

competent and compassionate manner.

While it is of paramount importance to protect hospitals and healthcare organizations

from a potential attack, and prepare staff to respond effectively to gun violence, it is also

important to recognize it is not possible to prevent every incident. As such it is equally

important organizations also develop processes for recovery and the resumption of

operations. Recovery is an ongoing process that occurs in phases. Each organization

and their staff will move through the phases of recovery in their own time and on their

own terms.

Crisis events are moments of truth; staff members, the community, key stakeholders and

the media will remember how an organization handled the incident for a very long time. It

is critically important to prepare for the entire life cycle of shooting attack, including

anticipating and planning for the complex post-shooting challenges well before the first

shot is fired.

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About Everbridge

Everbridge, Inc. (NASDAQ: EVBG) is a global software company that provides critical

event management and enterprise safety applications that enable customers to

automate and accelerate the process of keeping people safe and businesses running

during critical events. During public safety threats such as active shooter situations,

terrorist attacks or severe weather conditions, as well as critical business events such as

IT outages or cyber incidents, over 3,000 global customers rely on the company’s SaaS-

based platform to quickly and reliably construct and deliver contextual notifications to

millions of people at one time. The company’s platform sent over 1.5 billion messages in

2016, and offers the ability to reach more than 200 countries and territories with secure

delivery to over 100 different communication devices. The company’s critical

communications and enterprise safety applications, which include Mass Notification,

Incident Management, IT Alerting, Safety Connection™, Community Engagement™,

Secure Messaging and Internet of Things, are easy-to-use and deploy, secure, highly

scalable and reliable. Everbridge serves 8 of the 10 largest U.S. cities, 8 of the 10 largest

U.S.-based investment banks, all four of the largest global accounting firms, 24 of the 25

busiest North American airports and 6 of the 10 largest global automakers. Everbridge is

based in Boston and Los Angeles with additional offices in San Francisco, Lansing,

Beijing, London and Stockholm.

Visit www.everbridge.com to learn more.

References i Sotos, John G. (2006). Zebra Cards: An Aid to Obscure Diagnoses. Mt. Vernon, VA: Mt. Vernon Book Systems. iiU.S. Department of Homeland Security. (2013). Active Shooter: How to Respond. iii New York City Police Department. (2010 & 2012). Active Shooter: Recommendations and Analysis for Risk Mitigation. iv Kelen, G., Catlett, C., Kubit, J. and Hsieh, Y.H. (2012). Hospital-based shootings in the United States: 2000 to 2011. Ann Emerg Med. 60(6): 790–798.e1. v Federal Bureau of Investigation. (2014). A study of active shooter incidents in the United States between 2000 and 2013. vi House Bill No. 6725, Public Act No. 15-208. AN ACT CONCERNING ANIMAL-ASSISTED THERAPY SERVICES. Passed June 6, 2015. vii Norris, F.H. (2007). Impact of mass shootings on survivors, families, and communities, PTSD Research Quarterly, Vol. 18, No. 3, 1-8. viii Norris, F.H. et al. (2002). 60,000 disaster victims speak: an empirical review of the empirical literature: 1981-2001. Psychiatry, 65: 207-239. ix Bryant, R.A. (2000). Acute stress disorder. PTSD Research Quarterly, 11(2), 1-7.