Shared on behalf of Ryan Sears, Code Grey Air Exclusion Executive Sponsor

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The Hospital’s Code Grey – Infrastructure (EMER-10B) policy has been revised.

Actions required:

1. Read this memo and review the updated Code Grey – Air Exclusion (EMER-10) policy to familiarize yourself with important process changes.
2. Managers to ensure that the updated policy is added to their area’s emergency codes binder and that all workers review the attached policy and safety huddle.

Policy changes:

• Removal of Stage 1 Partial Exclusion and Stage 2 Full Exclusion; replaced with new single response for Code Grey – Air Exclusion to better align with building automation capabilities.
• New definitions for Air Quality Health Index, Hold & Secure, Regular Hours, and After Hours.
• Updated Roles & Responsibilities table to include steps for rapid onset events and prolonged air quality events.
• Emphasized that a Code Grey Air Exclusion is the complete shutdown of the HVAC system with serious downstream impacts; specific instructions are captured in Code Grey – Air Exclusion – Physical Plant Response (PP-711).
• Removed Appendix 2 – Forest Fire/Prolonged Air Quality Issues Response Guidelines, as actions for such situations are now covered in the Indoor Air Quality (IAQ) Monitoring (MTC-SOP-401).
• New Appendix 4 – Equipment Disruptions; this is a high level overview. 

Process Reminders:

• If a worker witnesses or suspects there is a situation involving an external toxic airborne substance:
  • Worker will immediately report the issue to the Maintenance Supervisor on Call via Switchboard at “55”.
  • Maintenance Supervisor on Call will assess for required immediate actions and advise Switchboard if any all-staff instructions and/or a Hold & Secure message needs to be announced.
• Upon Code Grey Air Exclusion Overhead Announcement:
  • Close all interior doors (including fire doors).
  • Encourage all building occupants to remain indoors until the “All Clear” is announced; Entrance to and exit from the Hospital will be restricted.
  • Any area that has specialized processing equipment that requires local exhaust system will cease to process as soon as practically possible and shutdown the exhaust thereafter.
  • Do not start new procedures.
  • Standby for further instructions. 

If you have any questions, please reach out to Mēsha Richard, Lead, Emergency Preparedness (ext. 6552 or mesha.richard@tbh.net)

Join us on Thursday, May 7 at 7:15 p.m.. in Auditorium A/B (3rd Level) for an engaging Trivia Night in support of Mental Health Awareness Week (May 4-8).

• Teams should consist of four to six members, and at least one member must be a TBRHSC/TBRHRI employee.
• Non-employees are welcome to join teams as well.
• If you don’t have a team, individual registration is available, and you will be placed on a team.
• Enjoy snacks and refreshments throughout the evening.
• Exciting prizes await the winning team.

What is the Regional Outreach Collaborative?

The Regional Outreach Collaborative (ROC) brings together Thunder Bay Regional Health Sciences Centre (TBRHSC) team members from a variety of programs who have regional outreach roles and are passionate about advancing education, collaboration, and health equity across Northwestern Ontario. ROC members extend their expertise beyond hospital walls to support communities throughout the region. Aligned with TBRHSC’s mission to provide quality care supported by research, innovation, and education, the ROC strengthens regional partnerships through shared learning, resource-sharing, and community outreach. Through regular collaboration, members raise awareness of their program’s activities across the region, ensuring efforts are well coordinated and duplication of work is avoided. This includes coordinating regional training, aligning travel schedules, and finding ways to support one another.

The aim of the ROC is to build regional capacity, to foster meaningful connections, and to support communities across Northwestern Ontario.

Current programs involved in ROC:

• Neurosurgery Education and Outreach Network
• Northwest Regional Renal Program
• Prevention and Screening Clinical Services – Northwest Regional Cancer Program
• Regional Cancer Care
• Regional Cardiovascular Program
• Regional Critical Care Education
• Regional Obstetrics Program
• Regional Pediatrics
• Regional Stroke Network
• Trauma Program

How to join:

If your role is focused on regional outreach through travel and educational opportunities, join us in making an impact across the region and help extend TBRHSC’s commitment to collaboration, compassion, and excellence in care.

For more information or to get involved, please contact amanda.walberg@tbh.net or whitney.kendall@tbh.net.

Congratulations Katelyn Methot from TCU, winner of last week’s Accreditation Trivia. Katelyn won a $25 gift card to Eat Local Pizza.

Keep an eye on Informed for the weekly Accreditation Trivia question for your chance to win.

Accreditation Trivia – Previous Questions and Answers

Week 1 Question: What are the four pillars of the Strategic Plan?

Answer: Equity, Diversity and Inclusion; Patient Experience; Staff Experience; Research, Innovation and Learning

Week 2 Question: How do you report a patient safety incident or near miss? 

Answer: Patient Safety Reporting console (Incident Learning system)

We are excited to announce the expansion of our Regional Paediatric Response Program.

The Regional Paediatric Program (RPR) provides real-time, registered nurse-led patient assessments and plan of care development through video conferencing through Ontario Telemedicine Network (OTN). These services are delivered in coordination with a Paediatrician and are available to nursing stations and small or rural hospital emergency and inpatient departments.

Previously, our RPR program ran Monday to Friday from 800 a.m. – 4:00 p.m.. We are pleased to announce that as of this month, our RPR program has transitioned to a 24/7 service with one paediatric trained registered nurse on each 12-hour shift. The RPR Nurse may be contacted directly at 807-630-9044 for clinical nursing-skill questions or educational support by regional or in-hospital staff for support related to paediatric patients in any department. RPR endeavors to have support available 24/7. In the event that no RPR Nurse is on shift, the support phone will be carried by the Paediatric Emergency Transport Team (PETT) when they are in-house, or by the NICU Unit Leader when PETT is unavailable. During these times, paediatric consultations from the region (Criticall) will take priority, and follow-up or nursing support may be limited due to clinical responsibilities of covering individuals.

Regional Paediatric Response Email: TBRHSC.RegionalPaediatrics@tbh.net

The transport team will no longer carry the “resource booking phone” this is now the RPR phone. If you need to contact the transport team directly for support, please reach out to them on their respective cell phones. 

• RN Day – 807-631-5707
• RT Day – 807-631-5713
• RN Night – 807-627-5609
• RT Night – 807-627-5608

The expansion of the Regional Paediatric Response Program to a 24/7 service will enhance support for our regional partners, improve communication and strengthen the continuity of care for paediatric patients. We appreciate your ongoing flexibility and collaboration as we implement this transition. Should you have any questions or require further clarification, please do not hesitate to reach out.

Thank you for your continued dedication to providing high-quality care to our youngest patients!

To facilitate the installation of a new door for the ICEI space, construction hoarding has been set up along the main level corridor near Volunteer Services. This temporary barrier is in place to ensure the safety of patients, visitors, and staff while work is underway.

The corridor remains open; however, access is narrowed, and there may be occasional noise or minor disruptions. Everyone is asked to proceed carefully when passing through this area, follow any posted signage, and remain aware of their surroundings.

We appreciate your patience and cooperation as we complete these improvements. If you have any questions or require assistance navigating the area, please contact Ian Kelly, Project Planner at 807-684-7222.

Accreditation Canada surveyors will be visiting Thunder Bay Regional Health Sciences Centre from May 11-14, 2026 to assess how well we are providing safe and effective care that aligns with national standards.

What does it mean to me?

Accreditation involves everyone at TBRHSC. We all play a role in delivering the highest standards of care to our patients, and families — each and every day.

For more information and resources, visit the Accreditation 2026 page on the corporate intranet page.

The Occupational Health and Safety (OHS) team at Thunder Bay Regional Health Sciences Centre plays a vital role in protecting both staff and patients in our Hospital, with a strong focus on immunization oversight from the very start of employment.

A key part of their work begins at the new hire stage, where they carefully review each employee’s immunization history to ensure it meets Hospital and public health requirements before staff begin their duties. Through thorough tracking and documentation, the OHS team maintains up-to-date immunization records for all staff. This proactive approach helps identify gaps early, ensuring new hires receive any required vaccines or follow-up before entering clinical areas.

By establishing this foundation from day one, the team helps reduce the risk of exposure and transmission within the Hospital. Beyond onboarding, the OHS team continues to monitor immunization status across the organization, supporting ongoing compliance and readiness. They also lead annual vaccination campaigns, such as the seasonal influenza (flu) program, making it easy and accessible for staff to stay protected. In the fast-paced acute care setting — where patients are often at their most vulnerable — this diligent tracking is essential to maintaining a safe environment.

As we recognize National Immunization Awareness Week (April 27 to May 3), we acknowledge the dedication and expertise of our OHS team. Their behind-the-scenes efforts, from onboarding reviews to continuous monitoring, help create a healthier, safer environment for everyone who walks through our doors.