Threat awareness and counter-terrorism preparedness of Dutch hospitals: A cross-sectional survey

Background: Hospitals are vulnerable targets for terrorism and extreme violence due to their easy accessibility and the high density of patients, staff and visitors. Nonetheless, little is known about the hospitals’ awareness of these risks, and to which extent these facilities protect themselves from violence. Methods: This was a cross-sectional survey study among emergency managers of acute care hospitals in the Netherlands. The questionnaire included 42 items across six themes: demographic (hospital) data; general and emergency department (ED) access control; ED security and preparedness; online security and offline transparency; violence, terrorism and warfare; and impact of the COVID-19 pandemic. Results: The questionnaire was completed on behalf of 33 out of 71 hospital organizations (46%), representing 38 out of 82 EDs (46%). Hospitals had broadly different policies with regards to patient and visitor registration, the presence of security guards, and vehicle access for the parking lot and ambulance bay. A terrorism paragraph was included in 34% of hospital disaster plans. Eighteen percent of hospitals had previous experience with extreme violence and 55% of hospitals had sustained (attempted) cyberattacks. On a 10-point Likert scale, the likelihood of a cyberattack scored higher (7.3) than a physical terrorist attack (3.6). A significant proportion of emergency managers experienced an increased risk of violence since the COVID-19 pandemic. Conclusion: Practice variation with regards to counter-terrorism defence measures in Dutch hospitals is high. The preparedness of hospitals for terrorist attacks or extreme violence could be improved and may benefit from uniform, evidence based hospital security policies.