3Emergency Codes Dial 3333 for all emergency codes Code Black CODE NAME EVENTCode AdamInfant/Child AbductionCode BlackBomb/Bomb ThreatCode BlueMedical Emergency-AdultCode BrownMissing Adult PatientCode GraySevere WeatherThunderstorm Watch or WarningTornado Watch or WarningCritical Condition – Take CoverWinter Storm WarningCode GreenEvacuationCode OrangeHazardous Material Spill/ReleaseCode PinkMedical Emergency-PediatricCode RedFireCode SilverPerson With Weapon/Hostage SituationCode VioletViolent Person/CombativeCode WhiteFloodCode YellowDisasterLevel 1 – 0-20 PatientsLevel 2 – PatientsLevel 3 – 51+ Patients
4CODE ADAM Infant/Child Abduction Policy DIS-02.01.01.25 Only the Chief Executive Officer/Administrator On-Call or the Director of Public Relations is authorized to make a public statement regarding the incident.Dial “3333”, announce “Code Adam” and department/unit involved (i.e., “Code Adam, Same Day Surgery”)All staff is to immediately search entire area.Do not remove anything from area, the area is now considered a crime scene.Secure all records of the infant/child.
5CODE ADAM Infant/Child Abduction Abductors are usually non-violent. Do not do anything that would put the infant/child in danger (ex. Attempt to physically detain)Abductors may be dressed as hospital personnel.Approach suspicious individuals with a question, such as “Can I help you find something”.Ask to look in any large bag or box (duffle bag etc.) prior to any person exiting.
6CODE ADAM Infant/Child Abduction If you feel threatened or uncomfortable by approaching a suspicious person, get a general description (height, weight, hair color, clothing).Follow them and see where they go, what make of vehicle they get in and a license number if possible. Note if they walk away on foot and what direction from the hospital (ex. South on Amherst)Report it to Security IMMEDIATELY by calling Switchboard (dial 3333), give the information to Switchboard and they can dispatch info to Security.
7CODE BLACK Bomb Threats Policy DIS-02.01.01.24 Take it seriouslyRemain calmDocument every wordKeep caller on the lineListen for accent, background noiseAsk questions regarding location, etc.Notify supervisor and SecurityComplete a bomb threat form on the Intranet under the Emergency Preparedness tab
8CODE BLUE MEDICAL EMERGENCY-ADULT Policy ADM 2-75 Request for emergency response when an adult is found in cardiac or respiratory arrest.Initiate via 3333 which rings into Switchboard or push the Code Blue button if available. Tell Switchboard the situation so they can announce overhead.Do not announce the room number.
9MEDICAL ASSISTANCE Emergency Response within 250 yards Policy ADM 2-124 New Code!To provide emergency care to a person that appears to require medical aid on Hospital property other than the dedicated Emergency Department or within a specified distance from the hospital in accordance with EMTALA.This includes the entire main campus, including the physical area immediately adjacent to the main hospital and other areas and structures that are located within 250 yards of the main buildings, including the parking lots, sidewalks, and driveways, but excluding other areas or structures of the hospital’s main building that are not part of the hospital, such as physician offices.
10MEDICAL ASSISTANCE Emergency Response within 250 yards Policy ADM 2-124 New Code!Initiate via 3333 and tell operator that you need Medical Assistance and the exact location.Medical Assistance calls are covered by the Medical Assistance TeamThe activities of a Medical Assistance Call should be documented in ERSAll medical assistance calls at outbuildings are a 911 call.
11CODE BROWN MISSING ADULT PATIENT Policy DIS-02.01.01.23 Notify your supervisor or charge nurse immediately.Notify Security via 3333 which rings into Switchboard. Give location, sex and age of missing patient.Ex. Code Brown—2100—M-42. Once announced, staff should man exits and check for unknown patients or suspicious persons
12CODE GRAY (SEVERE WEATHER) Policy DIS-02.01.01.22 Severe Weather can be Thunderstorm, Tornado, Winter Weather Watches and Warnings.A WATCH means conditions are favorable for a thunderstorm, tornado, or winter weather to occur.When a thunderstorm or tornado WATCH is issued:Remove all loose articles from counter tops and windowsillsClose all blinds, curtains and doors (except fire and smoke doors).Remove portable equipment and carts from hallways.Turn on additional lighting.Reassure patients and visitors that these are normal steps taken for their safety.
13CODE GRAY (SEVERE WEATHER) A WARNING means conditions are imminent for a thunderstorm, tornado, or winter weather to occur.When a thunderstorm or tornado WARNING is issued:Ask visitors to remain at their present locations or move to a safe area.Begin providing blankets to cover patients who will be unable to move to safe areas. Move patients as close to the “Bed 1” position as possible.Reassure patients/visitors.
14CODE GRAY (SEVERE WEATHER) Code Gray – Tornado – Critical ConditionRelocate patients and visitors – move all ambulatory patients and their visitors to safe areas.Protect patients – cover patients remaining in their rooms with blankets. Pull cubicle curtains.Move to safe areas – make sure all window draperies and doors, including smoke and fire doors, are closed.Reassure patients and visitors
15CODE GREEN EVACUATION Policy DIS-02.01.01.21 The level of evacuation will be determined by the magnitude of the danger presented.Code Green will be initiated by the Administrator On-Call or Senior Fire Official.Level I - removal of persons from the immediate danger zone to a safe area.Level II - removal of persons from the areas horizontally adjacent to the immediate danger zone at least beyond the first fire door separation on the same floor.Level III - the removal of patients vertically from the floor of the danger zone to a safe area on another floor.Level IV - removal of persons from a portion or all of the hospital building.Engineering will shut off utilities as necessary. Oxygen can be shut off by Engineering, Respiratory Therapy or Charge Nurse.
16CODE ORANGE HAZARDOUS MATERIAL SPILL Policy DIS-02.01.01.20 If small spill…follow all clean up procedures outlined on the MSDS. Notify Environmental Services and your supervisor.If large spill….Contain the SpillLeave the area and keep all persons out of area.Notify Switchboard by calling 3333 and telling them you have a Hazardous Spill to initiate the Code Orange.Safety & Security, Environmental Services and Engineering will be responsible for assembly of decontamination equipment. Environmental Services will perform cleanup after decontamination procedures conclude.
17Hazardous Materials Communication Standard (HCS) – “Right to Know” You have both the need and the right to know the hazards and identities of the chemicals you are exposed to when working.Know what protective measures are available to prevent adverse effects from occurring, check with your supervisor.Read product labelsChemical namePhysical and Health HazardsFollow Directions
18OSHA Hazard Communication Standard (HCS) – “Right to Know” MSDS (Material Safety Data Sheets)Contact MSDSonline by using the link provided on the Affinity Medical Center Intranet using the drop down menu and select ‘MSDSonline-Material Safety Data Sheets’. Look up the chemical by using one of the following:Product nameLocationSupplierHard copies of MSDS sheets are located in Engineering and Occupational Health
22CODE PINK MEDICAL EMERGENCY – PEDIATRIC Policy ADM 2-76 A Code Pink should be initiated in the event of a respiratory and/or cardiac arrest of a newborn (minutes-hours old), neonate (0-28 days), infant (0-1 year), or child (1-8 years). Guidelines to use are based not only on age but on size of patient.Dial "3333” and announce “Code Pink” and the location.Pull emergency code cord or push code button if available.
23CODE RED FIRE RESPONSE Policy DIS-02.01.01.19 A Code Red is used to provide a rapid and organized response to any actual or suspicious fire situation in any area within the facilityInitiate by pulling a Fire Alarm station or dial "3333” and announce “Code Red” and the exact location.Once activated, act quickly but safely. Avoid panic and stay calm while closing all doors.
24Life SafetyPer NFPA Life Safety Code, storage is not permitted in corridors.Corridors should be kept clear at all timesExits should never be blockedDoors should not be held open with block or wedges
26RACE R - Rescue those in immediate danger A - Activate the Alarm, pull the nearest pull station and dial 3333C - Contain the fire or smokeE - Extinguish or Evacuate
27PASS P - Pull the pin or locking lever A - Aim the nozzle at the base of the fireS - Squeeze the handles togetherS - Sweep the extinguisher from side to side
28Fire Safety FOLLOW R.A.C.E. Use fire extinguishers for small, contained fires
29Extinguisher Use Sweep along the base of the flame Do not aim directly into the fireStand 3-4’ backBack away from the fire – never turn your back to a fire area
30CODE SILVER PERSON WITH WEAPON Policy DIS-02.01.01.18 1. Remain calm.2. Do not approach person in a threatening manner.3. Move all persons out of immediate area.4. Call hospital operator to notify Security of a “CODE SILVER” situation and the area.5. Pull the fire Alarm to get help there quickly as soon as situation allows you to.6. Be prepared to identify number and identity of victims.7. Do not attempt to rescue hostages or negotiate with the violent person.8. Take description of person, ex. Height, weight, hair color, clothing, unusual characteristics etc. and location and direction they exited.
31CODE VIOLET Aggressive Patients or Customers Policy DIS-02.01.01.17 Initiate Code Violet by calling Tell Switchboard location and situation.Control Your BehaviorMaintain Distance From PatientProvide ChoicesListen ActivelyDon’t ArgueGive Simple InstructionsDo not belittle, challenge or argue with the person
32CODE VIOLET Aggressive Patients or Customers Policy DIS-02.01.01.17 Avoid threatening behaviors such as finger pointing, prolonged eye contact, or standing with your arms crossedDo not invade the person’s personal space“CPI Training” (Crisis Prevention Intervention) is required by all coordinators, security personnel, Charge nurses, and Senior Mental Health personnel. It is available through Senior Mental Health.
33CODE WHITE Flood Policy DIS-02.01.01.16 Initiate Code White by calling 3333 to have a hospital operator notify Engineering.Used when flooding occurs anywhere in the facilityWill only be paged overhead for severe flooding when requested by CEO or Admin On-call.
34CODE LAKE Building Lockdown Policy EM.02.01.01.9-10.s New Code!LAKE-Lock All Known ExitsInitiated by Administrator On-Call when necessary to lockdown the buildingUsed to protect and secure the hospital during threatening situations outsideOnce called overhead, Security and staff will secure and monitor entrances to the building.
35CODE YELLOW DISASTER Policy DIS 02.01.01.15 Report to your DepartmentFollow your individual Departmental Plans.If arriving from your home, please have your badge with you. You may need it to travel to/from the hospital or access the hospital.Employees are responsible to know what their responsibilities are during emergency situations
36Emergency Preparedness Unforeseen Incidents Occurring that stress normal hospital operationsInternal or External SituationsEmergency Preparedness/Disaster Manual is located on Intranet. Hard copies in Administration and Engineering.
38Weapons of Mass Destruction Affinity Medical Center cooperates with county, state and federal health departments and agencies to identify and manage any incident where actual or suspected biological agents, nuclear devices, incendiary devices, chemical agents or explosive devices have been used as WMD.
39Be Aware – Be ObservantRecognize and report any unusual activity outside or within the facilityRecognize and report any unusual occurrence of signs and symptoms of diseasesReport any suspicious behavior observed to SecurityReport suspicious letters, packages, boxes, or containersNotify Security if you hear any activity outside the facility that could endanger the occupants (air, water, food quality)
40CODE BELL Telecommunications Failure Policy DIS-02.01.01.26 New Code!A Code Bell is used to provide an alternate method of communication in the case of disruption to our phone system.If aware of telephone interruption, notify hospital operator by using red emergency phone located in strategic areas and dial Ext or use a runner to PBX.The hospital operator will notify Information Systems/Telecommunications and determine what level of Code Bell is announced depending on type of failure.Once announced overhead, refer to Code Bell policy for further procedures
41CODE Information Services Computer System Failure Policy EM.02.01.01.27 New Code!A Code Information Services is used to provide notice of computer system failuresWhen there is an unexpected downtime with any one of the computer systems, a “Code Information Services” will be announced overhead.The hospital operator will notify the specific timeframe when available depending on type of failure.Once announced overhead, hospital will initiate downtime procedures per individual departmental policies
42HarassmentCommitted to a work environment in which all individuals are treated with respect and dignity.Each individual has the right to work in a professional atmosphere which promotes equal employment opportunities and prohibits discriminatory practices and harassment.Affinity will not tolerate conduct such as discrimination, harassment or retaliation.Harassment is verbal or physical conduct that show hostility or aversion toward an individual because of his/her race, color, religion, sex, sexual preference, national origin, age, martial status, disability, or any other characteristic protected by law.
43HarassmentThis includes, but is not limited to, unwanted sexual advances, favors, jokes, comments, inappropriate touching or gestures, or any activity that would be viewed as being sexually offensive.An individual who believes they are being subjected to discrimination, harassment, or retaliation should promptly tell the offender that their behavior is unwelcomed and need to stop.
44HarassmentAny individual that feels uncomfortable or offended needs to discuss their concerns with at least one of the following:Immediate SupervisorHuman Resource Director or RepresentativeAdministrative Staff OfficerCompliance Officer
45Random Drug TestingAll Affinity Medical Center employees are subject to random drug testing
46Dress Code PolicyAll Affinity Medical Center employees are to maintain professional appearances and adhere to the dress code policy.The dress code policy can be found in the employee handbook.
47Electrical Safety Check For Label and Verify Date of Inspection. Do Not Use Unlabeled Equipment.Any equipment brought in, must be checked.Extension cords are not permittedCall Engineering at Ext or Biomed at Ext. 6410
48Electrical Safety Policy SAF-5.02.03.01.1.i Only approved power strips/surge protectors are permitted.Fans are not permitted in Patient Care areasA physician order must be written for fan use by a patient. Fans are obtained through Materials Management and belong to that particular patient.Unapproved appliances include toasters, toaster ovens, portable heaters, and plug-in air fresheners.Coffee pots are required to have a 2 hour automatic shutoff. All appliances should be UL listed and checked by Engineering prior to use.
49Utility Emergencies Oxygen In the event of a fire, the unit manager, charge nurse or designee will determine if it is necessary to turn off oxygen.Know the location of shut off valve in your areaPower FailureUse red power outlets for patient care or emergency operation items during power failure to access generator
50Safety During Construction Obey SignsObserve Restricted AreasFollow Traffic FlowReport Safety ConcernsReport Infection Control ConcernsAll contractors are required to read “Contractor’s and Service Vendor’s Manual” prior to starting any project.A receipt form must be signed and submitted to the Engineering office as confirmation of having received and reviewed the booklet.
51Radiation Safety TIME: Limit time of any exposure DISTANCE: Stay at least six feet from a portable X-ray machine when in useSHIELDING: Stay behind a protective shield, use other protective devices such as lead aprons, and gloves to perform x-rays.INDICATOR LIGHTS: Do not enter a room if the light is on or the door is shut unless you are sure no one is in there.
52MRI Safety MRI = Magnetic Resonance Imaging Emits an extremely strong magnetic fieldDo not enter area unless MRI Technician is in the area with you and you understand the dangers of the MRIIn case of fire, use only designated magnetically safe fire extinguishers
53SmokingThis is a Smoke Free Hospital and Campus. This includes all buildings and properties owned or maintained by the Hospital and parking lots.
54SECURITY Unusual Behavior or Persons Inside or Outside. Notify Security by calling Switchboard or dial 3333 if the need for Security is urgentImmediate need of Security, contact Switchboard, tell them you need Security STAT at what location.You are the extra eyes and ears of securityIf you feel insecure in walking to/from the building, contact Switchboard to ask Security for an escort. Security is here for your safety and security as well as that of our patients and visitors!Lost and FoundItems for Lost and Found for Patients/Visitors/Employees should be turned into Security before the end of your shift.