Uniform emergency codes: Will they improve safety?

California, NJ have systems, others may follow

In 2001, in the wake of a tragic incident in West Anaheim (CA) Medical Center where three employees were shot to death, state investigators questioned how the gunman was able to advance to a stairwell and a hospital lobby of the medical center after the first distress call was signaled. To ease staff confusion in such situations, the Healthcare Association of Southern California adopted the nation’s first standardized hospital emergency codes.

Now, three years later, the state of New Jersey has initiated what it claims is the first statewide voluntary program for uniform codes among hospitals, long-term care facilities, and home health providers. Other states, including Florida and Wisconsin, are considering following suit.

But the impetus for such systems goes far beyond protecting staff, says Diane Anderson, director of emergency preparedness and bioterrorism for the New Jersey Hospital Association based in Princeton. It started as a patient safety issue, she explains. In her area, hospitals often share staff, Anderson says. "So the idea of a code red’ being the same code red’ in every hospital supports that reality," she says. "They would know that whatever department or building they are in, a code red meant fire, and they would respond accordingly."

The New Jersey system, which closely mirrors the original one in California, includes the following codes:

  • Code Red: Fire.
  • Code Blue: Adult medical emergency.
  • Code White: Pediatric medical emergency.
  • Code Amber: Infant/child abduction.
  • Code Yellow: Bomb threat.
  • Code Gray: Security emergency/patient elopement.
  • Code Silver: Hostage situation.
  • Code Orange: Hazmat situation/decontamination needed.
  • Code Triage: Disaster situation.
  • Code Clear: The situation has been cleared.

Are they a good idea?

There remains some controversy as to whether uniform codes are a good idea. Uniform philosophies make sense, some argue, but not necessarily the specifics flowing from those philosophies.

That may be, in part, because the specifics are the hardest things to get right when it comes to emergency response — and yet they may be the most critical, says David Goldwag, DO, FACEP, chief of emergency medicine at Stamford (CT) Hospital.

"It’s more important to have the right systems in place — a structure for what the code is supposed to mean — and to drill on those processes," he says. Even code responses in hospitals are variable, Goldwag adds. "Those things need to be drilled, so everyone knows when you call X’ that everyone not only knows what to do, but they have done it," he explains.

For example, in Southern California’s code, there is a defined list of responses for each different code. Under the responsibilities of a Code Gray, a staff member witnessing verbal abuse should:

  • assist in attempts to verbally de-escalate the assailant;
  • call in a second person to take over;
  • add distance/barriers between victim and assailant.

If a staff member witnesses physical abuse, the proper responses under Code Gray are:

  • protecting self and others by assisting victim to stop/deflect blows by assailant;
  • creating a diversion by putting distance/barrier between victim and assailant;
  • getting medical assistance if needed.

Stamford Hospital managers found when working with Homeland Security Act issues, every time you have a disaster or a bioterror drill, you find they don’t work out as they were supposed to, Goldwag says. "To me, personally, it does not really matter what you call the thing as long as you have tested it," he says. "Two different EDs might hear the same overhead page, but one hospital may have a really good system and everyone knows what to do, whereas another has never really tested it."

If and when other states begin adopting uniform codes, EDs should take the lead role in hospital adoption, Goldwag notes. "ED docs are often those most familiar with emergency procedures, even though they affect the whole hospital," he explains.

There are strategies you can use to help make adoption of a uniform system run more smoothly, Goldwag continues. For example, one hospital put a list of the hospital codes and what they were supposed to do on the back of staff members’ name tags.

You need every advantage you can find, he asserts. "It seems like such an easy thing, but when you start putting it in place, it’s more work than you thought it would be," Goldwag concludes.

It’s been nearly a year since the new system rolled out to hospitals in New Jersey, and Anderson reports that more than 90% of the acute care hospitals in the state are implementing it or have fully implemented it. "The hospitals were enthusiastically behind it," she asserts. "We’re rolling out now to long-term care facilities, and EMS called this morning and expressed some interest."


For more information on uniform emergency codes, contact:

  • Diane Anderson, Director of Emergency Preparedness and Bioterrorism, New Jersey Hospital Association, 760 Alexander Road, P.O. Box 1, Princeton, NJ 08543-0001. Phone: (609) 275-4209. E-mail: DAnderson@NJHA.com.
  • David Goldwag, DO, FACEP, Chief of Emergency Medicine, Stamford Hospital, Shelburne Road and W. Broad St., Stamford, CT 06904. Phone: (203) 325-7000. E-mail: dgoldwag@stamhealth.org.

To obtain a free online copy of the 81-page guidebook from the Healthcare Association of Southern California, go to www.hasc.org. Then, click on the red and blue box that says, "Safety and Security Committee." This will take you to a page that contains the complete book and separate copies of each chapter. For additional information, contact Aviva Truesdell at (213) 538-0710. E-mail: atruesdell@hasc.org.