Schwerin Daniel L., Thurman Jeff, Goldstein Scott
Prisma Health-Upstate
University of Louisville/Norton Healthcare
Reports of active shooters occur almost weekly in the United States (US) and globally. In the past, most active shooter incidents occurred in businesses like post offices, factories, and corporations. Today’s general belief is that no profession, including healthcare establishments, is immune from gun violence due to active shooters. Active shooter incidents are as likely to occur in rural and urban healthcare facilities at any time. Unlike other businesses, the major problem with active shooter incidents in a healthcare facility is that unique challenges are posed in planning and response. Hospitals see thousands of patients every day, some of whom arrive due to gun violence. Gun violence is due to a myriad of factors, including the history or culture of a region and the local laws about the possession of firearms. Some events already have police on the scene (ie, in the emergency department), and the firearm is not necessarily brought into the facility. Moreover, hospitals have many entrances and exits, making planning for an active shooter incident complex. Further adding to the complexity of an active shooter is that most incidents occur without any hindsight and end quickly, often before law enforcement arrives. Thus, intervention by bystanders, hospital personnel, and other civilians may be necessary in a contingency plan during the initial phase of an active shooter at a healthcare facility. Gun violence refers to the use of guns to inflict violence in settings, including healthcare facilities. Though gun violence has a multifactorial etiology, food insecurity is one common predicting factor, as well as underlying or undiagnosed psychiatric disease. Hospitals located in food-scarce regions or food deserts may be more prone to active shooter incidents. Facilities that treat patients with psychiatric diseases may be at higher risk for such incidents. Within the US, state-to-state regulations vary regarding the possession of firearms. Healthcare professionals may agree or disagree depending on personal beliefs, and the focus on gun violence prevention is correlated to the increase in active shooter incidents, especially within hospitals and in the context of this activity. Several studies continue to examine the role of components of safe firearm use, including the use of safe storage, with insignificant results. Background checks that examine psychiatric stability are not required as of yet. Because active shooter events are now a common occurrence in the US, all healthcare facilities must prepare contingency plans to limit damage and death. The contingency plan provides a framework for when and if the healthcare facility is subject to gun violence. This plan includes the floor plan of each hospital section, identifying exits, first aid kits, and places of shelter. Key personnel are identified to facilitate the execution of the plan. Law enforcement officials now actively assist the hospital administration in planning and guidance in dealing with active shooter events. In 2016, the Occupational Safety and Health Administration (OSHA) updated its healthcare safety field Rule 3148, Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. Incorporating an active shooter incident plan is a part of every healthcare facility’s emergency management plan. Distinguishing between a shooting incident and an active shooter is important in emergency management protocols. An active shooter is a term used by law enforcement to describe a situation where a shooting is in progress, and this particular crime requires a set of protocols when responding to the incident. According to the United States Department of Homeland Security, an active shooter is “someone who is actively engaged in killing or attempting to kill people in a confined and populated area.” The majority of active shooter events are preplanned. In most cases, the active shooter has already accepted the fact that they may also die. Active shooter events usually do not last long; most are over within 19 minutes, either because law enforcement stops the shooter, the weapon malfunctions/jams, or the person runs out of ammunition. However, within these 10 minutes, the shooter may cause damage. Data show that multiple people can be shot within a few minutes, and at least two-thirds of active shooter incidents are over by the time law enforcement arrives. On the other hand, a shooting incident is a spontaneous, unplanned event that may involve 2 participants who either know or do not know each other. For example, a patient may have been unhappy with the surgeon following a surgical complication. The surgeon may unjustly blame the patient, and the latter shoots the surgeon. A clinician may also be upset at the manager for refusing to pay him overtime and draw a weapon. The unplanned or spontaneous events may occur because of impulsive action, extreme anger, or loss of control. Spontaneous shooting events in healthcare facilities usually involve 1 or 2 shots from a gun. They may be involved in a shooting between 2 or more individuals, for example, a spouse, manager, or colleague.
在美国及全球范围内，几乎每周都会有关于活跃枪手的报道。过去，大多数活跃枪手事件发生在邮局、工厂和公司等场所。如今，人们普遍认为，包括医疗机构在内，没有哪个行业能免受活跃枪手带来的枪支暴力威胁。活跃枪手事件随时都可能在农村和城市的医疗机构发生。与其他行业不同的是，医疗机构发生活跃枪手事件的主要问题在于，在规划和应对方面存在独特的挑战。医院每天接待数千名患者，其中一些是因枪支暴力而来。枪支暴力是由多种因素造成的，包括一个地区的历史或文化以及当地有关枪支持有方面的法律。有些事件现场已经有警察（如在急诊科），枪支不一定会被带入医疗机构。此外，医院有许多出入口，这使得针对活跃枪手事件的规划变得复杂。更增加活跃枪手事件复杂性的是，大多数此类事件毫无预兆地发生且迅速结束，往往在执法人员到达之前就已结束。因此，在医疗机构发生活跃枪手事件的初始阶段，应急预案中可能需要旁观者、医院工作人员及其他平民进行干预。枪支暴力是指在包括医疗机构在内的场所使用枪支实施暴力行为。尽管枪支暴力有多种病因，但粮食不安全是一个常见的预测因素，潜在的或未被诊断出的精神疾病也是如此。位于粮食匮乏地区或食品荒漠的医院可能更容易发生活跃枪手事件。治疗精神疾病患者的机构发生此类事件的风险可能更高。在美国，各州关于枪支持有的规定各不相同。医疗保健专业人员可能因个人信仰而赞同或反对，对枪支暴力预防的关注与活跃枪手事件的增加相关，尤其是在医院及此类活动的背景下。几项研究继续探讨安全使用枪支的各个组成部分的作用，包括安全储存的使用，但结果并不显著。目前还不需要进行检查精神稳定性的背景调查。由于活跃枪手事件在美国现在已屡见不鲜，所有医疗机构都必须制定应急预案以减少损害和死亡。应急预案为医疗机构何时以及是否会遭受枪支暴力提供了一个框架。该计划包括每个医院区域的平面图，标明出口、急救箱和避难场所。确定关键人员以促进计划的执行。执法官员现在积极协助医院管理部门制定应对活跃枪手事件的计划并提供指导。2016年，职业安全与健康管理局（OSHA）更新了其医疗安全领域规则3148，即《医疗和社会服务工作者预防工作场所暴力指南》。纳入活跃枪手事件计划是每个医疗机构应急管理计划的一部分。在应急管理预案中，区分枪击事件和活跃枪手事件很重要。活跃枪手是执法部门用来描述正在发生枪击情况的术语，应对这一特定犯罪需要一套相应的预案。根据美国国土安全部的定义，活跃枪手是“在封闭的人群聚集区域内积极参与杀人或企图杀人的人”。大多数活跃枪手事件都是预先策划好的。在大多数情况下，活跃枪手已经接受了他们自己也可能死亡的事实。活跃枪手事件通常持续时间不长；大多数在19分钟内结束，要么是因为执法人员击毙枪手、武器故障/卡壳，要么是枪手弹药耗尽。然而，在这10分钟内，枪手可能会造成破坏。数据显示，几分钟内可能有多人中枪，而且至少三分之二的活跃枪手事件在执法人员到达时已经结束。另一方面，枪击事件是自发的、无计划的事件，可能涉及两个相互认识或不认识的参与者。例如，一名患者在手术出现并发症后可能对外科医生不满。外科医生可能不公正地指责患者，后者便开枪射击外科医生。一名临床医生也可能因经理拒绝支付其加班费而心生不满并拔枪相向。这些无计划或自发的事件可能是由于冲动行为、极度愤怒或失去控制而发生。医疗机构中的自发枪击事件通常涉及一两枪。它们可能发生在两个或更多人之间的枪击，比如配偶、经理或同事之间。
