American Society of Anesthesiologists
Committee on Trauma and Emergency Preparedness
This committee work product has not been approved by ASA’s Board of Directors or House of Delegates and does not represent an ASA Policy, Statement or Guideline.
Before an Event
- Be aware that active shooter event could occur without warning.
- In work area, know exits and which rooms can be locked.
- Practice securing rooms and evacuating.
- Know facility procedures for calling for help (internal extension, “panic button”).
- Know options for active shooter response (Run-Hide-Fight) and alternative (Secure-Protect-Fight) if with incapacitated patients.
- Take a “Stop the Bleed” course.
- Control access to vulnerable areas (badge/code access).
- Maintain robust emergency notification system.
- Communicate in “plain language” rather than codes .
- “Stop the Bleed” training for staff.
- Place hemorrhage control kits in multiple locations.
- Conduct regular staff education on active shooter response.
- Conduct drills for staff to practice exit routes and securing rooms.
- Proactively identify potential threats and develop action plans to address.
- Plan facility active shooter response with local law enforcement and EMS agencies,
- Establish plan for communication with patient and staff families after event.
During an Event
There is no “one size fits all” approach for a healthcare professional to respond to an active shooter event. Each event is different, and decisions made in the moment will depend on the unique circumstances of the event, the proximity of the shooter, whether or not patients are able to evacuate or are incapacitated, and the individual choice of the healthcare professional.
The overreaching goal of triage is to do the most good for the most people. “Doing good” includes preserving your own life so that you do not become a casualty and can continue to help others. The speed at which you can properly orient yourself towards what is occurring directly impacts your survival.
Options for responses are outlined below:
- Rapidly move to a safe location away from the shooter.
- Encourage as many people as possible to go with you.
- Do not stop to render aid to victims.
- Call 911.
- Do not re-enter scene.
Hide or “Shelter in Place”
- Go to a room with a lockable door (“safe room”) or barricade the door/windows with large objects and/or a doorstop.
- If caring for incapacitated patients (e.g., in an operating room) strongly consider barricading room with heavy equipment and sheltering in place.
- Turn out lights.
- Cover windows.
- Stay quiet, silence cellphones and pagers.
If the shooter is close, you may have no option except to fight to save your life and the lives of those around
- Act aggressively. Your life depends on it.
- Act as a team.
- Use improvised weapons (e.g., fire extinguisher).
- Disrupt and incapacitate the shooter. Focus on EYES and AIR—disrupting vision and breathing.
When Law Enforcement Officers Arrive
- Keep hands raised and visible.
- Don’t point, scream or yell.
- Follow all law enforcement instructions.
- Don’t make sudden movements toward officers.
After an Event
- Render emergency medical aid only if safe to do so. Control of hemorrhage is the highest priority.
- Activate facility hospital incident command system.
- Anticipate that medical and non-medical operations will continue to be disrupted due to comprehensive searching of the facility by law enforcement and investigation of the crime scene.
- Disseminate information internally and externally via public information officer.
- Offer professional psychological support (debriefing, counselling) to those involved in the event.
The Healthcare and Public Health Sector Coordinating Council. (2017) "Active Shooter Planning and Response in a Healthcare Setting”
Blair, JP, and Schweit, KW. (2014) A study of active shooter incidents in the United States, 2000 - 2013. Texas State University and Federal Bureau of Investigation, U.S. Department of Justice, Washington D.C. 2014.
Active Shooter: How to Respond. (2008 booklet) U.S. Department of Homeland Security.
Denham II C, Botz, G, Denham III, C, Adcox, W. (2019) Hospital-based active shooter incidents: sanctuary under fire. JAMA, 313(12):1209-10.
Kelen, GD, Catlett, CL, Kubit, JG, and Hsieh, Y-H. (2012) Hospital-based shootings in the United States: 2000-2011. Ann Emerg Med, 60(6):790-8.
Phillips, JP. (2016) Workplace violence against health care workers in the United States. NEJM, 374:1661-9.
Jacobs, LM and Burns, KL. (2017) The Hartford Consensus: survey of the public and healthcare professionals on active shooter events in hospitals. J Am Col Surg, 225(3):435-42.
Inaba, K, Eastman, AL, Jacobs, LM, et al. (2018) Active-shooter response at a health care facility. NEJM, 379(6):583-6.
“Run, Hide, Fight” Training Video for the Healthcare Environment
2017 Active Shooter Update for Hospitals and Healthcare Systems
Active Shooter Awareness – Hospital
Just In Time Disaster Training Library
Surviving An Active Shooter – LA County Sheriff
(Not specific to healthcare environment, but high quality)