Hospital Codes

Hospitals by nature are subject to a variety of clinical and environmental dangers daily which require a method to alert staff to an emergency. Codes allow trained hospital personnel to respond quickly and suitably to various events while preventing concern or panic by visitors and patients (Dix, 2023). These codes are usually communicated by the switchboard department overhead to all departments via the hospital intercom/paging system. Because it is vital for all hospital staff to be familiar with the emergency code system in the hospital they work in, yearly training on hospital codes and the appropriate response is mandatory for all staff.

The codes outlined in the Hospital Emergency Codes table are recommended by the Ontario Hospital Association (n.d.); however, they are fairly standard across North America, with variations of these also used in law enforcement agencies, long-term care, and educational facilities (Dix, 2023).  This list is periodically updated with new codes to reflect current risks within the hospital and surrounding environment.

The HUC Role in Calling Codes

It is often the HUC’s responsibility to give the emergency signal. Therefore, it is important that the HUC

• be familiar with emergency protocols and their role in each code situation,
• ensure that they have all the required information to be able to clearly communicate the emergency (depending upon the code, this may include the patient room number or description of patient), and
• immediately contacts the appropriate area—in most cases, this will be switchboard/locating.

It is also important for the HUC to be familiar with the hospital’s emergency fan out notification system. In many jurisdictions, there are requirements for hospitals to develop, implement, and document 24/7 notification protocols for communications with their staff according to public health emergency preparedness protocols. Fan out systems are in place to quickly call all permanent, part-time, full-time and casual staff to the hospital in case of emergency or incident. These systems typically require the direct contact of all staff members, utilize a prescribed script, and require ongoing testing and documentation (Simcoe Muskoka District Health Unit, 2013).

Common Hospital Codes Explained

CODE GREEN – Evacuation

Refers to a disaster and other situations requiring a partial or complete evacuation of the health care facility. A CODE GREEN may occur because of either an internal or external event and may occur in conjunction with another code, for example a CODE RED – Fire or CODE BLACK – Bomb may necessitate evacuation. The two stages of CODE GREENs are usually differentiated by the intensity of the bell or siren that accompanies the pages overhead. Alternatively, they may be paged as Level 1 or 2.

CODE YELLOW – Missing Patient/Resident

Refers to a missing patient or resident, who is described in detail in the paged announcement. When this is paged, hospital staff are expected to search their specific area for the missing individual. When the patient is found, the care area notifies the switchboard, and the patient is returned to the appropriate care area. In some hospitals, patients who are known to wander may be outfitted in a special gown or robe, such as a striped one, so that hospital staff can easily identify them.

CODE ORANGE – Disaster or Chemical, Biological, Radiological or Nuclear (CBRN)

Refers to an event in which the hospital’s human or physical resources are overwhelmed (CODE ORANGE – Disaster) or an event involving a chemical, biological, radioactive, or nuclear agent (CODE ORANGE – CBRN) (North Shore Health Network, n.d.). External disasters include natural disasters such as tornadoes, explosions, plane or train crashes, and toxic spills. There are various responses to CODE ORANGES which typically focus on calling in more staff, decanting existing patients, and finding alternate treatment areas for overflow.

CODE AMBER – Missing Infant/Child

Refers to a missing infant/child. Like CODE YELLOW, there is a description provided on the overhead page, and staff are expected to search their specific care area. The hospital may be locked down in the event of a CODE AMBER to prevent the individual who has taken the child from leaving the premises, and the police may be notified (North Shore Health Network, n.d.).

CODE RED – Fire

Refers to a fire within the hospital. When a CODE RED is called and fire alarms are pulled, most doors will close automatically and elevators lock.  All patients should be returned to their rooms and staff should congregate in one area, typically the communication centre, to await further instructions.  If an area is required to evacuate, all staff participate in patient evacuation measures. Regardless of whether it is a drill, or when their shift ends, staff may not leave the unit until the ALL CLEAR is called.

CODE WHITE – Violent Person

Refers to a behavioural emergency, whether it be a patient, visitor, or staff member, where there is an immediate risk of harm to self or others. When a CODE WHITE is called, the overhead page states the location of the occurrence, and a trained response team attends to de-escalate the situation. CODE WHITES may be seen on many units, but may be more common in ERs, mental health units, and dementia units where these behaviours are symptomatic of their illness and require responses that balance a therapeutic response and the need for control and protection (North Shore Health Network, n.d.).

CODE PURPLE – Hostage Situation

Refers to a situation where any person is forcibly held against their will, with the threat of a weapon or threat of violence. When a CODE PURPLE is called, the police will be notified. Staff should not attempt any action or put themselves at risk but answer when spoken to and note any demands the hostage-taker may have. Staff away from the area should not contact persons outside of the hospital. This may result in many unwanted phone calls and visitors to the site (North Shore Health Network, n.d.).

CODE BROWN – Chemical Spill

Refers to a chemical spill or toxic fumes within the building or on the grounds. A CODE BROWN may require evacuation of an area if the spill is hazardous (chemical, flammable or explosive)(North Shore Health Network, n.d.). A spill that poses no threat may be cleaned up by environmental services.

CODE SILVER – Person with a Weapon/Active Shooter

Refers to a person with a weapon. Staff are advised to close all doors, turn off lights and hide out of the assailant’s view. They should silence cell phones, take cover, remain low to the ground, and not come out until the ALL CLEAR is called or orders to evacuate are given by the police response unit (North Shore Health Network, n.d.).

CODE BLACK – Bomb Threat

Refers to a bomb threat. Like CODE RED, internal doors will close, and elevators will turn off. Staff are expected to search their immediate area for anything suspicious and once their entire unit has been searched, call in their unit’s clearance. Once all units have responded that their units are clear, an ALL CLEAR will may be paged. If staff do find a suspicious item, they must call switchboard immediately.

CODE GREY – Infrastructure Loss or External Air Exclusion

Refers to a significant infrastructure loss that it interrupts day-to-day operations and negatively affects patient care, for example loss of power, water, power, or IT systems. Staff should wait for further instructions which may include reverting to down time procedures. May also refer to dangerous outside air conditions which may affect people within the building, for example, a large smoky fire. All exit doors will be sealed/locked down except for the main entrance and the ventilation systems will be turned off to minimize air infiltration (North Shore Health Network, n.d.).

CODE AQUA – Water Emergency/Flooding

Refers to a significant water event, either internal or external, which interrupt day-to-day operations and negatively affect patient care, for example, internal flood due to pipes bursting. Water emergencies typically affect functions situated in the lower levels of the hospital, including mechanical, sterilization, and materials management functions. Staff should wait for further instructions which may include cancellation of elective surgeries and procedures.

CODE BLUE or PINK – Medical Emergency/Cardiac Arrest

A CODE BLUE refers to a medical emergency/cardiac arrest of an adult; whereas, a CODE PINK refers to a medical emergency/cardiac arrest of a child/infant. In both cases, a rapid response/code team will transport a crash cart to the scene and take charge although medical staff may be expected to start treatment and assist as necessary. Clerical staff in an area that has a CODE BLUE/PINK emergency should remain close by to liaise with the switchboard for additional paging requirements, order any supplies, and communicate with the bed allocator regarding urgent transfers to areas such as ICU, CCU or NICU.

Mock Codes

It is common for hospitals’ risk management departments to organize mock code drills monthly or quarterly to rehearse responses to common code scenarios.  Mock codes provide staff members the opportunity to practice their response and help increase staff’s self-confidence, teamwork, and response time (Chu & Robilotto, 2018).

References

Chu, R. & Robilotto, T.  (2018, March).  Mock code training to enhance CPR skills. Nursing Made Incredibly Easy! 16(2), 11-15.

Dix, M. (2023, April 14). Code Blue, Code red, Code black: Definition of hospital color codes. Health Line.

North Shore Health Network. (n.d.). Emergency codes.

Ontario Hospital Association. (n.d.). Tools and resources: Emergency preparedness colour codes badges 2 x 3.

Simcoe Muskoka District Health Unit. (2013). Policy and procedure manual: Emergency fan out notification system.