Disciplines / locations to which this multidisciplinary policy applies:

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1 LEE MEMORIAL HEALTH SYSTEM POLICY & PROCEDURE MANUAL T Y P E ACTIVE SHOOTER RESPONSE PLAN: CODE SILVER System-wide - A formal statement of values, intents (policy), and expectations (procedure) that applies to every employee throughout the System. Multidisciplinary - A formal statement of values, intents (policy), and expectations (procedure) that applies to more than one discipline and is usually of a clinical nature. Check below all areas to which this applies. Departmental - A formal statement of values, intents (policy), and expectations (procedure) exclusive to a particular department or group of people within a department at one or multiple locations that does not impact any other area. LOCATOR NUMBER CHAPTER: S08 TAB: 08 POLICY #: 008 Disciplines / locations to which this multidisciplinary policy applies: Health Information Management Pharmacy Acute Care Hospital Nursing Housekeeping Plant Operations Ambulatory Services Information Systems Radiology Home Health Laboratory Rehabilitation Services HPCC Legal Services Respiratory Physician Offices Nutrition Security Rehab Hospital Other Date Originated: 7/28/11 Reviewed/No Revision: Dates Revised: Next Review 7/13 Author(s): Doug Wade, System Director of Security Reviewed by: Clinical Practice Council: Clinical Education Council Education Plan Required: Yes No: Education Completed: Approved by: Policy Administrator: Dave Kistel, VP of Facilities & Support Services 8/17/11 As Needed: Medical Director: Board of Directors: PURPOSE: To provide an immediate and effective response to an active shooter event. Active Shooter Response Plan: Code Silver Page 1 of 7 7/11

2 POLICY: In order to preserve life and address the reality of an active shooter event, these guidelines have been established to guide our response to this event to maximize survivability. DEFINITIONS: A. Active Shooter - An armed person who has used deadly physical force on other persons and continues to do so while has unrestricted access to additional victims. Active shooters have caused a paradigm shift in law enforcement training and tactics, especially as these persons do not necessarily expect to escape or even survive these situations. In most cases, an active shooter uses firearms and there is no pattern or method to their selection of victims. B. Hostage A person or entity which is held by a captor. C. Active shooter situations are unpredictable and evolve quickly. Typically, the immediate deployment of law enforcement is required to neutralize the shooter and mitigate harm to the victims. Active shooters generally do not take hostages. Response to hostage situation will be governed by the information contained in the Hostage Response Plan (Code White) S However, a hostage situation can transition into an active shooter incident thus involving elements of both of these response plans. PROCEDURE: The intent of most active shooters is to kill as many people as quickly as possible. Therefore, the traditional law enforcement response of surround and contain allows the subject to accomplish this goal. In order to save lives, those involved will initiate an immediate response. A. Upon discovery of an active shooter situation, notify the PBX Operator using the Emergency Number for your location (LMH and HP 8, CCH 444, GCMC 3333, Offsites 911 ). The PBX Operator will conduct an overhead announcement of CODE SILVER, STAT (3 times) and location. This announcement will be repeated every 5 minutes until the alert is cancelled upon authority of the Incident Commander. B. At the acute care facilities, Security Officers will meet and guide law enforcement officers as appropriate. The goal of law enforcement is to locate, isolate, and neutralize the shooter as quickly as possible to prevent additional deaths or injuries. C. The Security Officer manning Security Control will attempt to track the active shooter using CCTV, duress alarms being activated, or phone calls being received by the PBX Operator or security dispatch. SPECIFIC DEPARTMENTAL RESPONSES: A. Clinical Response in Patient Care Areas Active Shooter Response Plan: Code Silver Page 2 of 7 7/11

3 1. Clinical staff and support staff in patient care areas will remain calm and calm the fears of patients and visitors. 2. Staff, patients, and visitors will be directed to patient rooms or other adjacent rooms, close the door and attempt to barricade the doors. 3. If possible, consider locating into the bathroom and locking the door, stay as low to floor as possible and remain quiet and still. 4. Do not flee from the area or leave the facility unless instructed to do so by law enforcement or to protect them from imminent danger. Staff must communicate to patients, visitors, and others the meaning of this code and the appropriate response. 5. If employees can safety call the PBX Operator using the Emergency Number or Security Control (LMH , HPMC , CCH , GCMC ) using a cell phone or phone to call 911 from the area where they are concealed, they should do so and provide the following information: a. Description of suspect and possible location b. Number and types of weapons c. Suspect s direction of travel d. Location and condition of any victims 6. If shooter is nearby, silence your cell phone or pager. 7. Patients, visitors and others will remain behind closed or locked doors until rescued by law enforcement or they hear CODE SILVER ALL CLEAR announced overhead. B. Non-Clinical Staff Response in Non-Clinical Areas, Physicians and Others 1. Staff should remain calm and calm the fears of others. 2. Non-clinical staff, patients, students, contractors, vendors and others should immediately evacuate or proceed to areas that can be locked. 3. Individuals are to stay as close to the floor as possible, using office furniture or something solid as cover. 4. Individuals should remain quiet and still. If shooter is nearby, silence your cell phone or pager. 5. Individuals will remain behind closed or locked doors until rescued by law enforcement or they hear CODE SILVER ALL CLEAR announced overhead. 6. If employees can safely call the PBX Operator using the Emergency Number or Security Control (LMH , HPMC , CCH - Active Shooter Response Plan: Code Silver Page 3 of 7 7/11

4 , GCMC ) using a cell phone or phone to call 911 from the area where they are concealed, they should do so and provide the following information: a. Description of suspect and possible location b. Number and types of weapons c. Suspect s direction of travel d. Location and condition of any victims C. Security Department 1. Security will immediately obtain the LEO Response Bag from the office or Security Control and respond to the opposite end of the facility to meet law enforcement. Use of a personal cell phone by this response officer may be desirable to communicate information to law enforcement via 911 during this interim period. 2. Unless directed by the security supervisor, security will only set up an interior perimeter to keep others from entering the area. They will then wait for law enforcement to arrive and take over the situation in coordination with the Security Department. 3. Security Control will immediately call the System Director of Security and supervisor and advise them of the situation. Based upon the situation at hand, a recall of all off duty officers may be necessary. 4. Security, nor any other employee, will attempt to establish contact or negotiations with the suspect(s). D PBX Operators 1. Upon receiving call, make announcement CODE SILVER, STAT with location. Announce three (3) times and repeat every five (5) minutes. 2. Follow the internal emergency notifications as indicated in the Emergency Notification Plan S Upon notification from the Incident Commander, make announcement CODE SILVER IS CANCELLED. Announce three (3) times. E. Plant Operations 1. Provide current floor plans, HVAC, and utility control information of the facility as directed by law enforcement. 2. Provide assistance and support to the Security Department as directed by Security Supervisor, Lead or Senior Officer in charge. Active Shooter Response Plan: Code Silver Page 4 of 7 7/11

5 F. Food Services 1. Assist with providing food and nutrition for a prolonged or specific period as requested from the Emergency Operations Center. G. Spiritual Services 1. Provide prolonged, specific, or requested spiritual needs. 2. Assist in implementing the Critical Incident Stress Response Plan, S HOSPITAL EMERGENCY OPERATIONS CENTER A. The nature and duration of a Code Silver incident may preclude the immediate activation of the Hospital Incident Command System (HICS) during the event. LMHS attempts to follow Unified Incident Command concepts where possible but the responding law enforcement department is in charge of the incident at the onset. However, when practical, or as soon as the active shooter is neutralized, the LMHS Hospital Incident Command system will be activated and the Emergency Operations Center will be opened to address immediate and after-action issues. Refer to Hospital Incident Command System, S for specifics. B. When advised by the law enforcement commander of the incident, the LMHS Incident Commander is responsible for notifying the PBX Operator to announce Code Silver is Cancelled. C. The Incident Commander is responsible for drafting an After Action Report. RESPONDING TO AN ACTIVE SHOOTER AT AN OFFICE OR OFFSITE LOCATION A. Before law enforcement arrives on the scene, individuals must be prepared both mentally and physically to deal with the incident. B. Quickly determine the most reasonable way to protect your own life and your patients. Visitors, patients, volunteers, etc., tend to follow the lead of employees and supervisors during Active Shooter incidents. C. Evacuate - If there is an accessible escape path, attempt to evacuate the premises. Be sure to: Have an escape route and plan in mind Evacuate regardless of whether others agree to follow Leave your belongings behind EXCEPT YOUR CELL PHONE if possible Help others escape if possible Active Shooter Response Plan: Code Silver Page 5 of 7 7/11

6 Prevent individuals from entering an area where the Active Shooter may be. D. Hide Out - If evacuation is not possible, find a place to hide where the Active shooter is less likely to find you. If possible, your hiding place should: Be out of the shooter s view Provide protection if shots are fired in your direction, (i.e., an office with a closed and locked door) Attempt to find a location that does not trap or restrict your options for movement Lock the door(s) or barricade with heavy furniture If the shooter is close by, silence your cell phone or pager Turn off any sources of noise (i.e., radios, televisions) Hide behind large items such as desks, cabinets, heavy partitions Remain quiet E. Take Action against the Active Shooter - As a last resort, and only if your life is in imminent danger, attempt to disrupt and/or incapacitate the shooter by: Acting as aggressively as possible against him/her Throw items and improvising weapons Yelling Fully committing to your actions This is not a recommendation to attack the shooter, but rather a choice to fight when this is the only option left. HOW TO RESPOND WHEN LAW ENFORCEMENT ARRIVES A. Law enforcement s goal is to locate, contain, and stop the Active Shooter as soon as possible. Officers will proceed directly to the area in which the last shots were heard. B. The first officers to arrive will not stop to help injured persons. Expect rescue teams of additional officers and emergency medical personnel to follow to treat and remove any injured persons. C. Officers may wear regular patrol uniforms or vests, helmets, and other tactical gear. Active Shooter Response Plan: Code Silver Page 6 of 7 7/11

7 D. Officers may shout commands and push individuals to the ground for their safety. E. Remain calm and follow officer s instructions. F. Put down any items in your hands (i.e. bags, jackets) G. Immediately raise your hands and spread your fingers. H. Keep your hands visible at all times. I. Avoid making any quick movements toward officers such as attempting to hold on to them for safety. J. Avoid screaming or yelling. K. Do not ask officers for directions or help when evacuating, just proceed in the direction from which officers are entering the location. RELATED POLICIES: S Critical Incident Stress Response (CISR) and Activation Plan S Dangerous Area Avoidance Response Plan: Code Gray "Stay Away" S Disaster Codes S Emergency Operations and Management Plan S Emergency Notification Plan S Facility Lock Down Plan S Hospital Incident Command System S Hostage Situation Plan REFERENCES: Active Shooter, How to Respond - U.S. Department of Homeland Security, October 2008 Active Shooter, Policy EC 2.24; January 1, 2009; Jim Kendig, Vice President, Health First, Melbourne, FL Hostage/Active Shooter Situation Response Policy ; March 11, 2010; Lakeland Regional Medical Center, Lakeland, FL Safety Tips & Guidelines Regarding Potential Active Shooter Incidents Occurring on Healthcare Organization Campuses August 9, 2007; Dr. Earl J. Motzer, Ph.D., CEO, The James B. Haggin Memorial Hospital, Harrodsburg, KY Active Shooter Response Plan: Code Silver Page 7 of 7 7/11