Shared on behalf of Anne-Marie Heron, Code Red & Code Grey Executive Sponsor; Aaron Skillen, Code Brown Executive Sponsor; David McConnell, Alert-99 Executive Sponsor; Amy Carr, Emergency Fan-Out Executive Sponsor

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The Hospital’s Code Red – Fire Alarm (EMER-30), Code Grey- Air Exclusion (EMER-10); Code Brown- Unknown/ Unmanageable Hazardous Substance or Spill (EMER-100), Alert-99/Alert-99 Trauma (EMER-120), and Emergency Fan-Out (EMER-110) have been reviewed and updated.

Actions required:

Managers:

1. Review the attached codes and contact your Director or Emergency Preparedness with any questions;
2. Circulate this memo to your staff;
3. Print the updated policies and add them to the area’s emergency binder, remove/recycle previous versions of the policies, and distribute updated policies to staff for review;
4. Print and post Alert 99 poster.
   

Staff/Professional Staff:

1. Read this memo to familiarize yourself with department instructions;
2. Review the attached codes, and contact your manager with any questions.

Code Red- Fire Alarm (EMER-30)

Policy Changes:

1. Roles and Responsibilities table and Algorithm added for clarity.

Process Reminders:

1. Code Red sub plans provide important department specific instructions to supplement the policy that must be reviewed annually by the department manager.
2. Code Red – Fire Alarm (EMER-30) instructions apply to the Hospital building. For external buildings, call 9-1-1 (see section 6 of policy for details). 

Code Grey- Air Exclusion (EMER-10)

Policy Changes:

1. Precautionary Code Grey stage to include prolonged air quality issues;
2. Roles and Responsibilities table and Algorithm added for clarity;
3. Forest Fire/ Air Quality guidelines, maps, IMS guide, and Equipment Disruptions table added to the appendices as additional tools for Incident Manager and response team.

Process Reminders:

1. Contact supervisor to notify Switchboard for Precautionary Code Grey.
2. Only the Senior Leader on Call or Admin Coordinator (after hours) can confirm a Code Grey once the precautionary announcement has been made.

Code Brown- Unknown/ Unmanageable Hazardous Substance or Spill (EMER-100)

Policy Changes:

1. Inclusion of Nuclear Medicine Technologist for radioactive spills;
2. Roles and Responsibilities table and Algorithm added for clarity

Process Reminders:

1. There is an “All Department” Code Brown sub plan that differs from the Code Brown sub-plan that is designed for use by the Response Team. Both templates are available on the intranet. Please complete (or print) the appropriate document.

Alert-99/Alert-99 Trauma (EMER-120)

Policy Changes:

1. Updated maps with stairs and elevators;
2. Roles and Responsibilities table added for clarity.

Process Reminders:

1. Alert-99 is to be called for responsive persons requiring medical assistance outside of inpatient units; for non-responsive patients, call a Code Blue.
2. For persons outside the hospital building, including external buildings, call 9-1-1.

Emergency Fan-Out (EMER-120)

Policy Changes:

1.    Fan-out lists may be kept as hard copy or electronically so long as the list is secure.

Process Reminders:

1.     Departments are responsible for updating and maintaining fan-out lists in their department’s Emergency Code Binder.

For more information, please contact Nicole Moffett, Manager, Emergency Preparedness and Security (ext. 6185 or moffettn@tbh.net)