Highland Park Shooting Anniversary: From Tragedy to Strategy

Mass casualty incidents (MCIs)—defined as events that quickly overwhelm emergency medical response systems and result in the rapid depletion of local resources and capabilities1—are on the rise in the United States.2 Historically, MCIs were linked to natural disasters like tornadoes, hurricanes, and wildfires; however, a noteworthy shift has occurred such that the majority are now caused by humans,3 most notably potent acts of violence. In fact, recent data from the National Threat Assessment Center reveal a 33% increase over a 5-year period in the number of violent attacks where 3 or more people, not including the perpetrator, were harmed.4 This evolution highlights the pressing need for updated MCI preparedness strategies that account for both natural disasters and human-made threats. Typifying this national trend was the tragedy that occurred on July 4, 2022, in Highland Park, Illinois. During the city’s annual Independence Day Parade, a lone gunman tragically took the lives of 7 parade watchers and wounded 39 others. The majority of these victims, some arriving on foot, turned to Highland Park Hospital for emergent medical assistance. Despite only being a Level 2 Trauma Center, the hospital swiftly activated emergency medicine, trauma surgery, anesthesia, and critical care services. The dedicated care team worked tirelessly to triage and provide life-saving care to the influx of patients, including an 8-year-old boy. The July 4 tragedy in Highland Park underscores the vital role that well-prepared hospitals play in an effective MCI response, even in settings with resource limitations. After this tragedy, Endeavor Health—a nine-hospital system in the Chicago area that includes Highland Park Hospital—recognized the critical need to consolidate lessons learned from it to ensure that if any other hospital within the system was confronted with a similar MCI, team members would be equipped and have the competency to respond as swiftly and effectively. To this end, a comprehensive process was launched to establish a system-wide MCI preparedness plan, creating alignment across hospitals in their emergency policies and supplies, communication and coordination response activities, and education and training exercises for MCIs. The Endeavor Health process, described herein, offers a potential model for other healthcare systems as they enhance their own MCI preparedness efforts. The vehicle that endeavor health used to propel the system through this process was its System Quality Collaborative (SQC) model. Inspired by other successful collaborative quality improvement frameworks such as Johns Hopkins Medicine’s Clinical Communities and the Blue Cross Blue Shield of Michigan-funded Collaborative Quality Initiatives,5,6 an SQC brings together clinician champions from each acute care hospital within endeavor health. It is supported by a multidisciplinary team from Endeavor Health’s central Quality Department, comprising a data analyst, performance improvement specialist, and a patient advocate. The success of the SQC model lies in its ability to harness the group’s collective expertise and diverse clinical perspectives to address system challenges like MCI preparedness. SQC participants first drafted a charter that defined their scope of work and expected deliverables, outlined their respective duties and expectations, and set criteria for gauging goal achievement (Supplemental Appendix 1, https://links.lww.com/AOSO/A438). Guided by a succinct aim statement that encapsulated the SQC’s overarching objectives, the participants collected and meticulously organized hospital-specific policies, communication strategies, and training materials related to MCIs. This effort was complemented by templated site visits to each hospital, where participants conducted thorough reviews of supplies, equipment, and physical spaces dedicated to MCI response. Finally, participants conducted a crosswalk analysis to assess alignment across entities and identify potential opportunities for enhanced collaboration among the hospitals. SQC participants found some differences across hospitals due to diversity in their geography and trauma center status. In particular, the Endeavor Health hospitals are located in 4 of the 11 Emergency Medical Services regions delineated by the State of Illinois, each with its own operational and reporting standards to guide emergency response. Further, while Endeavor Health Evanston Hospital maintains Level 1 Trauma Center status, 5 other hospitals in the network, including Highland Park, operate as Level 2 Trauma Centers, and 3 have no trauma center designation. Despite these differences, there existed substantial alignment among the hospitals concerning their policies, communication strategies, and training materials for MCIs. Nonetheless, the SQC identified 3 opportunities for harmonization (Fig. 1).FIGURE 1.: Key recommendations for cross-system unification of mass casualty incident responses.The first opportunity centered on standardizing internal emergency resource request and allocation through an emergency preparedness supply formulary. This formulary has 3 essential components: a core cache, a pediatric cache, and a mass casualty cache. Each cache is tailored to address specific needs during an MCI and can be requested individually or as a whole based on the type of MCI. Supplies included in them are supplementary to the emergency preparedness supplies on hand at the hospitals. Their contents range from surge provisions to burn supplies and hemorrhage-control methods like tourniquets. The formulary was deployed throughout Endeavor Health, allowing any hospital within it to activate and access additional supplies swiftly and efficiently in response to an MCI. The second opportunity related to emergency response code standardization. SQC participants found varying practices between hospitals, where some used color-coded schemes, while others employed a hybrid method of colors and plain-speak alerts. Within color-coded schemes, hospitals were inconsistent in the emergency response assigned to each color. Such inconsistency could lead to confusion, especially for providers and staff covering multiple hospitals. In response, a standardized set of emergency response codes was implemented that retained three universally recognized color alerts (e.g., red for fire) but transitioned the rest to plain-speak alerts, ensuring that team members at any hospital who hear or see an alert can quickly discern the required actions without the need for interpretation. Finally, while each hospital had an emergency preparedness training curriculum for MCIs, there was notable variability in their comprehensiveness. Thus, SQC participants developed a holistic framework to provide team members with the core knowledge and skills needed to perform optimally during an MCI. This included bolstering internal support for educational courses such as Advanced Trauma Life Support. SQC participants also created a standardized set of training objectives for tabletop exercises and mid-fidelity simulations that allow team members to practice their core skills in experiential learning environments, leading to more complex memory creation and retention.7 These trainings are in development with plans to roll them out by the second anniversary of the July 4 tragedy. In conclusion, endeavor health’s response to what happened in Highland Park 2 years ago illustrates how to turn tragedy into strategy, catalyzing positive system change. The collaborative efforts and initiatives undertaken in the aftermath of this event not only reflect resilience but also acknowledge the sobering reality of a nonzero probability of future MCIs. The endeavor health approach, from standardizing supply formularies and emergency codes to developing rigorous training curricula, serves as a blueprint for other healthcare systems facing similar challenges. By leveraging lessons learned, fostering collaboration, and prioritizing readiness, Endeavor Health has set a standard for proactive and effective MCI response, ultimately enhancing the safety and well-being of communities that it serves.