Metro hospital system aligns emergency codes

One set of codes lowers risk of confusion

A Code Red is probably the same as "Paging Dr. Red," but what in the world is a Code Roamer? And whatever a Code Yellow is, it's probably something bad. Now, if only you actually knew what the code meant, you'd know what to do if you heard it.

Coded alerts for the hospital intercom system are standard in health care, but there is no standard set of codes that is used across the board. Instead, hospitals usually develop their own set of emergency codes, based a little bit on logic and obvious wordplay, and based a lot on nothing more than tradition. That's fine as long as your staff work only at one facility, where everyone can be taught that "Paging Dr. Hurry" means the hospital is activating its response to an outside disaster.

But in today's complex environment for health care professionals, it is common for people to work at many facilities, either through cooperative arrangements or because of rapid changes in employment. That can leave staffers struggling to remember emergency codes that differ from one facility to the next, says Barbara Pope, MBA, ARM, RRA, CPHQ, assistant administrator for support services at Children's Hospital in Richmond, VA.

Health care workers who move from one facility to another always have some difficulty in adjusting to the new procedures and policies, but emergency codes can pose a particularly difficult problem, Pope says. Unlike many procedures that are carried out every day and therefore ingrained quickly, emergency codes are more likely to be used only occasionally. And even though the codes are not often heard, it's also crucial for the employee to know them so no time is lost in responding.

"The real risk comes with employees who are not your regular employees but are visiting in some way from another facility," Pope explains. "If we contract with another facility to provide pediatric physical therapists, for instance, those people might not know the code or what they're supposed to do. There's a lot of room for confusion."

That confusion poses a real risk for the hospital because its response plan for various emergencies may not be carried out properly. If employees don't know the emergency code for an infant abduction, for example, they may not realize they should cover the exit just outside their work area and watch for the abducted baby. Crucial minutes can be lost while employees figure out what the code means and then take action. There also is the risk that visiting staff will just ignore all emergency codes because they don't know what they mean, relying on other staffers to respond appropriately.

Ultimately, the response of the staff will determine whether your emergency plan was effective. If you had an excellent plan on paper for an evacuation, but part of the hospital staff responded to what they thought was a combative patient, you could be held liable for ineffectively preparing for an emergency.

"The way your staff responds to an emergency code is a major part of your emergency plans," Pope explains. "No matter how good your plan is, it does no good if the employees don't know how to implement it when the code goes out."

Cooperation for consistency

Those concerns were on Pope's mind when she was reviewing her hospital's emergency codes two years ago. She saw that the list of codes followed no logical pattern even within her own facility, with some using whole words and some using only code letters. Pope was considering an update of her own facility's codes when she decided to check with other local hospitals to see what codes they used. She found that no one used the same codes, and everyone felt uneasy about it, especially with the increase of personnel floating among the institutions.

Pope organized a committee that would try to come up with a consistent set of emergency codes that could be used throughout the entire Richmond area. That would include 12 hospitals, most of them competitors from different hospital groups.

"I polled the risk managers and security managers, and we decided to try to make a uniform set of codes and then take it to our administrators," she says. "There was overwhelming support for making this a uniform set of codes. Everyone agreed that it was the right thing to do."

The first step in the project was to gather all the codes in use and compare them. It was apparent from the beginning that there was no pattern and little consistency among facilities. The only constant was that the code for a hospital fire incorporated the word "red." But even with that code, some hospitals used a simple "Code Red," and some used the more discreet "Paging Dr. Red" or "Paging Mr. Red." Would an employee used to the "Paging Dr. Red" code automatically know that a "Code Red" is the same thing? Not necessarily.

Even the standard "Code Blue," known even by TV viewers as the code for a cardiac arrest, was not used across the board. Two hospitals used "Code 99" instead. At one hospital, a "Code Pink" would send clinicians scurrying to a pediatric cardiac arrest. At another, "Code Pink" meant there was a bomb threat.

The following codes were in use around Richmond before the committee went to work (in box):

Once the committee discussed the codes, the project turned out to be fairly simple. Pope met with two safety and risk managers representing five hospitals, and another representing five others joined them by phone. They discussed ways to make the codes uniform and devised a list of proposed codes for the entire metro area. Then they sent a memo to all hospitals asking for approval.

The proposal went through safety committees at the hospitals, and only a few reservations surfaced. A local Veterans Adminis tration hospital opted out because its large national administration made it difficult for one facility to change its codes. Likewise, administrators at a university medical center decided it might be counterproductive to retrain its large staff on the new codes.

When settling on the new set of codes, the committee questioned whether the hospitals should use code words such as "Code Red" or code letters such as "Code R." There was general agreement that the letters provided a more consistent system, while also providing some euphemism as the codes were broadcast for all to hear. But on the other hand, the committee members didn't want to substitute code letters for a few of the code words that were almost universally used, such as "Code Red" and "Code Blue." That seemed as if would cause more confusion.

Committee members compromised by using the most popular code words, and code letters for the rest. Then they discussed whether to use only letters or to use the terms "Alpha" for A, "Bravo" for B, "Charlie" for C, and so on. Security managers expressed concern that letters alone wouldn't be sufficient because they can sound alike over a radio or intercom. (That's why the police and military say "Alpha, Bravo, Charlie" instead of "A, B, C.") In the end, the committee decided using alphabet words would amount to a whole new set of code words, so they went with code letters.

The 10 participating hospitals agreed they would use the new set of emergency codes, providing consistency throughout the metro area. The only caveat was that the hospitals wanted freedom to disregard some codes that weren't necessary in their facilities. Of the original 14 code categories, the committee developed uniform codes for 12 categories. Toxic atmosphere and radiation contamination were eliminated from the list. The toxic atmosphere emergency could be included in the hazardous spill or leak category, and the one facility using the radiation contamination code, Code Brown, decided it wasn't needed.

Here are the new emergency codes used by most hospitals in the Richmond area (in box):

Pope says implementing a new set of emergency codes requires thorough education for all staff. In the short run, that may require extra work, but she says eventually it will decrease the need to retrain staff on the codes every time they go to a new facility. The effort also pays off in improved staff comfort levels and timely, informed response to occurrences. "Our staff now say they can remember what the codes mean so much better than they did before. Regulatory agencies have been impressed during surveys, not only by our staff awareness of our emergency preparedness system, but also by the community joint effort toward reducing risks."

Previous Richmond Codes

    o Fire Code Red, Paging Dr. Red, Paging Mr. Red

    o Adult cardiac respiratory arrest Code Blue, Code 99

    o Pediatric cardiac arrest Code 99, Code Pink

    o Combative patient or visitor, or similar need for security Code Atlas, Paging Mr. Atlas, Code Yellow, Code Roamer (for a suspicious person roaming the hospital), Code C

    o Criminal activity Code C

    o Infant abduction or missing infant Code A, Code Stork

    o Bomb threat Code B, Code Pink, Code Bravo

    o External disaster Code D, Code Orange, Paging Dr. Hurry

    o Evacuation Code E, Code Yellow

    o Hazardous spill or leak Code H, Code Green, Paging Dr. Hazard

    o Weather hazard Code W, Tornado

    o Utility failure Code Grey, Code Green

    o Toxic Atmosphere Code White

    o Radiation contamination Code Brown

New Richmond Codes

    o Fire Code Red

    o Adult cardiac respiratory arrest Code Blue

    o Pediatric cardiac arrest Code 99

    o Combative patient or visitor, or similar need for security Code Atlas

    o Criminal activity Code C

    o Infant abduction or missing infant Code A

    o Bomb threat Code B

    o External disaster Code D

    o Evacuation Code E

    o Hazardous spill or leak Code H

    o Weather emergency Code W

    o Utility failure Code U, followed by the specific type, such as Code U-electric