Sent on behalf of Crystal Edwards, Code White Executive Sponsor, Director, Women & Children’s and Adult & Forensic Mental Health Programs
The Hospital’s Code White – Violent or Threatening Person (EMER-50) policy has been revised.
Actions required:
1. Read this memo and review the updated Code White (EMRG-50) policy to familiarize yourself with important process changes.
2. Managers to ensure that updated policy is added to their area’s emergency binder.
Policy changes:
· Revised to reflect Infection Prevention and Control guidelines.
· Code White Response Team has been clarified to include a minimum of 7 responders: 2 security guards, 1 staff from all clinical departments, and AMH staff with restraints.
· More detail regarding responses for Inpatient vs. Outpatient vs. Non-Patients.
· New one page “Hot Wash” Debrief form used immediately after the conclusion of a Code White in order to document initial responder feedback, including recommendations for improvement.
Process Reminders:
· Code White is called when a person is threatening/violent inside the Hospital (980 Oliver Rd). Police are to be contacted via 9-911 for all situations occurring outside the Hospital.
· Code White is initiated by calling Switchboard. Workers in the immediate area of the aggressor are to remove themselves and others from danger and assist the Code White Response Team as necessary. Switchboard will announce “[Protected] Code White + location”. If the level of threat may overwhelm the Hospital’s internal response capacity, Police will be contacted via 9-911.
Upcoming Education:
· Safety Huddle (see link below)
· Mock Code White drills (July 19 & 21) with support from Inter-Professional Education.
· Hot Wash training video.