ANCC CONTACT HOUR Active Shooter On Campus!
1.0ANCCCONTACT HOURActive shooteron campus!Prepare for when, not if.By Deborah L. Sikes, DNP, RN, CNE; Glenn A. Barnes, MSN, RN, EMT-P;and Deborah L. Casida, MSN, RN34 Nursing made Incredibly Easy! January/February 2018articles. The majority of publicationsadvocated for training and preparation within hospital settings. One articlefocused specifically on educational facilities, but was only available for purchasethrough the university library.In this article, we provide informationto help nurses in educational settingsprepare for an active shooter event.Definitions and statisticsAccording to the U.S. Federal Bureauof Investigation (FBI), an active shooteris defined as “one or more individualsactively engaged in killing or attempting to kill people in a populated area.”In 2014, the FBI reported that 160 active shooter events occurred in theUnited States between 2000 and 2013,with over 1,000 casualties (486 killed,557 wounded). An updated 2016 FBIreport indicated that there were an additional 20 active shooter events eachyear in 2014 and 2015, resulting in 231ALPTRAUM / DREAMSTIMEAs colleges and universities face therealities of today’s educational environment, preparing for an active shooterevent is a necessity. Managing emergencies on campuses is a top safety priority.Training students, faculty, and staff torespond according to guidelines developed by law enforcement and emergency management personnel in theevent of an active shooter provides thegreatest chances of survival (see Quicktips for nurses in an active shooter event).Although predicting an active shooterevent is nearly impossible, preparing forone is a grim reality that must be faced.A scarcity of literature exists regarding specific resources and plans forpreparing nurses in educational settingsfor an active shooter event. A recentCINAHL search limited to publicationdates between 2007 and 2017 in academic journals, using the search terms“active shooter” and “nursing,” yielded37 results, with only 6 nursing journalwww.NursingMadeIncrediblyEasy.comCopyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
www.NursingMadeIncrediblyEasy.comJanuary/February 2018 Nursing made Incredibly Easy! 35Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
casualties (92 killed, 139 wounded).The locations of reported active shooterevents included businesses, educationalinstitutions, government buildings, openspaces, residences, healthcare facilities,and houses of worship.A mass shooting event is defined asone in which four or more people areinjured or killed in a single incident, notcounting the shooter. The Gun ViolenceArchive has reported 299 mass shootingevents in 2017, with more than 300 killedand more than 1,500 injured. This includesthe worst mass shooting in U.S. history,which occurred at Mandalay Bay in LasVegas, Nev., on October 1, 2017, resultingin 58 deaths and 546 injuries when a gunman opened fire during a concert.In educational settingsBetween 2000 and 2016, the FBI reporteda total of 48 active shooter events in educational settings, including elementaryschools, middle schools, high schools,colleges/universities or technical schools,and school board meetings. Everytownfor Gun Safety, an independent organization dedicated to reducing gun violence,reported 242 school shootings (definedas a firearm being discharged inside aschool building or on school or campusgrounds) since 2013. In 2015, 23 activeQuick tips for nurses in an active shooter eventRun: The urge for nurses may be to run toward the situation to assist, butyou should run away from the shooter. Your personal safety is the firstpriority. Don’t stop to take personal belongings, such as a purse or cellphone. As you leave a building, if law enforcement personnel are present, keep your hands high in the air to indicate you aren’t the shooter.Remember, you won’t be able to assist anyone if you become a victim inthe incident.Hide: Take shelter if you’re unable to flee the situation. Close and lockdoors, block the door, hide under desks or in a closet, turn off the lights,and don’t open the door until clearly notified by law enforcement. If youhave your cell phone, turn off notifications and ringers. Be as still as possible and don’t attract attention.Fight: As a last resort, fight for your life. Use physical aggression andwhatever is available. Attempt to incapacitate by throwing objects at theshooter.36 Nursing made Incredibly Easy! January/February 2018shooter events were reported on collegecampuses.An added challenge in Texas highereducation settings was created with theauthorization of Texas Penal Code 46.03(a)on August 1, 2016, allowing individuals tocarry concealed firearms on college campuses. As the number of active shooter eventscontinues to rise in the United States, theneed for nurses in educational settings tobe prepared to respond in concert with lawenforcement officers increases dramatically.Simulation trainingThe following is a description of the procedures used to develop and participatein an active shooter simulation in a westTexas city. Faculty and students from anursing program were involved in thesimulation as nurses and patients in theactive shooter event. The training wasinitiated and sponsored by a local helicopter manufacturer. Development of theactive shooter simulation required manyresources and steps to ensure an effectiveand safe learning environment.PlanningThe first step in the planning processwas defining the activity and creating aplan for executing the simulation. Theactive shooter event was to be conductedin a simulated office building. To ensurethe safety of participants, the simulationneeded to be conducted in a secure location to prevent anyone from mistakingthe simulation for an actual event.The second step included identifyingkey personnel and initiating collaborationbetween the agencies that would participate in or be affected by the event. Clarification of roles and responsibilities wasnecessary to assist in the planning and execution of the simulation. Numerous agencies were notified about the simulation;first and foremost, law enforcement officials at the federal, state, and local levels.Law enforcement notification is critical toensure the safety of the public and preventwww.NursingMadeIncrediblyEasy.comCopyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
accidental initiation of emergency responses. The specific law enforcement agenciesincluded the FBI, the Drug EnforcementAdministration, the Department of Energy,and the Defense Security Service; the Amarillo, Tex., police department, the RandallCounty (Tex.) sheriff, Rick Husband Amarillo International Airport police, and Pantex nuclear weapons plant police (locatednortheast of Amarillo).An incident command post (ICP) wasestablished, allowing the various lawenforcement agencies to collaborate anddetermine which agency would be thefirst to respond to the scene. In a realactive shooter event, the ICP is essentialto the establishment of communication,coordination of efforts, and disseminationof information to the public.The third step included notification ofpublic agencies in the area and an invitation to participate in the event. Emergencymedical services (EMS), Amarillo CollegeEMS students, and the City of AmarilloFire Department participated in the event,but were informed initially to make themaware of potential injuries from participation. Hospital personnel were invited toparticipate to provide tertiary care, withspecific notification given to ED staff andhospital administrators. Local hospitalswere on alert, including BSA HealthSystem and Northwest Texas HealthcareSystem. A helicopter company was on-siteduring the simulation. The Texas TechUniversity Health Sciences Center communication director participated in theevent by taking videos and photos.Community support services werenotified, including utility companies, thelocal media, and the American Red Cross,to inform the public that the simulationwas a training activity and not an actualactive shooter event. In a real situation,the media are involved to keep the publicinformed of unfolding events and remindthe public to stay away from the area.During the planning phase, severalmeetings were necessary to set up the ruleswww.NursingMadeIncrediblyEasy.comof engagement. Communication betweenthe various departments was establishedby defining the roles for each entity duringthe simulation. The defined roles includedsecuring the area (police, SWAT) and evacuating the victims (fire department). Policeescorted the fire department into the building to complete Simple Triage and RapidTreatment (see The START adult triagealgorithm). Victims were carried out of thebuilding using a police escort. EMS personnel transported the victims out of the areato the local hospitals. American Red Crosspersonnel were on the scene, supportingemergency first responders with water andadditional identified needs.MethodsAn active shooter event is usually a highintensity, short-duration incident. In thedescribed simulation, all casualties weresustained within 20 minutes; FBI statistics indicate that most mass shootingslast less than 10 minutes. The nationalaverage response time of law enforcement is approximately 10 minutes. Thefindings also reflect the damage that canoccur in a matter of minutes: 44 of 63 incidents (70%) studied ended in 5 minutesor less; 23 ended in 2 minutes or less.Police response time may be delayed inheavy urban areas due to traffic and inrural areas due to the distance of trainedemergency response personnel.At the end of our simulation scenario,the shooter was killed by law enforcement. Active shooter events usuallyresolve in one of the following ways: The shooter is killed or captured by lawenforcement. The shooter kills him- or herself. The shooter is killed or captured bycivilians at the scene. The shooter expends all means ofviolence and surrenders. The shooter barricades him- or herself.Communication is critical during anyemergency. Simulated active shooterevents are no exception. CommunicationAn activeshooter eventis usually ruary 2018 Nursing made Incredibly Easy! 37Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
The START adult triage algorithmSimple Triage and Rapid Treatment, or START, is a rapid assessment method used to triage victimsduring a mass casualty event. Victims are quickly labeled according to the assessment processdescribed below.START adult triageAble towalk?YesMINORSECONDARY TRIAGENoSpontaneousbreathingNoPosition NTTriage categoriesEXPECTANT Black triage tag colorVictim unlikely to survive given serverityof injuries, level of available care, or both 30RespiratoryrateIMMEDIATEPalliative care and pain relief shouldbe providedIMMEDIATE Red triage tag colorVictim can be helped by immediateintervention and transport 30Requires medical attention withinminutes for survival (up to 60)PerfusionRadial pulseabsentor capillaryrefill 2 secIncludes compromises to patient’sairway, breathing, circulationIMMEDIATEDELAYEDVictim’s transport can be delayedRadialor capillarypulserefill 2 secpresentMentalstatusYellow triage tag colorIncludes serious and potentiallylife-threatening injuries, but status notexpected to deteriorate significantlyover several hoursDoesn’t obeycommandsIMMEDIATEMINORGreen triage tag colorVictim with relatively minor injuriesObeys commandsDELAYEDStatus unlikely to deteriorate over daysMay be able to assist in own care:“walking wounded”Source: U.S. Department of Health and Human Services. START adult triage algorithm. ion.38 Nursing made Incredibly Easy! January/February 2018www.NursingMadeIncrediblyEasy.comCopyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
between different services must be preplanned to enhance collaboration and execution, thereby controlling and decreasingthe risks of unintended consequences. Inour simulation, there were limited issueswith interservice coordination due todeconflicting the communication planbefore the simulation. Inclusion of seniorleaders from major services down to entryteams and EMS responders will preventconfusion and improve outcomes.After actionIf medical resources are overwhelmed during or following an active shooter event,it’s deemed a mass casualty incident. Receiving hospitals may need to initiate theirmass casualty plan. Even after the primaryshooting has ended, there’s no guarantee of an end to hostilities. There may beother shooters or even a secondary attackaimed at first responders. For this reason,EMS and law enforcement personnel mustpractice and work together to be able toenter a dangerous area as a cohesive team.LimitationsPreparing for an active shooter simulationrequires extensive resources. Involvingas many agencies as possible provides abroader perspective and a more realisticsimulation. Communication between allagencies involved is critical to establish aclear plan of action. Time must be allottedfor planning and coordinating the simulation, as well as preparing the simulationsite and moulage (creating mock injuries)of victims. Participating agencies mustschedule time for personnel to be available to perform an active role in the simulation. Including multiple simulated victims in the scenario will reveal potentialweaknesses in the use of current resourcesand establish a clear picture of how resources would be utilized in a real event.All participating community agenciesand local businesses will be called onto provide financial support. Donationscan also help offset costs. Supplies thatwww.NursingMadeIncrediblyEasy.commay be needed include providing mealsand water for participants, building andlocation sites, and establishing mediacoverage. Simulation equipment includesmoulage, simulated weapons and ammunition, emergency vehicles, and site security officers. Offering clinical hours orcontinuing education may provide addedincentives for volunteer participants.According to the standards of bestpractice for simulation, debriefing is a“learner-centered reflective conversation.intended to assist learners in examining the meaning and implications ofactions taken during a simulated experience.” Participants in a simulated activeshooter event must be debriefed; however,debriefing may be limited due to thetime needed to meet with all of the personnel involved in the simulated event.Faculty may need to schedule additionaldebriefing time or assign reflective journalentries to ensure that student participantsare fully debriefed.Repeating simulations, reviewinglimited resources, and increasing community involvement boost awareness andthe potential for a positive outcome in areal active shooter event. For methods ofimproving community involvement during an active shooter event, see Increasingcommunity involvement. Considering alternative sites to practice scenarios, especially on campuses where guns are nowallowed, may improve student involvement and preparation.If medicalresources areoverwhelmedduring orfollowing anactive shooterevent, it’sdeemed amass casualtyincident.Organizational preparednessAn active shooter event on a campus canhave devastating consequences. Policy,if not already developed, should be wellthought out to be achievable, sustainable,and realistic. Once policy is establishedor reviewed, a tabletop exercise shouldbe done with all key leaders. A tabletopexercise provides a step-by-step processto establish timelines and ensures thatthe basic components of the plan don’tconflict, such as having first respondersJanuary/February 2018 Nursing made Incredibly Easy! 39Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
Increasing community involvement Open community casting call for training exercises. A larger involvement of community participants will improve diversity and inclusionbased on the needs of your area. Broader community participationincreases not only awareness of the event, but also demonstrates thecommitment of law enforcement and EMS personnel to all groups withinthe community. Agencies such as the American Red Cross can increasecommunity exposure by supporting simulation events while providingtraining for their roles within the disaster management plan. Public service announcements (PSAs) to educate the community.PSAs can direct community members to existing resources to increasepreparedness for an active shooter event. Resources that may be usefulinclude:— The Federal Emergency Management Agency’s free interactive, webbased course Active Shooter: What You Can Do (www.training.fema.gov/is/courseoverview.aspx?code IS-907) and 4-hour virtual tabletopexercise for college campuses are suitable for healthcare providers,educators, and EMS personnel (a list of available trainings may beobtained at �� The U.S. Department of Homeland Security’s Active Shooter: How toRespond training is specifically for private citizens, human resourcesor security personnel, workshop participants, and first ive shooter booklet.pdf).— The California Hospital Association’s Planning for Active ShooterIncidents is a guide for hospitals to prepare healthcare personnel;multiple resources are available, including a pocket card (www.calhospitalprepare.org/active-shooter).— The City of Houston’s Run. Hide. Fight. Surviving an Active ShooterEvent video demonstrates the steps to survive an active shooterevent (https://www.youtube.com/watch?v 5VcSwejU2D0).— The Texas A&M Engineering Extension Service’s 16-hour trainingprogram is for law enforcement, firefighters, and EMS e-technical-assistance.aspx).— The National Academy of Medicine’s Health and Medical Responseto Active Shooter and Bombing Events provides information on howto prepare and respond to an event, initial actions by first responders,secondary considerations, hospital priorities and actions, and community recovery -Events.pdf). Training for specific institutions with a historic background of activeshooter events (universities, clinics, or churches). As communitymembers and law enforcement personnel work together, trust is established and strengthened.enter the area before police officers havecleared it.Upon completion of a tabletop exercise, a full-scale simulation is done to“pressure test” the plan. Reviewing theresponses during an active shooter simulation through debriefing helps ascertain40 Nursing made Incredibly Easy! January/February 2018what went well, but particular attentionmust be given to what went wrong. Corrective actions can be made for identifiedareas of concern.If you’re in a state that has a campuscarry law, like Texas, additional trainingmust be provided for students and facultymembers who choose to carry concealedweapons. Training should teach armedcarriers how not to be perceived as athreat by law enforcement entry teamsand include campus police and local lawenforcement agencies. Interprofessionalcollaboration is required to decrease roleconfusion and enhance synergy of actionfor entry teams, as well as rescue andrecovery teams.State of readinessPreparing faculty, students, and community members for an active shooterevent on campus through simulation canimprove outcomes. Proper planning andtraining increase the odds of survival anddecrease the number of potential casualties. The resources provided in this articleare merely a starting point. Make sureyour campus is ready for when, not if, anactive shooter event occurs. REFERENCESArmed Campuses. Laws concerning carrying concealedfirearms on campus in Texas. www.armedcampuses.org/texas.Blair JP, Schweit KW. A study of active shooter incidentsin the United States between 2000 and 2013. he-united-statesbetween-2000-and-2013.California Hospital Association. Planning for active shooterincidents. www.calhospitalprepare.org/active-shooter.City of Houston. Run. Hide. Fight. Surviving an activeshooter event. https://www.youtube.com/watch?v 5VcSwejU2D0.Critical Illness and Trauma Foundation, Inc. STARTflowchart. http://citmt.org/Start/flowchart.htm.Downs S. Active shooter in educational facility. J EmergManag. 2015;13(4):303-326.Everytown For Gun Safety. Analysis of school alysis-ofschool-shootings.Everytown For Gun Safety. 242 school shootings inAmerica since 2013. .NursingMadeIncrediblyEasy.comCopyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
Federal Bureau of Investigation. Active shooter incidentsin the United States from 2000-2016. https://www.fbi.gov/file-repository/activeshooter incidents 2001-2016.pdf/view.Texas State University. Advanced law enforcement rapidresponse training (ALERRT) center. http://alerrt.org/page/about.Texas State University. Avoid, deny, defend. www.avoiddenydefend.org.Federal Bureau of Investigation. Active shooter incidentsin the United States in 2014 and 2015. ncidentsus 2014-2015.pdf/view.U. S. Department of Homeland Security. Active shooterpocket card. ns/active shooter pocket card 508.pdf.Federal Bureau of Investigation. Guide for developinghigh-quality emergency operations plans for institutionsof higher education. https://www.fbi.gov/file-repository/rems-ihe-guide 508.pdf/view.U. S. Department of Homeland Security. Active shooterpreparedness. https://www.dhs.gov/active-shooterpreparedness.U. S. Department of Homeland Security. IS-907: activeshooter: what you can do. www.training.fema.gov/is/courseoverview.aspx?code IS-907.Gun Violence Archive. http://www.gunviolencearchive.org.Hick JL, Hanfling D, Evans B, et al. Health and medicalresponse to active shooter and bombing events. vents.pdf.Utah.gov. Tabletop exercise facilitator’s guide: activeshooter event. tive Shooter tabletop exercisefacilitator guide.pdf.Kates G. Report: U.S. averages nearly one mass shooting per day so far in 2017. early-one-mass-shooting-perday-so-far-in-2017.At Texas Tech University Health Sciences Center School of Nursingin Lubbock, Tex., Deborah L. Sikes is the Veteran to BSN ProgramDirector and an Assistant Professor, Glenn A. Barnes is a SiteCoordinator and an Assistant Professor, and Deborah L. Casida is aSite Coordinator and an Assistant Professor.Sanburn J. These are all the college campus shootings in2015. y-school-shootings-2015.The authors and planners have disclosed no potential conflicts ofinterest, financial or otherwise.Texas A&M Engineering Extension Service. Exercise andtechnical assistance. 55.28For more than 98 additional continuing education articles related toemergency care topics, go to NursingCenter.com/CE.Earn CE credit online:Go to www.nursingcenter.com/CE/nmieand receive a certificate within minutes.INSTRUCTIONSActive shooter on campus!TEST INSTRUCTIONS To take the test online, go to our secureweb site at www.nursingcenter.com/CE/nmie. On the print form, record your answers in the testanswer section of the CE enrollment form on page 56.Each question has only one correct answer. A passingscore for this test is 13 correct answers. You may makecopies of these forms. Complete the registration information and courseevaluation. Mail the completed form and registrationfee of 12.95 to: Lippincott Professional Development,74 Brick Blvd., Bldg. 4, Suite 206, Brick, NJ 08723. We willmail your certificate in 4 to 6 weeks. For faster service,include a fax number and we will fax your certificatewithin 2 business days of receiving your enrollment form. You will receive your CE certificate of earnedcontact hours and an answer key to reviewyour results. Registration deadline is February 28, 2020.www.NursingMadeIncrediblyEasy.comDISCOUNTS and CUSTOMER SERVICE Send two or more tests in any nursing journal published by LippincottWilliams & Wilkins together by mail and deduct 0.95 from the priceof each test. We also offer CE accounts for hospitals and other health care facilities onnursingcenter.com. Call 1-800-787-8985 for details.PROVIDER ACCREDITATIONLippincott Professional Development will award 1.0 contact hour for thiscontinuing nursing education activity.Lippincott Professional Development is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’sCommission on Accreditation.This activity is also provider approved by the California Board ofRegistered Nursing, Provider Number CEP 11749 for 1.0 contact hour.Lippincott Professional Development is also an approved provider of continuing nursing education by the District of Columbia, Georgia, and FloridaCE Broker #50-1223.January/February 2018 Nursing made Incredibly Easy! 41Copyright 2018 Wolters Kluwer Health, Inc. All rights reserved.
34 Nursing made Incredibly Easy! January/February 2018 www.NursingMadeIncrediblyEasy.com Active shooter on campus! Prepare for when, not if. 1.0 ANCC CONTACT HOUR As colleges and universities face the realities of today’s educational environ-ment, preparing for
ACTIVE SHOOTER CHARACTERISTICS OF AN ACTIVE SHOOTER An Active Shooter is an individual actively engaged in killing or attempting to kill people. Active Shooters usually target a confined and populated area. Weapons used by Active Shooters can include, but are not limited to: firearms (most frequently used), bladed weapons, vehicles, or
14 Active Shooter: How To Respond PROFILE OF AN ACTIVE SHOOTER An Active Shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearms(s) and there is no pattern or method to their selection of victims. Active shooter situations are unpredictable and
30 active shooter After Action Reports (AARs) and identified trends in on-site incident management procedures during a response to an active shooter incident. The active shooter AAR research and analysis showed that establishing on-site incident management during an active shooter incident, in order to maintain situational awareness, is
Active Shooter Response Strategic Plan 1 Executive Summary In the booklet Active Shooter: How to Respond, the United States Department of Homeland Security (US DHS) paints the “Profile of an Active Shooter”: An Active Shooter is an individual actively engaged in killing or attempting to
PAGE 1 AVADE ACTIVE SHOOTER STTOR S T Education, Prevention, and Mitigation for Violence in the Workplace ersonal Safety Training nc. AVA Training AVADE ACTIVE SHOOTER INSTRUCTOR CERTIFICATION COURSE Upon successful completion of the 1-Day (8-Hour) AVADE Active Shooter Training program, Instructors will receive the following:
ALERRT training is good for all active shooter situations: schools, workplaces, malls, theaters, private homes, etc. Alabama's ALERRT Program Officers are given the 16-hour (two-day) course Rapid Response to Active Shooter: Level I. Day one focuses on the history of the active shooter phenomenon from the first recorded event in
ACTIVE SHOOTER HOW TO RESPOND. RUN! HIDE! FIGHT! 2. PROFILE OF AN ACTIVE SHOOTER An active shooter is an individual actively engaged in killing or attempting to kill people in a confined and populated area; in most cases, active shooters use firearm(s) and there is no
The new 2nd grade Reading Standard 6 has been created by merging two separate reading standards: “Identify examples of how illustrations and details support the point of view or purpose of the text. (RI&RL)” Previous standards: 2011 Grade 2 Reading Standard 6 (Literature): “Acknowledge differences in the
