The Hospital’s Code Yellow—Missing or Wandering Patient policy (EMER-70) has been revised and will be implemented July 7th 2021.

Actions required:

Managers:

1. Circulate this memo to your staff.
2. Update and submit Code Yellow sub-plan to Lori Siver, Administrative Assistant, Cardiovascular Sciences Program (siverlo@tbh.net) no later than July 23rd, 2021 using that attached sub-plan template. To complete the template, fill in the information that is highlighted. All other content is to remain as is.
3. Print the updated policy and sub-plan and add them to the area’s emergency binder, remove/recycle previous versions of the policy, and distribute updated policy and sub-plan to staff for review.
4. Print and utilize Code Yellow Safety Huddle resource.
5. Interprofessional Education will be in contact with managers to coordinate education for Code Yellow within departments.

Staff/Professional Staff:

1. Read this memo to familiarize yourself with important process changes.
2. Review the Code Yellow—Missing or Wandering Patient policy (EMER-70) and department sub-plans. Contact your manager with any questions.

Significant policy changes:

1. Applies to all patients 16 years and older. For a missing or abducted infant or child, refer to Code Amber policy.
2. New definitions and processes:
   1. High Risk Patient: A patient who is considered to be at high risk for personal injury or negative outcomes related to their unknown whereabouts. Cognitive impairment may be a factor, but many conditions/circumstances contribute to an individual’s risk status.
   1. Only patients who meet the criteria for a High Risk Patient will trigger a Code Yellow Search
   1. Separate process within Code Yellow policy for Not High Risk Patients
3. Admitting to call all units for inspection results.
4. Senior Leader on call notified in the event of a Code Yellow Activation.

Process Reminders:

Code Yellow – Search: A Hospital-wide response to search for a high-risk patient (age 16 years or older) that is missing from within the Hospital and there is reason to believe they are on Hospital grounds.

Code Yellow – Check: A Hospital-wide response to support the identification of a wandering patient(s) (age 16 years or older), who appears to be high risk and unaccompanied, found on or nearby Hospital property.

Wandering patient: A person that is believed to be a high risk patient who is wandering unaccompanied on or near Hospital grounds.

Unless a patient is at immediate risk to themselves, dial “0” to have to patient paged (first name, last initial) to return to unit/ department. Wait 5 minutes. If the patient has not returned, and is considered to be High Risk, dial “55” to activate a Code Yellow Search.

For questions, please contact Morgan Reilly, Lead, Emergency Preparedness reillym@tbh.net ext. 6552

Many thanks,

Meaghan Sharp, Director, Cardiovascular Sciences Program, Chief Nursing Executive
Nicole Moffett, Manager, Emergency Preparedness & Security