The Code Silver Exercise: a low-cost simulation alternative to prepare hospitals for an active shooter event

Area of Science:

• Healthcare emergency preparedness
• Medical simulation and training
• Public health and safety

Background:

• Mass shooting incidents are rising, making hospital active shooter response protocols (Code Silver) a critical concern.
• Hospitals must proactively prepare staff for realistic security threats.
• Theoretical safety measures are evolving into essential preparedness initiatives.

Purpose of the Study:

• To conceptualize and trial a Code Silver Exercise (CSE) for feasibility and efficacy.
• To develop a reproducible simulation alternative for operationalizing Code Silver policies.
• To assess the impact of CSE on staff understanding and preparedness.

Main Methods:

• A Code Silver Exercise (CSE) involving mental practice, written responses, and facilitated debriefing.
• Piloted in three settings: in situ (ED/ICU), offsite workshop, and virtual platform across four Canadian cities.
• Pre- and post-simulation surveys administered to in situ and virtual participants.

Main Results:

• The CSE proved feasible and effective across diverse settings and locations.
• Participants showed improved understanding of Code Silver protocols post-simulation.
• The training model is versatile, accessible, and reproducible for healthcare institutions.

Conclusions:

• The CSE is a sustainable and accessible training model for healthcare institutions facing active shooter threats.
• Mental rehearsal and debriefing within CSE can help staff develop a mental schema for active shooter events.
• Implementing CSE may indirectly improve survivability during real active shooter incidents.