Home On the Wards Hospital shootings: rare, with "directed" motives

Hospital shootings: rare, with "directed" motives

February 2013

Published in the February 2013 issue of Today’s Hospitalist

Some believe that doctors, perhaps over other hospital employees, have more freedom to voice concerns over potential safety threats. In our August 2015 article, “How violent is your hospital? we cover both recommendations for protecting health care providers and standards hospitals can use to respond to workplace violence.

TWO SEPTEMBERS AGO, a distraught 50-year-old son of a patient who had undergone spinal surgery pulled a legal handgun on the surgeon he thought had failed his mother. He shot and wounded the physician, then killed his mother and himself at Johns Hopkins Hospital in Baltimore.

That horrific murder-suicide ” and the fear it stoked among health care workers “prompted a team of Johns Hopkins researchers to review 12 years of national data on hospital shootings in the U.S. Their study, published online in September 2012 by Annals of Emergency Medicine, found that while workplace violence may occur frequently in hospitals, gunfire is relatively rare. Even more rare are shootings that target doctors.

Nonetheless, researchers found some clear patterns among the 154 hospital-related shootings they identified in 148 hospitals affecting 235 victims between 2000 and 2011. For one, most “involved a determined shooter with a specific target.” Top motives were “grudge or revenge (27%), suicide (21%) or ending the life of an ill hospitalized relative (14%).” Another 11% were “escape attempts by patients in police custody.” Spillover of “societal violence,” such as gang wars, accounted for 9%, and “mentally unstable patients” were the cause of 4% of the incidents.

“Health care providers are unlikely to be the victims of indiscriminate violence within hospitals.”

catlett~ Christina Catlett, MD Johns Hopkins Hospital

Contrary to the popular belief expressed repeatedly during the town hall meetings held after the Hopkins shooting, she says, there seems to be no uptick in violence in hospitals located in dangerous neighborhoods. Moreover, the study authors pointed out, the data did not reveal any patterns or factors that could help “profile vulnerable sites and situations, including traditional predictors such as drug use, homelessness and psychiatric disorder.” Traditional security measures such as metal detectors would have helped avert only a minority of the incidents.The findings were “a surprise even to us,” explains Christina Catlett, MD, associate director of the Johns Hopkins office of critical event preparedness and response. Dr. Catlett is also an assistant professor of emergency medicine at Johns Hopkins and one of the study’s coauthors.

In an interview with Today’s Hospitalist, Dr. Catlett described the paper’s findings and shared her thoughts on what hospitalists can do in their own hospitals to prepare for the unthinkable.

Tragic shootings in workplaces and public places have been much in the news. Are hospitals dangerous places to work?
Hospital shootings are rare compared to other forms of workplace violence “and as a hospitalist, you are unlikely to be the victim of indiscriminate violence. Most shooters have a motive or a method to their madness, so to speak.

Our environment is a little different than other workplaces. NIOSH [the National Institute of Occupational Safety and Health] observed that 85% of workplace homicides are categorized as “criminal intent,” meaning they occur during a robbery or a hold-up. Ours are not. Our data show that hospital shootings usually happen between people who had a previous relationship. It dispels the myth of random criminal violence as an etiology of hospital shootings.

Most perpetrators of hospital shootings had what we called a “directed motive.” They were shooters with a specific target, and hospital shootings commonly involved cases of domestic violence.

We think of domestic violence as happening in the home, and we don’t think of perpetrators coming to the hospital to commit their final act of domestic violence. I was surprised that the grudge motive category was fairly high.

The study found that about 30% of shootings in hospitals happen in the ED. How do shootings that occur there differ from those on the wards?
In the ED, the perpetrators were more likely to be younger and male and, often, a security guard’s weapon was involved. Grudge motive was seldom encountered in the ED, and none of the shootings targeted an ill relative.

On the floor, shooters often went to the hospital to kill an ill relative and then frequently committed suicide themselves. It’s hard to generalize lessons from these. Most cases were elderly people, usually in their 70s and 80s, and it was usually the husband who killed the wife and then committed suicide.

Were doctors a common target?
One thing we learned is that we as health care providers are unlikely to be the victims of indiscriminate violence within hospitals. In the whole period studied, only 3% of victims were physicians and 5% were nurses.
Is there anything doctors can do to reduce the risk?

The one thing that doctors and nurses on the floor need is de-escalation training so they can recognize warning signs of escalating violence and diffuse those situations.

Health care providers aren’t necessarily trained in how to do that. We are used to dealing with physically or verbally abusive patients. But we need to learn how to recognize an escalating and potentially dangerous situation so we can quickly diffuse the anger and calm the situation back down before it rises to that level of assault.

Hospitalists can also see if their hospitals have an “active shooter” policy and, if not, work with administration to develop one. This is a policy that tells staff what to do during an active shooter situation. It’s sometimes called a Code Silver.

What does Johns Hopkins cover in its active shooter policy?
The active shooter policy describes things like initial actions to be taken by staff to secure the area, as well as protective measures, incident command and communications.

There’s also a really good video called “Run, Hide, Fight,” which was produced by Homeland Security and demonstrates how to survive an active shooter situation. There is a lot of discussion at the hospital administration level about how to interpret the three commands in the video within the health care setting because there are patients present. The ethical and moral issues make a response complicated.

What did you learn from your 2010 in-hospital shooting?
Even though we had only three casualties, it was a disaster because it put us out of commission for a number of hours. The hospital went on lock-down. We had to evacuate a unit. We had to shut down the ED.

We did learn things. We have had to look at the ways we do information sharing, for instance. How do you alert the campus that there is a shooter without spreading panic and fear? We learned a lot about our incident command system because ultimately it’s the police or the FBI who is in charge. So how do you meld your incident command system with that of the external response agency? We also learned about which team to send to a hospital shooting. We had put out an alert for a code blue because our surgeon was down, but you can’t send someone to do a resuscitation in a hot zone. The shooter was on the ward.

Would more metal detectors help?
We found that roughly 40% of shootings could possibly have been prevented by a metal detector, which means 60% may not have been. That’s because a fair number of shootings occur right outside the doors of the hospital or in parking structures. Also, when you have a determined shooter, the person will likely find a way around metal detectors.

In addition, most security experts agree that the public won’t tolerate an intrusive level of security, and it probably isn’t obtainable at most hospitals. At Johns Hopkins, we have more than 100 hospital entrances, and thousands of people come through our doors every day including employees, patients and visitors. People are not going to tolerate standing in line for an hour to get into the hospital like we do at airports.

What security precautions might work instead?
Our data do show that there are some high-risk areas where a hand-held magnetometer would be wise. For example, all psychiatric patients in the ED who are brought back to the psychiatric area are hand-metal detected. We have been doing that for a long time. We live in a city where a fair number of people are armed at any time.

While the study shows that metal detectors may not be a panacea to prevent gun violence in the hospital, there are plenty of other security measures that most hospitals already have or should have to mitigate violence within their walls.

The most basic strategy, which is in place at most hospitals, is security at the entrances. We conduct ID checks and apply visitor bands to make sure IDs are screened when visitors come into the hospital. We also have physical barriers to a lot of our wards. You have to be able to card-swipe into a ward, or a security guard has to buzz you in in most of our wards.

A lot of the nursing stations have security alert buttons. So if you feel threatened, you can press a button underneath the desk and it will alert the security team to come running to that area.

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

Facts on shooting incidents in hospitals

IN A STUDY PUBLISHED ONLINE by the Annals of Emergency Medicine last September, researchers identified 154 hospital-related shootings in the U.S. between 2000 and 2011. Here are some of the study’s findings:

  • More than one-third of those shootings took place in just five states: Florida, California, Texas, Ohio and North Carolina.
  • Large hospitals (those with more than 400 beds) had the highest incidence rate “99.8 events per 1,000 hospitals vs. 6.7 events per 1,000 hospitals among small facilities.
  • Nearly 60% of shootings occurred inside the hospital building, with the rest outside on the grounds or in parking structures. Of the in-hospital incidents, 34% happened in the ED and 32% in patient rooms.
  • 91% of shooters were men.
  • Most shooters were neither current nor former patients, nor current or former employees.
  • Most shooters had a specific target and were classified by researchers as “determined.”
  • Researchers estimated that about 40% of the shooting incidents could have been prevented by use of a metal detector.