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Recommendations and template for an active shooter protocol in the operating room: an integrative review

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Content ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

RECOMMENDATIONS AND TEMPLATE FOR AN ACTIVE SHOOTER PROTOCOL IN
THE OPERATING ROOM: AN INTEGRATIVE REVIEW
by
Marty Angelo B. Espina

A Doctoral Capstone Presented to the
FACULTY OF THE USC KECK SCHOOL OF MEDICINE
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF NURSE ANESTHESIA PRACTICE

May 2022

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The following manuscript was contributed to in equal parts by Kevin D. Currie, Marty Angelo B.
Espina, and Lucas J. Kalina.

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Acknowledgements and Disclaimer
We would like to thank our faculty chair, Dr. Elizabeth Bamgbose, and committee
members, Erica McCall and Dr. Natalie Meyers, for their patience, guidance, dedication, and
contributions to this project. We would also like to thank the faculty of the Doctor of Nurse
Anesthesia Practice program at the University of Southern California for their thoughtful
instruction and unwavering support, even amidst a pandemic. To our fellow doctoral students,
thank you for providing friendship, support, and encouragement as we progressed through our
studies. And lastly, to our families, thank you for the never-ending love and prayers, to which we
owe our present and future accomplishments.
This article is meant to highlight gaps in the literature and encourage hospital
administration to develop specific active shooter protocols for the operating room. No
information presented in this article should be considered legal advice and we encourage hospital
administrators to collaborate with their risk management teams, legal advisers, surgical teams,
and law enforcement to create the best active shooter protocol for their specific institution.

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Table of Contents
Distribution of Work………………………………………………………………………………ii
Acknowledgements and Disclaimer …………………….……………………………………….iii
List of Figures.……………………………………………………………………………………v
Abstract...…………………………………………………………………………………………vi

Chapter 1: Introduction……………………………………………………………………………1
Specific Aims.……….…………………………………………………………………...…… 2
Background...….…….…………………………………………………………………………2
Chapter 2: Literature Review...……………………………………………………………………5
Workplace Violence………………………………………………………………………….. 7
Current Guidelines and Recommendations…………………………………………………...8
Ethical Considerations……………………………………………………………………….10
Chapter 3: Methodology…………………………………………………………………………13
Chapter 4: Practice Recommendations and Template………………………………………….. 15
Threat Assessment Team (TAT)……………………………………………………………. 15
Emergency Response Activation……………………………………………………………. 15
Secure, Run, Fight……………………………………………………………………………16
Role Assignments…………………………………………………………………………… 18
Surgeon…………………………………………………………………………………. 19
Anesthesia Provider……………………………………………………………………... 19
Registered Nurse………………………………………………………………………… 20
Surgical Fellows, Residents, and Technicians…………………………………………... 20
Additional OR Personnel………………………………………………………………... 21
Chapter 5: Discussion…………………………………………………………………………… 22
Limitations………………………………………………………………………………….. 23
Conclusion....…..…………………………………………………………………………….24
References………………………………………………………………………………………. 25
Appendix A……………………………………………………………………………………… 30
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List of Figures
Figure 1: PRISMA Diagram……………………………………………………………………..14
Figure 2: Secure, Run, Fight Diagram…………………………………………………………...16

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Abstract
Hospital-based shootings have become increasingly prevalent within past decades. While
most hospital systems have protocols in place for such an event, the operating room (OR) suites
may require an amended protocol. AIMS: (1) Identify best practices for managing an active
shooter incident in the OR through an integrative review of the literature and current guidelines.
(2) Provide recommendations and a template for hospital administrators to prepare for an active
shooter event in OR suites. METHODS: An integrative review of the literature and relevant data,
guidelines, and reports from state and federal government organizations were explored.
RESULTS: A total of 32 sources were identified. To address unique security concerns for the
OR, the authors recommend hospital administrators develop a threat assessment team, which
would utilize the template in this article to establish a specific protocol for the OR, including role
assignments in the case of an active shooter. The recommended protocol is: Secure, Run, Fight.
CONCLUSION: The authors offer recommendations and a template to guide hospital
administrators through preparing for an active shooter incident in the OR and acknowledge the
need for staff education.

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Chapter 1
Introduction
An active shooter is defined as an individual who is actively engaged in killing or
attempting to kill people in a confined and populated area (Healthcare & Public Health Sector
Coordinating Council, 2017). Active shooter incidents in the United States have drastically
increased over the past two decades. The U.S. Federal Bureau of Investigation (FBI, 2013)
reports the average annual active shooter incidents was 6.4 between 2000 and 2006, and 16.4
between 2007 and 2013. A concerning trend of mass shootings in the United States, defined as
four or more casualties, has also developed in recent years: 337 in 2018, 417 in 2019, and 611 in
2020 (Gun Violence Archive, 2021). Active shooter incidents in health care settings have been
less frequent with only six reported incidents between 2000 and 2015; however, 154 hospital-
based shootings (most of which did not qualify as “active shooter”) were reported in the United
States between 2000 and 2011 (Kelen et al., 2012), and 88 hospital-based shootings were
reported between 2012 and 2016, with 77 fatalities (Wax et al., 2019). This rise in average
annual hospital-based shootings parallels the recent exponential rise in mass shootings across the
United States.
Hospital facilities are vulnerable targets for an active shooter due to the high
concentration of people, ease of access, and the propensity of health crises to induce acute
psychological distress (Kelen et al., 2012). Furthermore, healthcare facilities have numerous
entrances and areas with hazardous materials, complicating the maintenance of safety and
security (Hauk, 2018). These institutions generally have contingent emergency policies in the
event of an active shooter, such as the Run, Hide, Fight model, but none have addressed the
specific needs of the operating room (OR) and its personnel (Brown et al., 2018). This
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integrative review synthesizes current active shooter literature and guidelines to develop
recommendations for hospital administrators to better prepare for an active shooter in the
healthcare facility or perioperative setting.
Specific Aims
1. Identify best practices for managing an active shooter incident in the OR through an
integrative review of the literature and current guidelines.
2. Provide recommendations and a template for hospital administrators to prepare for an
active shooter event in OR suites.
Background
Hospitals generally accommodate large concentrations of people and are easily
accessible. Visitors are typically required to present a form of identification prior to entry and are
occasionally screened by metal detectors (Wands, 2016). In the event of a hospital emergency,
notification systems facilitate rapid, facility-wide announcements and activation of emergency
response plans. For example, an operator may announce a “Code Silver,” indicating an active
shooter is in the hospital, and a predetermined emergency response plan should be enacted
(Brown et al., 2018).
An active shooter emergency response plan typically follows the Run, Hide, Fight model,
as supported by inter-agency federal guidelines (U.S. Department of Health and Human Services
[HHS], U.S. Department of Homeland Security [DHS], U.S. Department of Justice [DOJ], FBI,
& Federal Emergency Management Agency [FEMA], 2014). Based on this model, a person in
danger from an active shooter incident should first attempt to evacuate to a safe location, or Run.
If unable to safely escape, the person should then attempt to seek shelter in a safe place, or Hide.
If the previous two actions in the model fail, the last resort is to use aggressive force to subdue
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the shooter, or Fight. However, the collaborative federal report acknowledges the Run, Hide,
Fight model is imperfect and is not equipped to handle every situation or environment, such as
the OR (HHS et al., 2014). In 2017, the Healthcare & Public Health Sector Coordinating Council
(HPHSCC) noted that staff and patients in the OR may be unable to avoid an active shooter
because of in-progress procedures. In this multi-agency government report, the HPHSCC details
how to plan for and respond to an active shooter in a healthcare facility.
The efficacy of the Run, Hide, Fight protocol was highlighted during a 2015 active
shooter incident at Brigham and Women’s Hospital in Boston, Massachusetts, when a
cardiothoracic surgeon was shot twice by an assailant, who then turned the weapon on himself
(Goralnick & Walls, 2015). Hospital staff were unsure whether the assailant was still a threat, so
they secured patient rooms and barricaded themselves behind closed doors. Goralnick and Walls
(2015) acknowledge it is difficult to prove whether adherence to the protocol saved any lives
during this incident, but they underscore the importance of hospital planning and preparation in
the event of an active shooter.
In the OR, healthcare professionals with diverse educational backgrounds work to
provide care for patients during surgical procedures. Patients are often obtunded and immobile
due to the delivery of anesthesia. If an anesthesia provider were to evacuate the OR during an
active shooter incident, the patient would be left vulnerable on the operating table and would be
at risk for possible life-threatening complications. According to the Code of Ethics for Certified
Registered Nurse Anesthetists (CRNAs), a CRNA’s ethical responsibility is primarily to the
patient and is sensitive to the vulnerability of the patient undergoing anesthesia (American
Association of Nurse Anesthetists [AANA], 2018). The ethical responsibility to the patient
competes with the instinctive drive for self-preservation. This creates a burden on the CRNA to
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make a choice that may not follow ethical standards in order to preserve one’s life in the event of
an active shooter.
The case report of Charmain Czubinsky v. Doctors Hospital (1983) describes an example
of an abandoned patient who subsequently developed irreversible brain damage secondary to
cardiac arrest. Several members of the operating team, including the surgeon and circulator
nurse, left the OR suite prior to the patient emerging from anesthesia and failed to respond to her
deteriorating condition. If there had been additional medical professionals available to observe
these signs and assist with resuscitation, the patient may have survived. In the trial, the surgeon
for the case testified that all OR personnel are required to observe and monitor the patient, an
assertion supported by an expert witness. The jury ruled in favor of the patient’s family, citing
negligence by the hospital staff. This case of patient abandonment and neglect highlights the
legal repercussions resulting from a breach in a medical professional’s oath to cause no harm to
patients. Inaba et al. (2018) report that death of a patient may result from abandonment,
particularly if the patient is critically ill and undergoing lifesaving treatments. With specific
consideration for the OR, an active shooter incident presents complex ethical and legal dilemmas
for the surgical and anesthesia team (HPHSCC, 2017).

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Chapter 2
Literature Review
Brown et al. (2018) demonstrate how the creation of a protocol and the execution of a
simulation can enhance an individual’s preparedness to react in the event of workplace violence.
The authors found participants often froze or panicked when faced with acts of aggression,
assault, or other acts of violence. The researchers hypothesized that if staff were not prepared to
deal with active shooter incidents before the arrival of law enforcement, they would freeze or
panic. Brown et al. (2018) devised the ABLE protocol: Accept that the potential or actual
violence is happening, Barricade behind a closed door or Leave the area to ensure staff and
patient safety, and Engage the perpetrator to disrupt or end the violence if no other options are
viable. Brown et al. (2018) implemented a corresponding staff educational intervention to
demonstrate the utility of the ABLE protocol during an active shooter incident. Through
quantitative analyses of pre- and post-tests, the educational interventions on the ABLE protocol
via simulation training significantly improved preparedness of the 136 participating staff to react
in the event of workplace violence (Brown et al., 2018). After the educational intervention, there
were increases in the percentage of participants who felt prepared to handle workplace violence
(62% from 6%), protect themselves (61% from 11%), protect their patients (51% from 9%), and
get immediate help during workplace violence (39% from 8%).
In 2019, a group of researchers in Boston studied the response of health care personnel to
an educational session about active shooter incidents in the perioperative environment
(Hemingway et al., 2019). All participants were shown four vignettes depicting an active shooter
incident. Pre- and post-tests were administered to measure knowledge around emergency
preparedness strategies. After the intervention, participants demonstrated statistically significant
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improvements in their ability to identify safe hiding spots (p < 2.2 x 10
-16
), communicate
effectively (p <2.2 x 10
-16
), identify egress (p = 5.3 x 10
-9
), and improvise self-defense objects (p
= 2.18 x 10
-6
). The authors concluded that communication in a violent situation, such as an active
shooter incident, may not be as intuitive as many believe. For example, 15% of respondents on
the pre-test correctly identified that “9-911” would need to be dialed to contact municipal
emergency services; this improved to a 91% correct response rate on the post-test. Hemingway et
al. (2019) recommended the widespread multidisciplinary education of perioperative personnel
to improve active shooter preparedness.
Landry et al. (2018) explored the efficacy of implementing an active shooter incident
response program tailored to non-manager hospital staff in one community-based hospital in
Southeastern Virginia. The departments of nursing, risk management, and security teamed up
with local law enforcement to develop an active shooter response plan, address unique
challenges associated with active shooter events, and minimize fear among health care workers.
The program was based on information and guidance provided by the DHS, the International
Association for Healthcare Security and Safety, and the Joint Commission (TJC). Landry et al.
(2018) explained that only top and middle-management employees are typically aware of their
organization’s preparedness for an active shooter incident. The authors further suggested that by
increasing an employee’s perception of organizational preparedness (the organization’s ability to
manage an active shooter event), they are more likely to retain crisis response information and
act accordingly when required.
The goal of the intervention was to increase knowledge, perceived organizational
preparedness, and self-efficacy among non-managerial staff. The authors conducted pre- and
post-intervention questionnaires regarding the study group’s knowledge about the active shooter
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response program. Of the 66 participants, 65 demonstrated an increase in knowledge (p < 0.001),
and 64 demonstrated an increase in perceived organization preparedness (p < 0.001). There was
no improvement in self-efficacy following the intervention. The authors concluded the increased
perception of organizational preparedness can be an environmental trigger for appropriate action
to be taken when needed.
Workplace Violence
According to the Occupational Safety and Health Administration (OSHA) (2016),
employees in the healthcare industry are four times more likely to experience workplace violence
than employees in other industries. The United States has the highest incidence of workplace
violence among developed countries, and the majority of those incidents are premeditated (Kelen
et al., 2012). In 2013, assaults and violent acts made up 27% of fatalities in healthcare and social
service settings (OSHA, 2016). OSHA (2016) also reported specific risk factors for healthcare
workplace violence, including working with gang members and their relatives, a workplace
design that may block an employee’s vision or escape, inadequate security, and long waits with
overcrowded waiting rooms. These findings imply that components of the structural environment
may be altered to improve workplace safety.
Kelen et al. (2012) reviewed eleven years of hospital-related shootings and found while
hospital shootings are rare, they are carried out by highly motivated individuals who have some
form of a relationship with their victim(s). The U.S. Department of Justice (DOJ) (2011)
reported five percent of workplace assaults involve a firearm, and these cases represent 80% of
workplace homicides. The New York City Police Department (NYPD) (2016) claimed an active
shooter is a man acting alone 97% of the time. At the time this report was published, one-third of
the active shooters in the United States were disgruntled employees targeting their place of
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employment. When active shooter incidents involve a healthcare facility, two-thirds of the
perpetrators have historically been employees (Kelen et al., 2012). With access to restricted
areas, employees can easily bypass security measures such as metal detectors and locked doors
(Gerold, 2019). The rates of workplace violence in healthcare facilities and insight into the
typical shooter profile highlight the susceptibility of the OR to an active shooter incident and the
need for enhanced security measures and protocols.
Current Guidelines and Recommendations
The Joint Commission (TJC) uses a list of set standards to accredit healthcare facilities in
the United States. This accreditation allows facilities to be eligible for Medicare and Medicaid
reimbursement (National Academy of Medicine, 2007). One of the standards established by TJC
delegates to hospitals the following responsibilities: proactively identifying and minimizing
security risks through a hazards vulnerability analysis (HVA), identifying individuals entering
the facility, controlling access to security sensitive areas, and developing written procedures in
the event of a security incident (TJC, 2016). The Centers for Medicare and Medicaid Services
(CMS) Emergency Preparedness Rule also requires an annual HVA for healthcare facilities
(HHS, 2019). State regulations may additionally require hospitals to develop evacuation
procedures, run disaster drills, and assign specific responsibilities to personnel during internal
disasters (University of Minnesota Division of Health Policy & Management, 2011). To prepare
for such an event, hospitals may establish an active shooter protocol that is commonly activated
by announcing, “Code Silver” (Brown et al., 2018).
Several federal agencies collaborated to address the risks posed by active shooters to
healthcare facilities and published guidelines for developing an active shooter protocol in a
report titled “Incorporating Active Shooter Incident Planning into Health Care Facility
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Emergency Operations Plans” (HHS et al., 2014). The HPHSCC (2017) later published “Active
Shooter Planning and Response: Learn How to Survive a Shooting Event in a Healthcare
Setting.” This 115-page report offers more detailed recommendations for development of an
active shooter plan and has been endorsed by TJC and the FBI. It addresses prevention,
preparation, response, and recovery. This plan is structured on the Run, Hide, Fight model, but it
also mentions four alternative models (HPHSCC, 2017). The HPHSCC (2017) further
recommended healthcare facilities develop multidisciplinary threat assessment teams (TATs) to
evaluate and prepare for security threats, coordinating with local law enforcement at every step.
OSHA (2016) supports this claim and recommends top healthcare administrators regularly
evaluate their violence prevention programs, which should have clear goals and objectives, be
suitable for the size and complexity of operations, and be adaptable to specific situations,
facilities, or unit(s). To mitigate the risk of assault on healthcare workers, OSHA (2016) also
recommends video surveillance, curved mirrors, metal detectors, bulletproof glass for
receptionists, panic buttons, and locking doors.
A number of the HPHSCC recommendations deviate from the conventional Run, Hide,
Fight model. For example, the report states that in patient care areas where patients may be
unable to evacuate, staff must make every reasonable attempt to continue patient care. If this
continuity of care becomes impossible without risking additional loss of life, providers may
consider leaving the OR (HPHSCC, 2017). HPHSCC (2017) calls upon hospital leadership to
develop a well-planned response to an active shooter near or in OR suites, working with security
and law enforcement personnel to establish security procedures, so medical personnel can
continue to care for surgical patients.
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Ethical Considerations
The Association of Perioperative Registered Nurses (AORN) report a majority of
healthcare personnel feel a special obligation to protect patients in the OR during an active
shooter incident, with 45% believing they should accept significant personal risk because of
patient vulnerability in these situations (Hauk, 2018). Additionally, Hemingway et al. (2019)
acknowledge leaving a vulnerable patient presents ethical and moral challenges for staff.
Individual surgeons, anesthesia providers, and nurses would need to balance the ethical,
clinical, and systems-coordination issues when deciding whether to continue the case, await
further information, or abort the case (Leppert et al., 2019). Continuing a surgical procedure in
the midst of an active shooter incident may avoid the need to perform a secondary operation;
however, there is an increased risk of surgical error due to surgical staff distraction, fear, and
limited support-staff availability (Leppert et al., 2019). With the many possible plans and
decisions that have to be made during an active shooter incident, one response plan may
include evacuating all non-essential personnel, while keeping the surgeon, anesthesia provider,
and essential nurses in the OR (Leppert et al., 2019).
Inaba et al. (2018) stress the importance of a pre-emptive, hospital-based active shooter
protocol for the OR. Inaba et al. (2018) also recommend a Secure, Preserve, Fight strategy that
hospital personnel can undertake if the Run, Hide, or Fight strategy is not feasible. The authors
suggest healthcare professionals are obligated to not abandon their patients, which directly
conflicts with the primary directive to Run. However, this course of action is disputed.
Gerold (2019) argues an active shooter incident may require caregivers to abandon care
and return when declared safe to ensure the least loss of life. Uninjured caregivers are able to
provide medical assistance to those injured in the incident, and it may not be feasible to move
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patients undergoing surgery or critical procedures (Gerold, 2019). According to the Secure,
Preserve, Fight model, in the event of an active shooter, healthcare personnel should first Secure
the OR doors, dim or turn off nonessential lights, and silence all technology (Inaba et al., 2018).
Next, in order to Preserve as many lives as possible, the authors recommend staying away from
all windows and doors, truncating non-essential procedures, and discontinuing any diagnostic
imaging (Inaba et al., 2018). Similar to the Run, Hide, Fight protocol, the final step is to Fight
the shooter in the event that the shooter breaches an immediate perimeter protecting healthcare
personnel (Inaba et al., 2018).
Giwa et al. (2020) address how a healthcare provider’s moral obligations during an active
shooter incident remains unclear despite a healthcare professional’s moral and ethical
responsibility to remain with the patient. Giwa et al. (2020) highlight the moral dilemma that a
healthcare provider may encounter when deciding to protect their patient or themselves during an
active shooter incident. However, the authors acknowledge the importance of the healthcare
provider’s duty to the patient and the special circumstance an active shooter incident presents.
Lastly, they assert that the moral duty in medical disasters is prima facie but may be overridden
by other professional or personal duties (Giwa et al., 2018).
Giwa et al. (2020) further examine the duty of the healthcare provider by reviewing
responses to the HIV/AIDS crisis in the United States, the Ebola crisis, and natural disasters.
They recognize that these crises are imperfect comparisons for an active shooter incident,
primarily because active shooter threats may change on a second-to-second basis. The authors
state that an active shooter incident is not under the control of healthcare providers, and the
institution holds the duty to provide safety for the patients and the health care providers. Giwa et
al. (2020) recognize the Secure, Preserve, Fight model proposed by Inaba et al. (2018) as
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superior to the Run, Hide, Fight model. However, Giwa et al. (2020) state the dynamic nature of
active shooter incidents precludes an algorithm, and the decision to continue providing care or
flee to safety is a healthcare professional’s personal choice, which no agency may mandate.

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Chapter 3
Methodology
A comprehensive search of peer-reviewed literature using PubMed, Cumulative Index to
Nursing and Health Allied Literature (CINAHL), Google Scholar, and Embase was performed.
The authors searched the terms “active shooter” AND “surgery,” “active shooter” AND
“hospital,” “active shooter” AND “operating room,” or “OR” and “active shooter” AND
“CRNA” or “anesthesia,” which yielded 228 results. All materials were initially included
regardless of publication date. Upon initial review, studies were excluded if they described
events outside of the United States, were not published in English, referenced community-based
active shootings and drills, and were periodical-based, surveys, or duplicate publications. Studies
were screened for relevance through their abstract, then a full-text analysis was conducted for
relevance (211 excluded).
In addition to the published studies, the authors explored relevant data, guidelines, and
reports from state and federal government organization websites (e.g., FBI, OSHA, DHS),
yielding 12 sources. Three additional sources were included for supporting statistics and
reference. A snowballing technique was used to identify additional articles that met the inclusion
criteria. A PRISMA diagram of the search methodology is presented in Figure 1. Then, the
authors synthesized the existing literature with guidelines to develop practice recommendations
and a template for hospital administrators to prepare for an active shooter event in OR suites.

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Figure 1
PRISMA Diagram for Search Methodology

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Chapter 4
Practice Recommendations and Template
The recommendations in this paper are not legal advice, and healthcare facilities should
follow the advice of HPHSCC (2017) by constructing a threat assessment team (TAT) to produce
a comprehensive active shooter protocol, including a specific plan for the OR environment.
Appendix A offers a graphical depiction of an OR active shooter response template developed by
the authors of this integrative review.
Threat Assessment Team
Threat assessment teams (TATs) will help healthcare institutions craft unique active
shooter response plans to better protect patients and OR staff while accounting for factors such
as institution size, security officer presence, location, and facility layout. The response plan for a
rural outpatient surgery center would likely look very different from that of a large urban
hospital. TATs should include healthcare facility administrators, counselors, current employees,
medical and behavioral health professionals, public safety, and law enforcement personnel
(HPHSCC, 2017). The authors encourage a representative from each surgical subspecialty to
contribute to the planning process, as different surgical techniques (e.g., cardiopulmonary
bypass, robotic surgery, endoscopy) will likely necessitate different courses of action. Anesthesia
department input is essential for understanding risks and benefits of proposed surgical plans.
Emergency Response Activation
Once an active shooter has been recognized, staff should immediately activate the
emergency response plan. To hasten activation, facility TATs may consider installing gunshot
detectors throughout the facility with the capability of automatically initiating the emergency
response system, including a facility-wide notification system. Similarly, TATs may heed the
ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

16
advice of OSHA (2016) by considering a network-based panic button system on facility
computers, such as the LynxKeyPro Duress Alarm (Lynx Systems, n.d.), that immediately
dispatches security to the location of the computer that entered the panic code (e.g., F9 + F11).
Secure, Run, Fight
The authors suggest amending the Run, Hide, Fight model in the OR to Secure, Run,
Fight, indicating that OR personnel should initially stay with the patient to provide care for as
long as possible, while armed security personnel offer enhanced protection to the OR. It is
important to acknowledge that OR staff must agree to stay in the OR to continue the surgical
procedure. The decision of the OR personnel to stay or escape is a personal decision that no
agency should mandate (Giwa, 2020). This Secure, Run, Fight model assumes that immediately
aborting the procedure would likely cause significant morbidity or mortality for the patient. The
authors of this manuscript emphasize that this Secure, Run, Fight model is specific to the OR,
and the commonplace Run, Hide, Fight model or the Secure, Preserve, Fight model by Inaba et
al. (2018) may be best for other locations in a healthcare facility.
Figure 2
Diagram for Secure, Run, Fight

Note. Adapted from the “Run, Hide, Fight” model from “Active Shooter Planning and Response:
Learn How to Survive a Shooting Event in a Healthcare Setting” by the Healthcare and Public
Health Sector Coordinating Council, 2017.
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To Secure the OR, staff should barricade the door, obscure all windows, turn off all
extraneous lights, and stay as quiet as possible. The OR suite entrances should be locked, and
OR scheduling boards should be erased or turned off, as these could direct the shooter to the
location of specific individuals or targets. Additionally, armed security personnel and law
enforcement should secure the perimeter of the OR suites once they arrive. The surgeon must
decide the surgical course of action, while considering the imminence of the threat and location
of the shooter. Example plans include continuing the procedure to a reasonable stopping point or
rapidly closing incisions to abort the procedure.
Running is appropriate when OR personnel are in immediate danger and escape is
possible. The proximity of the shooter and access to escape routes will determine if running is
the safest option. The decision to abandon the OR should be determined with the safety of the
patient and the OR staff in mind. It may be best to immediately evacuate non-essential personnel,
such as students or residents (Leppert et al., 2019). There are considerable ethical and legal
dilemmas presented when making these decisions, which the authors believe have no uniform
solution. Nonetheless, the authors agree with Gerold (2019) that the greater good of the hospital
and an individual’s right to life supersedes the patient’s well-being.
Fighting the shooter is the last resort. If the staff are in immediate danger and escape is
not feasible, OR staff may use physical force and improvised weapons to subdue and disarm the
assailant. Gerold (2019) recommends staff position themselves behind cover, yet as close to the
door as possible, in preparation for an attack. The use of fire extinguishers and chairs has been
suggested (HHS et al., 2014), but the OR may have unique equipment that could be considered.
According to data reports, incapacitating the shooter before law enforcement could arrive has
stopped one-third of active shooter events, and coordinated attacks towards the shooter with
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18
multiple people have been most effective (HHS et al., 2014). It is important to understand that
fighting the shooter may only be done if left with no other option.
Role Assignments
It is widely accepted that effective teamwork may improve efficiency, and the authors
acknowledge the importance of role assignments and clarity during emergent situations. To
better understand unique team dynamics of health professionals in emergent situations, the
authors analyzed research on performance during cardiopulmonary resuscitation. Shortcomings
in teamwork and leadership may contribute to deviation from established resuscitation
algorithms (Hunziker et al., 2011), emphasizing the importance of clear and accurate direction in
an emergency to achieve best outcomes. Furthermore, ad-hoc team building during
cardiopulmonary resuscitation has been identified as a significant cause of delayed defibrillation
and reduced hands-on time (Hunziker et al., 2009). A delayed response by healthcare workers
during an active shooter incident could have fatal consequences (Brown et al., 2018). Clearly,
roles and responsibilities of health professionals should be pre-determined and understood by
everyone.
The clarification of roles and responsibilities of individuals in an OR should be
established by the TAT of each institution. This strategy allows for consideration of facility-
specific circumstances, such as number of people in a given OR, state and local regulations
(including scopes of practice), physical layout of the facility, and law enforcement response time.
A TAT may wish to include a review of the facility’s active shooter protocol in the preoperative
“time-out.” The following is an overview of suggested roles for OR personnel to aid the
development of facility-specific policies.
ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

19
Surgeon
Hughes et al. (2014) report communication between team members in a crisis improved
when a team leader was designated. The authors of this paper suggest that the attending surgeon
be assigned the role of team lead, as they are best suited to determine the coordination and
continuity of surgical care (American College of Surgeons [ACoS], 2007). Aborting the
procedure could facilitate a more rapid patient emergence from anesthesia (Leppert et al., 2019).
As stated by the ACoS (2007), it is within the surgeon’s scope of practice to be knowledgeable
and considerate of the duties of OR personnel. Therefore, the surgeon may appropriately guide
supporting staff to help accomplish the revised surgical plan. The authors encourage shared
decision-making between the attending surgeon, anesthesia provider, and the rest of the OR
team.
Anesthesia Provider
It is widely understood that the management of anesthesia is dynamic and exists on a
continuum. The scope of practice for both physician anesthesiologists and certified registered
nurse anesthetists (CRNAs) are similar in that both professions constantly monitor hemodynamic
alterations and changes within the patient’s level of anesthesia (AANA, 2020). The anesthesia
provider may provide valuable insight for the plan of care in an active shooter incident.
Furthermore, it would be the sole discretion of the anesthesia provider to safely emerge and
extubate the patient if the surgeon were to abort the procedure. Similar to the attending surgeon,
the anesthesia provider may delegate tasks to other OR personnel, such as the registered nurse or
anesthesia technician. If the anesthesia provider must emergently flee the OR without time to
extubate the patient, the provider may first consider optimizing the anesthetic delivery method.
ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

20
The ideal anesthetic could continue for a long time without titration and maintain hemodynamic
stability, considering the lack of surgical stimulation.
Registered Nurse
The responsibilities of an OR circulator registered nurse include, but are not limited to,
direct and indirect patient care, collaboration with the surgeon and anesthesia provider, and
patient safety (American Nurses Association, 2020). The OR circulator is typically non-sterile
and therefore has the flexibility during a procedure to move about the OR to perform supportive
tasks. This versatility is crucial during an active shooter incident. The authors suggest that the
OR circulator should be responsible for executing the Secure component of the Secure, Run,
Fight protocol. If danger is not imminent, the OR circulator would be responsible for barricading
the OR entrances, obscuring all windows, and turning off all unnecessary lights. The OR
circulator would additionally serve as a communication liaison between the OR team leader and
incident command.
Surgical Fellows, Residents, and Technicians
As outlined by the ACoS (2007), the scope of a surgical fellow and resident includes, but
is not limited to, participating in the surgical procedure under the guidance of an attending
surgeon, managing patient hemodynamics and safety (e.g., blood loss), and serving as an
advocate for patient needs. However, Slagel et al. (1985) state certain trauma procedures are too
difficult and beyond the scope of a surgeon-in-training, and in the interest of patient care, the
attending surgeon should be responsible for the delivery of surgery. If the surgical procedure
were to be aborted in an active shooter incident, the attending surgeon may take control of
surgical closing and management of the patient. The surgical fellow, resident, or technician can
maintain sterility to assist with surgical care, as needed.
ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

21
Additional OR Personnel
If the threat is not imminent and escape from the OR suite is possible, non-essential
personnel should consider the Run component of the Secure, Run, Fight protocol. If
circumstances do not allow for this action, ancillary staff can assist the OR circulator in securing
the OR and may be helpful in mounting a group attack. It is important that clearly delineated
roles be established, but the course of action must account for the imminence of the threat, safety
of the care team and patient, and the uniqueness of the situation presented.

ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

22
Chapter 5
Discussion
To start preparing for an active shooter incident in the OR, Wands (2016) asserts that the
first step toward developing a culture of safety is removing an attitude of complacency.
Establishing an active shooter protocol is imperative to decrease response times and reduce
confusion about the best course of action. However, establishing an active shooter protocol is not
as clear as it may seem. The OR is a unique environment in a hospital, containing many
entrances and exits, staff and visitors with diverse specialties, and a dynamic workflow. Patients
place their lives in the hands of the surgical care team and are completely vulnerable while under
anesthesia. Moral and ethical considerations arise when considering a response to an active
shooter incident. This uncertainty and emotional distress may complicate a healthcare provider’s
decision making. One goal of this publication’s authors is to empower OR personnel with
knowledge about active shooter incidents, so they may more quickly respond.
Existing scientific literature and government publications lack a detailed exploration of
OR response plans for active shooter incidents. Furthermore, the historical infrequency of active
shooter incidents in healthcare facilities make it difficult to fully understand and plan for such
events. Although healthcare-based active shooter incidents have remained infrequent, a worrying
trend of increasing gun violence and mass shootings is developing in the United States. Due to
their multiple access points and relative lack of protection, healthcare facilities and their ORs are
particularly vulnerable to active shooter incidents. Administrators and personnel must become
actively involved in developing facility-specific active shooter response plans and addressing
existing security weaknesses to minimize the potential for casualties. The authors of this
manuscript would like to call upon The Joint Commission to make healthcare organizations
ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

23
responsible for independently developing active shooter protocols, in accordance with the
standard to proactively identify and minimize risks.
Previous publications have acknowledged the many ethical, legal, logistical, and personal
conflicts that may arise while developing an active shooter protocol in the healthcare setting.
However, these documents fail to produce detailed recommendations for administrators to
prepare OR personnel for such a tragic event. Our manuscript achieves its primary aims by
compiling current evidence and guidelines, further developing them into recommendations and a
template to aid administrators in the development of an OR active shooter response plan.
Although there are many unique considerations for an active shooter incident in a healthcare
facility, thorough planning by facility-specific TATs, along with implementation of an OR
specific active shooter protocol, is imperative to optimize safety for patients and OR personnel.
Limitations
One limitation of this study is the scarcity of relevant academic articles, many of which
contain low levels of evidence, such as case studies and expert opinion. Another limitation is the
variability among healthcare facilities (e.g., resources, size, building layout, security, etc.) that
make it difficult to develop a universal protocol. Administrators may face ethical and legal
barriers, which are difficult and tedious to navigate without legal consultation.

ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

24
Conclusion
After an integrative review, the authors’ recommendations synthesize government
guidelines, case reports, and expert advice for an active shooter protocol tailored to the OR.
Many of the resources analyzed in this article suggest establishing an OR-specific protocol to
facilitate a coordinated response to active shooter incidents. Without a protocol in place, actions
and response times may be incongruent, resulting in detrimental effects for the patient and the
OR staff. The authors found several articles insinuating that a Run, Hide, Fight protocol is the
best general approach to an active shooter incident, but other similar models have also been
proposed by other authors to adapt to unique circumstances. For the OR, we recommend Secure,
Run, Fight.
The OR is different from other areas of a healthcare facility, so it requires a specialized
active shooter response plan. Unique OR safety considerations include sterility, vulnerability,
and staffing. The decision to abort or continue the procedure must be made with the patient’s
best interest in mind, while also considering the safety of healthcare personnel. The authors of
this paper recommend that the attending surgeon act as team lead, consulting with the anesthesia
provider to develop a surgical plan, while the OR circulator serves as communication liaison.
The authors urge healthcare facility administrators to create a TAT and use HPHSCC
(2017) guidelines to develop a facility-specific active shooter protocol. The proposed Secure,
Run, Fight framework may be used to guide development of an active shooter response plan for
the OR. Developing a comprehensive facility-specific active shooter protocol will help ensure
the safety and best interests of the patients and OR staff.
ACTIVE SHOOTER PROTOCOL IN THE OPERATING ROOM

25
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Appendix A

Abstract (if available)

Abstract Hospital-based shootings have become increasingly prevalent within past decades. While most hospital systems have protocols in place for such an event, the operating room (OR) suites may require an amended protocol. AIMS: (1) Identify best practices for managing an active shooter incident in the OR through an integrative review of the literature and current guidelines. (2) Provide recommendations and a template for hospital administrators to prepare for an active shooter event in OR suites. METHODS: An integrative review of the literature and relevant data, guidelines, and reports from state and federal government organizations were explored. RESULTS: A total of 32 sources were identified. To address unique security concerns for the OR, the authors recommend hospital administrators develop a threat assessment team, which would utilize the template in this article to establish a specific protocol for the OR, including role assignments in the case of an active shooter. The recommended protocol is: Secure, Run, Fight. CONCLUSION: The authors offer recommendations and a template to guide hospital administrators through preparing for an active shooter incident in the OR and acknowledge the need for staff education.

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Asset Metadata

Creator Espina, Marty Angelo Buzon (author)

Core Title Recommendations and template for an active shooter protocol in the operating room: an integrative review

School Keck School of Medicine

Degree Doctor of Nurse Anesthesia Practice

Degree Program Nurse Anesthesiology

Publication Date 04/01/2021

Defense Date 03/31/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag active shooter,anesthesia,certified registered nurse anesthetist,CRNA,emergency preparedness,Hospital,OAI-PMH Harvest,operating room,Security,Surgery

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Contributor Electronically uploaded by the author (provenance)

Advisor Bamgbose, Elizabeth (committee chair), McCall, Erica (committee member), Myers, Natalie (committee member)

Creator Email martyang@usc.edu,martyespina@yahoo.com

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