Health Service Applications

Planning for a Mass Casualty Incident in Arkansas SchoolsJames Graham, Rebecca Liggin, Steve Shirm, Brian Nation, Rhonda Dick

School preparedness includes the possibility of a nat-ural disaster,1,2 but recent events also confirm a need

for preparedness and prevention efforts for intentionalmass casualty incidents (MCIs).3-7 This survey examinedthe preparedness for the prevention and response forMCIs at public schools in Arkansas.

SURVEY METHODSA mailed survey was sent to superintendents of all

307 public school districts in Arkansas in August2003, using a list obtained from the Arkansas Depart-ment of Education. A second mailing was sent to non-responders in September 2003. The survey assuredsuperintendents that no individual school districtresponse would be released and only aggregate datawould be reported. An addressed, stamped envelopewas included for survey return. The survey was re-viewed and exempted by the University of Arkansasfor Medical Sciences Institutional Review Board.

SURVEY RESULTSSome 226 of 307 surveys were returned (74%).

Most school districts (51.3%) reported they did nothave a written plan for the prevention of a terrorist ormass casualty event. Very few districts reported usingstudent (14.6%) or teacher (29.2%) identificationbadges. When asked about any kind of physical barrieror restricted vehicular access (such as fences or gates)to school grounds, only 27% reported having suchbarriers.

Most districts (78.8%) reported having a writtenplan for an MCI. Most (76.2%) reported having a planfor lock down of the facility in an emergency. Mostdistricts (91.2%) reported having plans for evacuationby a variety of means (28.6% on foot, 27.2% byschool bus, 18.4% by parental and/or teacher vehicles).Although most districts reported an evacuation plan,55% reported never having conducted an evacuationdrill.

Most school districts (57.5%) reported havingmade arrangements for an alternate building for shelterin case of evacuation as follows: houses of worship(69 districts), other school buildings (25 districts),and community centers or other public buildings (14districts).

About one half (50.4%) of superintendents reportedthat parents in the district knew what buildings wouldbe used as an alternate shelter; the other half saidparents did not know. A few superintendents reportedthat they do not publicize the location for securityreasons.

The majority (55.7%) reported having a writtenparental reunification plan for release of students toparents, guardians, or family members in a disasteror mass casualty situation. Most authorized a person toinitiate lockdown or evacuation measures in the districtas follows: superintendent only (59 districts); superin-tendent or principal (54 districts); principal only (49districts); superintendent, principal, or local law enforce-ment personnel (28 districts); and school resourceofficer (1 district).

Virtually all school districts (98.9%) reported main-taining an updated master list of students, usually inindividual school offices. Only 25% (57 districts) re-ported keeping a backup copy of the master list atcentral district offices.

A minority (30.1%) reported no plans for mentalhealth counseling or referral in the event of mass casu-alty. Slightly more than one half (51.3%) reported spe-cial provisions for children with special health careneeds in their emergency plans.

Superintendents reported meeting with localemergency medical services (EMS) officials to discussemergency planning as follows: never met with EMSofficials (114 districts), met 1 or 2 times with EMS offi-cials (99 districts), and meet regularly with EMSofficials (14 districts). Superintendents reported meetingwith local law enforcement officials to discuss emer-gency plans as follows: never met with local lawenforcement officials (75 districts), met 1 or 2 timeswith local law enforcement officials (130 districts),and meet regularly with local law enforcement officials(20 districts). Most school districts (61.6%) providedcopies of floor plans for their buildings to local lawenforcement officials.

SURVEY IMPLICATIONSApproximately 53 million children in the United

States attend public or private schools each day. In

James Graham, MD, Professor, (grahamjames@uams.edu); RebeccaLiggin, MD, Assistant Professor, (ligginrebeccal@uams.edu); SteveShirm, MD, Associate Professor, (shirmstevenw@uams.edu); andRhonda Dick, MD, Associate Professor, (dickrhondam@uams.edu).Department of Pediatrics, University of Arkansas for Medical SciencesCollege of Medicine, 800 Marshall St, Little Rock, AR 72202;and Brian Nation, MPA, Trauma System Coordinator, (bnation@healthyarkansas.com), Arkansas Department of Health, Office of EMSand Trauma Systems, 4815 West Markham St, Little Rock, AR 72205.This study was supported by a grant from the Health Resources andServices Administration—Maternal and Child Health Bureau (MCH#1H33 MC 00088 01).

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addition, approximately 6 million adult teachers andstaff work in those facilities.8 Because large gatheringsoccur daily, schools represent a risk for an MCI fromeither natural or intentional causes. Therefore, schoolpersonnel must ensure the safety and security of schools,and schools also have a special responsibility because oftheir in loco parentis role.

In this survey, most school districts reported theydid not have a written plan for prevention of anMCI. Schools have traditionally prepared for natural orunintentional disasters, such as fires, earthquakes, andtornadoes. Such disasters are unpredictable and unpre-ventable. With the advent of school shootings and ter-rorism, the need for prevention or mitigation hasbecome apparent.

Proper identification of individuals who are appro-priately on campus and the rapid identification of thosenot authorized to be on school property is important.Identification badges provide a simple, inexpensivemeans to mark those appropriately on campus but areused by few school districts in Arkansas. Other organi-zations, such as hospitals, routinely use identificationbadges for security purposes. Vehicle barriers may pre-vent a vehicular threat, such as a car or truck bomb, inclose proximity to a school building. Only a few super-intendents reported using such barriers. The expense ofsuch structural modifications can be significant.

Most schools did not have a prevention plan, butmost reported having a written plan for responding toa disaster on campus. Almost all districts reported hav-ing an evacuation plan, including movements by foot,school bus, and private vehicles. Although mostschools had an evacuation plan, less than one half hadever conducted an evacuation drill to evaluate theeffectiveness of such a plan. For example, Seattleschools conducted drills of emergency plans, includingevacuation and shelter-in-place plans, and revised theplans after the drill.8

In an MCI, schools must be prepared to informparents of the location of their children and how toreunite with their children. Such an event can occur atany time, and children may not be on school groundswhen reunification occurs, so a master list of studentsand a plan for releasing students to parents or responsi-ble relatives is important. Slightly more than one halfof districts in this survey reported having a writtenparental reunification plan. Most districts kept a masterlist of students, but only about one fourth of them kepta copy of the master list off the school campus. Ifa disaster destroyed a school building, an offsite listwould be important in accounting for everyone in theschool.

Children with special health care needs presenta special challenge in emergency plans.9-11 Mobilitymay be impaired, posing a challenge for evacuation.If sheltering-in-place is necessary, an adequate supply ofitems needed to care for these children must beprovided.

Ensuring that plans are coordinated with local emer-gency agencies is important. During the Columbineschool shootings, local law enforcement special weap-ons and tactics (SWAT) teams and ambulances initially

were told that there was shooting in the library. Becausethey did not have a current floor plan, there were diffi-culties in the initial emergency response and getting per-sonnel to the school library.3,4 A previous studydemonstrated that EMS ambulances are frequentlycalled to schools for emergencies, even outside thedisaster or mass casualty situation.9 Although mostschool superintendents had met with local law enforce-ment personnel, most had never met with local EMS of-ficials to discuss emergency planning. Few schooldistricts reported holding regularly scheduled meetingswith either EMS or law enforcement.

CONCLUSIONSThis survey demonstrated that most school districts

in Arkansas have plans for responding to a mass casu-alty event, but less than one half have a plan for pre-vention or mitigation of such an event. Since thissurvey was conducted, Arkansas has passed a lawrequiring all school districts to develop such an emer-gency response plan. The findings highlight a needfor continued planning and preparation. For example,most schools had not conducted a mass casualty drill.Most superintendents had not met with local EMSofficials, and only a few have regularly scheduledmeetings. Schools should continue to plan and preparefor the unwelcome prospect of a disaster at a school.School district administrators, nurses, physicians, localemergency response agencies, and the local medicalcommunity should all be involved in formulating acoordinated plan for their local community schools. j

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2. Van Horst J. An earthquake preparedness plan at WebsterElementary School. J Sch Health. 1989;59:367-368.

3. Heightman AJ. Assault on Columbine. J Emerg Med Serv.1999;24(9):32-46.

4. Nordberg M. When kids kill: Columbine High School shooting.Emerg Med Serv. 1999;28(10):39-45.

5. Merz K. The Columbine High School tragedy: one emergencydepartment’s experience. J Emerg Nurs. 1999;25(6):526-528.

6. Brener ND, Simon TR, Anderson M, et al. Effect of the incidentat Columbine on students’ violence- and suicide-related behaviors.Am J Prev Med. 2002;22(3):146-150.

7. Kostinsky S, Bixler EO, Kettl PA. Threats of school violence inPennsylvania after media coverage of the Columbine High Schoolmassacre: examining the role of imitation. Arch Pediatr Adolesc Med.2001;155(9):994-1001.

8. National Advisory Committee on Children and Terrorism.Schools and terrorism: a supplement to the report of the NationalAdvisory Committee on Children and Terrorism. J Sch Health.2004;74(2):39-51.

9. Sapien RE, Allen A. Emergency preparation in schools: a snap-shot of a rural state. Pediatr Emerg Care. 2001;17(5):329-333.

10. Abrunzo T, Gerardi M, Dietrich A, et al. The role of emer-gency physicians in the care of the child in school. Ann Emerg Med.2000;35(2):155-161.

11. Emergency Cardiovascular Care Committee. Response tocardiac arrest and selected life-threatening emergencies: the medicalemergency response plan for schools. A statement for healthcare pro-viders, policymakers, schools administrators, and community leaders.Pediatrics. 2004;113(1):155-168.

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