Code Grey – Air Exclusion Policy Update

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

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)