Less than a month ago, FBI agents along with local firefighters and police descended upon Phoenix Children's Hospital to practice what they would do if an active shooter were to enter the building.
The three-day drill in the working emergency department was the culmination of months of planning between hospital officials and emergency officials—and a part of preparation that took on new significance in the wake of a shooting at a Chicago's Mercy Hospital & Medical Center on Monday. Four people, including an emergency room doctor, a pharmacy resident and a police officer, died in the incident that stemmed from a domestic dispute.
"Ten years ago, we would have been doing anthrax or weapons of mass destruction [training] because that was the major concern at that time," said Ken Crouch, manager of emergency preparedness at Phoenix Children's Hospital. "As the active shooter phenomenon, for lack of a better term, continues to get more and more prevalent and more and more press, that's a concern."
Conducting drills has become increasingly important at hospitals around the U.S. in light of growing concerns about mass casualty incidents. But there have also been growing concerns that hospitals themselves could become targets, such as with reports that suspects arrested at a New Mexico compound earlier this year indicating they planned to attack Atlanta's Grady Memorial Hospital. In 2014, the Department of Health and Human Services provided guidance (PDF) on active shooting preparation for healthcare facilities.
In the wake of incidents like what happened in Chicago, Crouch is among hospital leaders around the country reflecting on their own training and security plans, and watching how Chicago leaders respond in the aftermath of the tragic incident.
"They have to start recovering from it and getting back to the business of being a trauma center," Crouch said. That includes offering appropriate support to a large group of staff members, some of whom may not want to come to work and others who may not recognize their need for support since they are caregivers themselves. The hospital is also likely immediately beefing up their security in the wake of the incident and increasing the police presence.
"Everybody does it a bit differently, and it can be an important lesson to see how they do that."
Incidents like what happened in Chicago can hammer home the importance of hospitals training for their worst day.
"Hospitals serve our communities and they are to be open and accessible and accommodating and often a place of refuge," said Gerry Roy, who is chief compliance and privacy officer at Phoenix Children's. "You can add layer upon layer upon layer of security to that institution, but ultimately that impacts the ability of the hospital to serve the community."
Part of Crouch's job is assessing the concerns and the time spent preparing for them against other major concerns at the desert hospital.
"What if our HVAC system goes down? That can have a greater effect on us," Crouch said. "We have to prepare for all the eventualities and look at the ones with the highest potential of occurring with the highest effect to the organization and prepare for them."
That includes drills for mass casualty incidents in the community or large-scale evacuations from the hospital. "The training evolves to what the need is," he said.
During the recent training, FBI and police officials created a scenario involving a homegrown terror organization angry about a genetic testing lab at the hospital and using potential threats of an active shooter entering the hospital and a bomb being sent to an ambulatory location.
A group of hospital employees involving clinicians, administrators and security personnel agreed to participate. They ran through drills from 8 a.m. to 1 p.m. for two days and had a third day to reflect on lessons learned.
What went right? One of the areas the hospital has invested in heavily is training both clinicians and nonclinicians in "Stop the Bleed" protocols, Crouch said. It also co-located first aid kits with supplies like tourniquets and compression gauze to stop bleeding with AEDs, at security stations and other strategic spots and even made them able to be sent through the pneumatic tubes around the hospital.
After practicing the chaos of responding to an active shooter breaking into the ED, Fire and EMS officials were impressed to find so many of the nonclinicians had jumped in to respond and pack the wounds of the "victims" in the drill before responders arrived to address the casualties.
But the importance of more communication and marketing of the event—up until the very last day— is something Phoenix officials emphasized. Even with signage and continued warnings, they said there were some employees who didn't realize the training was happening until the last minute.
Finally, hospital emergency managers often have a challenge getting administrators to stop what they are doing and participate. But Crouch urged them to make the time to see and participate in the training.
"I get all the support I need from our C-suite here," Crouch said. But he recognizes his job is to pull people away from their core job functions, which plenty of administrators are reluctant to do. "If I could have my best day ever, it would be to shut down the C-suite and put every single one of them into the command center so they have a chance to experience it and see it and understand what it takes to manage an incident such as this."
Weighing the risks
The hospital, like any organization, needed to weigh the risks before deciding to hold the training.
The optics of having a parking lot full of SWAT trucks, police vehicles and other emergency responders in the hospital parking lot can cause anxiety among passersby.
And even though the bulk of the drill was occurring in hallways that had been cordoned off for the particular exercise, it's always a calculated risk of practicing with police responders and mock "bad guys" shooting live training rounds.
"If you're going to fire a weapon in a building, how many adjoining offices above and below and left and right do you have to go talk to let them know we're just training, everything's fine. And how often do you have to tell them that because people forget," Roy said.
Last minute, there was a group of individuals who had missed some of the messaging that raised concerns, he said.
"They brought concerns to our attention about the appropriateness of conducting an exercise like this at a pediatric facility like this. Those are legitimate concerns," Roy said. "I think you have to listen when people bring these to your attention regardless of how late in the game it was, we had to address these issues so everyone has that comfort level."
Next time, Roy said, we will be assessing how to hold a better campaign to try to ensure there are not individuals in the hospital who miss the message.
"Institutions going into that have to realize there is a potential here for an adverse impact on your operation. You have to weigh that with the training and the experience you get to be prepared for such an event," Roy said.