Emergency Preparedness Plan

CODE RED announces that there is a fire situation at the facility. Health care facilities have a two-stage fire alarm notification. 1st stage is an alert where all staff must check for signs of fire or smoke. 2nd stage indicates a possible evacuation of a work area. If an evacuation is needed, the Incident Commander will direct the evacuation.

Most fires in health care facilities are electrical due to poor maintenance and poor monitoring of the equipment. Small appliances are responsible for the majority of fires and result from lack of supervision during equipment operation and/or by accumulation of crumbs. Popcorn in microwave ovens has be-come a regular cause of fire. Small appliances (toasters, toaster-ovens, kettles and microwave ovens) must be attended to by the user at all times during its operation.

The following is the sequence of events and roles:

Call Centre: is notified regarding a Code Red by a caller dialing “888” and reporting a Code Red, by a monitoring device, or by the fire alarm monitoring company. The notification is then sent out from the Call Centre via the P.A. system: CODE RED – Area, if known. The Call Centre contacts: 911, Plant Services and Security; if the alarm is a real fire, Call Centre contacts: 911 again, Leader On-Call, Emergency Preparedness and Communications.

Staff: will follow Code Red procedures. At the sound of an alarm, check your work area for signs of fire, smoke or smell of smoke. Close all doors and windows. Report any findings by dialing “7111”. Depending on the situation, you may need to report back to your work area, check on patients/residents to assess the situation and/or report problems to the EOC.

• Providence Health Care Code Red Brochure

If you find a Fire, smell or see smoke you have to RACE:

If you hear Stage 1 Fire Alarm bells ringing:

• Check my work area for signs of smoke or fire.
• Close all doors and windows.
• Report to the Fire Floor Warden for further instructions.

Security: will follow Code Red procedures and will Coordinate the fire response with the Fire Dept. Investigate the source of the alarm.

Incident Commander: Notify the Leader On-Call and Senior Leader On-Call; Establish the Emergency Operations Centre (EOC) as required; request briefings from Security, Physical Plant, and Nursing as required.

CODE ORANGE is called when mass casualties are expected to arrive at our doorsteps. Mass casualties can originate from any manufactured or natural emergency or disaster, such as a plane crash or an earthquake.

The following are the sequence of events and roles:

The Emergency Department is notified by BC Ambulance Services or other external agencies that an emergency or disaster has occurred and to expect mass casualties. The Clinical Nurse Leader and Physician Leader in the ED assess the information and a decision is made as to whether to call a Code Orange or not. Code Orange signifies that many, if not all, facilities and personnel in the facility are needed to care for casualties.

Emergency Department (ED): will immediately empty all admitted patients and other stable patients to in-patient units. The ED will prepare the work area for surge capacity.

Call Centre: will announce the Code Orange level over the P.A. system and page all on-call staff.

Staff: upon hearing a Code Orange, all personnel must report immediately to their work area for assignments. The Charge person on the nursing unit at the time will be responsible for completing the DEPARTMENT STAFFING STATUS REPORT (Form 06), found on the EPP online plan.

Security: will ensure traffic flow and crowd control in the ED.

Incident Commander: has total authority over the response actions necessary in order to deal with the event. He/she will notify necessary work areas and nursing units of the type of disaster and the number of staff to call back to work.

Commonly Asked Questions and Answers:

Can I take my break during a Code Orange? ALL breaks and meals are cancelled until scheduled by Leader or Supervisor as work-loads permit.

Can I leave when my shift is over? Personnel completing their shifts are not permitted to leave until the “ALL CLEAR” has been announced, or until given permission by their Leader or Supervisor. This includes when a “Prepare for Code Orange” and a “Code Orange in Effect” have been announced

What if I’m at home and hear about the emergency. How do I know whether I should report to work or not? If phone contact with the facility is impossible, listen to CKNW 980 AM for an announcement from the facility. CKNW 980 AM has agreed to help PHC during an emergency. You must have your ID badge with you in order to have access to the “Disaster Response Routes System”. ID Badges have a logo (yellow triangle within a circle) that indicates that you are entitled to be on a “disaster response routes”.

CODE GREEN is called when an area of the facility has to be evacuated. It involves the movement of staff, patients/residents and visitors from their rooms to a safe area following an event that compromises their health and safety. A Code Green could be called following: Code Red, Code Brown, Code Black, Code Grey.

The following are the sequence of events and roles:

The decision to call a Code Green is determined by a person in charge of the work area that has the authority to move patients/residents, staff and visitors to safety in the case of an emergency that requires immediate action. There are two main levels of evacuation: “Primary Evacuation” and “Alternate or Secondary Evacuation”.

• Primary evacuation to a relocation area involves the horizontal movement of occupants to the nearest refuge area.
• Alternate or Secondary evacuation to a relocation area involves the movement of occupants either down or up stairwells, or on occasion, by elevators.

It is important to note that you should only use the elevators with the Incident Commander or fire department’s direction. There are three levels of evacuation: Unit, floor and building.

Call Centre: will announce Code Green over the P.A. system and page all on-call staff.

Staff: upon hearing a Code Green, all personnel must immediately return to their work area to prepare for assignments or evacuation.

Security: will facilitate traffic and evacuation flow.

Incident Commander: will determine the appropriate staff requirements for for the evacuation are in place. The Incident Commander will also request staff from other areas to report to a designated meeting place, known as the Muster Point.

Muster Point Warden: delegates staff to perform various roles such as, Stairwell Monitors, Patient Guides, Searchers or others as required.

Floor Warden: has the responsibility of coordinating the evacuation of a unit or area. If after an initial code call an evacuation is deemed necessary l, the Floor Warden will, initially, begin the evacuation with the staff available. The priority for evacuation should be: those who are in immediate danger and those who require assistance.

Stairwell Monitors: are assigned in pairs. One Stairwell Monitor will follow the assigned stairwell down to the outside exit door ensuring that this evacuation route is not obstructed. Once at the outside exit door, they will remain inside at that exit to provide access to Fire or Police personnel. The second Stairwell Monitor will go up the stairwell to the alarm floor and prepare to follow the last occupants out, ensuring that no stragglers are left behind.

Searchers: will assist the Floor Warden and Security staff in the final check for occupants in a fire zone. Work in pairs, keeping in close contact with your partner. Check each room in order. Check the closets and washrooms in each room. Once a room is clear, close the door and place a wastebasket or pillow in front of the closed door.

CODE BLACK Every year in Canada alone thousands of hours are lost as a result of bomb threats. Most bomb threats are made by anonymous callers over the telephone. While the overwhelming majority of reported bomb threats are unfounded, some are not. Therefore, care must be taken to deal with each incident calmly and consistently. Who makes the bomb threat? It is usually someone associated with the organization. It could be a dis-gruntled employee, dissatisfied patient or an angry spouse in a bitter divorce.

The following are the sequence of events and roles:

The anonymous caller calls in the threat either to a work area or the main PHC number . Staff receiving the call will notify the Call Centre by dialling “7111” , complete the “Form 24” and send to the Emergency Operations Centre (EOC).

Call Centre: is notified regarding a Code Black either by: receiving the bomb threat call themselves or by a staff member who has reported the bomb threat by calling a Code Black via “7111”. The notification is then sent out from the Call Centre via the P.A. system: CODE BLACK – and Area if known. The Call Centre pages all on-call staff for Code Black response.

Staff: will immediately end tasks at hand and a visual search of their work area must be completed. Refer to Code Black Search Procedure ED0200 on the EPP plan online. Results will be recorded on “Form 24” and then sent to the EOC. Staff should limit movements in the facility unless absolutely necessary.

Security: will notify staff in the area, if known, and contact Vancouver City Police. The Leader of Security or Delegate will proceed to the EOC with the Vancouver City Police Representative and assist Police as required and conduct a thorough facility wide search in coordination with the EOC.

Incident Commander will:

• Establish the EOC as required (refer to EB0300) upon receiving notification of a bomb threat to the facility.
• Meet the police upon their arrival and brief them about the situation.
• Request the Floor Wardens (refer to EC1000) to send the Search Results Form (Form 24) to the EOC.
• Inform the Leader On-Call/Designate of the bomb threat.
• Determine, in consultation with the police and the Leader On-Call, if it is necessary to implement evacuation procedures (Code Green).
• Initiate Fanout and Evacuation/Relocation procedures if required (refer to EM0100 – Fanout, Section EI: Evacuation, and Section EJ: Relocation)

Commonly Asked Questions and Answers:

What do I do when I receive a bomb threat directly? Staff receiving a bomb threat will have to notify the Call Centre by dialing “7111” and completing “Form 24” and sending it to the EOC.

Where can I find “Form 24”? ”Form 24” is located on PHC Connect under Emergency Preparedness – St. Paul’s Hospital – Forms – Code Black – Form 24. There is also a direct link to the form on the Code Black section page.

How will I find out if there is a bomb threat in the building? The Call Centre will send out a notification via the P.A. system: CODE BLACK – and Area if known. The Call Centre also pages all on-call staff for Code Black response.

Do I leave the area immediately when I hear about a bomb threat? No. Oftentimes bomb threats turn out to be a false alarm, but nevertheless each incident must be dealt with calmly and consistently. Staff are asked to end tasks at hand and a visual search of the work area will be done. Results will be recorded on Form 24 and then sent to the EOC. The Incident Commander will, in consultation with Police and the Leader-On-Call, determine if it is necessary to implement evacuation procedures.

Will there be someone in charge of evacuation and giving directions to everyone? Yes. Upon receiving a bomb threat, the Incident Commander will establish the Emergency Operations Centre as required.

CODE WHITE WorkSafe BC defines a code white as a “response intended for a situation in which a ‘client’ is behaving in a potentially dangerous manner towards himself or others and indicates a potential for escalating or is escalating beyond the abilities of the present staff to control the situation”. In healthcare, violence in the workplace programs address the safety of both employees and clients who may be at risk of injuries from an aggressive individual.

The following are the sequence of events and roles:

Call Centre: is notified regarding a Code White by a caller dialling “7111” and reporting a Code White. The Call Centre will make the P.A. announcement and contact Security. The notification is then sent out from the Call Centre via the P.A. system: CODE WHITE – Area.

Staff:

• If you receive or notice verbal or physical aggression occurring, use the nearest telephone and notify the Call Centre by dialing “7111” and state: “Code White, Building, Room”.
• Remain on the line while you listen for the Code Announcement over the P.A system.
• Confirm that you have heard the announcement and provide your name and the number of the phone you are calling from.
• You should call a Code White when there is a situation where staff and clients may be at risk of injuries from an aggressive individual, either through verbal or physical aggression.
• If you notice a suspicious person, you should not call Code White. Suspicious persons, theft, etc. are not considered a Code White. For these instances, you should contact Security per usual procedure.

Team Leaders: assess the situation; call for additional resources as needed; coordinate the response.

Team Members: follow instruction of Team Leader; assist with the management of the disruptive client.

Security: will assist Team Leaders and Team Members as required.

Security or the Response Team are sometimes delayed when in responding to a Code White. When consecutive codes are called, Security or the Response Team may not be able to respond to 2nd/3rd calls in a timely manner.

CODE BROWN is the designated code announcement to be used for hazardous material spills/leaks. When the Call Centre announces a Code Brown over the public address system, it is intended only to warn others to keep out of the affected area. Code Brown is not a code for alerting an emergency response team.

The following are the sequence of events and roles:

Call Centre: is notified of a Code Brown by the In-Charge Person in the work area. The Call Centre will make the PA announcement via the PA system: “CODE BROWN and Area”. When the Code Brown is over the Call Centre will make the following announcement over the P.A System: “Code Brown All Clear”.

Staff: reports spills or leaks. Whenever a hazardous substance is spilled or a leak occurs, the primary concern is to ensure the safety of yourself and others in the area. In all instances the following procedure must be followed:

• Ensure your own safety. Avoid skin, eye, and respiratory exposure to the substance.
• Evacuate all people from the area of the spill or leak, and prevent any unauthorized people from entering.
• Avoid the affected area. Leave the room/area and close the doors (or otherwise isolate the area as much as possible).
• Report the spill. Dial “7111” and report a CODE BROWN and location.
• Wait for further instructions.

Security: will assess and secure the area. They will ensure non-essential personnel are kept out of the area; help to remove patients/residents if necessary; tape off the area with barrier tape if necessary.

Housekeeping: will clean up blood and body fluid spills.

Plant Services: will respond to the area of the spill/leak as soon as possible to determine if the spill/leak will affect facility systems, to determine fire hazard, etc. Respond appropriately to the determined needs.