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The Many Codes for a Disaster: A Plea for Standardization
DMR
Editorial
The Many Codes for a Disaster: A Plea for Standardization Margaret M. McMahon, RN, MN, CEN, FAEN
T
he use of special code words announced overhead to communicate emergency situations is fairly standard in most American hospitals. What are not standard, though, are the terms used for these emergencies. While the terms may vary, some such as Code Red for fire and Code Blue for a cardiac arrest are relatively easy to decipher. Even a Code Blue, though, is not consistently applied. Some facilities use numbers such as Code 99 or 707 to indicate a cardiac arrest. An alternative, in an effort to minimize patient and visitor anxiety, are terms such as ‘‘Doctor Heart’’ for a cardiac arrest, ‘‘Doctor Trip’’ for a visitor fall, and ‘‘Doctor White’’ for a HAZMAT incident. Others use alphabet codes, such as Code A being a cardiac arrest. This is somewhat confusing in that Code A, Code Alpha, or Code Amber are also used to indicate child abduction, consistent with the nationwide ‘‘Amber Alert’’ system. In Texas, however, a Code Amber is used to indicate a theft or armed robbery. A Code Pink is used both to indicate a child abduction and a pediatric cardiac arrest. Codes used for a disaster include Code Amber, Code Orange, or a Code Triage. A bomb threat may be called a Code White, a Code Yellow, or a Code R-1. Finally, the term Code Green,
Disaster Manage Response 2007;5:1-2. 1540-2487/$32.00 Copyright Ó 2007 by the Emergency Nurses Association. doi:10.1016/j.dmr.2006.12.001 January-March 2007
used by many facilities to indicate that the emergency is now over, is used in other facilities to indicate that a physician or service is urgently needed, e.g., a STAT call. A study of hospital codes by the Hospital Association of Southern California revealed that while 90% of the hospitals used Code Blue to indicate cardiac arrest, there were 47 different codes for an infant abduction and 61 different codes for a combative person.1 As a clinician working in several facilities simultaneously, with each using different terminology, I found the lack of standardized codes to be both annoying and frightening. Given both the nursing shortage and the increased number of emergency codes, this inconsistency is a now a larger safety issue for staff and patients alike. Nursing shortages have resulted in widespread use of agency and pool nurses who come from all over the country or work at a number of facilities across several state lines. The use of service contracts for other hospital services also increases the potential for a number of transient workers. Orientation for temporary staff is brief at best, with a great deal of information to process. I suspect that, with the exception of a cardiac arrest and fire, most other codes are not easily remembered by temporary staff, and that regular staff might have some difficulty as well. Much energy has been directed at the issue of ‘‘failure to rescue’’da term used to denote an adverse patient event that was potentially avoidable. I wonder if any of these events result
from delays in activating the appropriate code or dialing the operator rather than the special emergency number. Another concern is staff safety. The increase in violent acts against health care workers has been identified by the National Institute of Occupational Health and Safety and by many researchers.2,3 The Hospital Association of Southern California began exploring emergency codes after an investigation into the shooting death of a hospital employee by an armed visitor suggested that confusion existed regarding the correct code to use. The organization has been instrumental in standardizing emergency codes throughout the state of California and has made its manual, Healthcare Facility Emergency Codes: A Guide for Code Standardization,4 available for download at http://www.HASC.org. The State of New Jersey has also developed state-wide standardization of hospital emergency codes. The implications of inconsistent terminology on disaster response became very clear during a recent meeting involving colleagues from several adjoining states. One of the participants was discussing a Code Orange in her facility; however, the context didn’t make sense to me, since a Code Orange is a HAZMAT incident in my state. After a few minutes, it became clear that a Code Orange in her facility was a disaster, not a HAZMAT incident. The differences in terminology have implications for planning, communication, and operations during an actual event.
Disaster Management & Response/McMahon 1
DMR Responders to a large-scale disaster will most likely come from a number of different states, if not nations. Patient and worker safety hinge on our ability to communicate emergency situations clearly. While the newly revised Hospital Incident Command System guidance does not dictate standardization of emergency codes, it emphasizes the need to use clear language to describe an event, especially to external resources. Instead of communicating a code, simply state what the nature of the situation, e.g., disaster, HAZMAT, armed individual, etc. While
2 Disaster Management & Response/McMahon
this may not address the issue of inconsistency of internal codes, at least external responders will have a clear understanding of the issue. I challenge each of us to become involved in efforts to standardize hospital emergency codes within our respective states with hopes for national standardization as well; your life as well as those of your patients and colleagues may well depend on it.
References 1. Wikipedia, the free encyclopedia. Hospital Emergency Codes [online;
cited 2006 Nov 15] Available from: URL: http://en.wikipedia.org/wiki/ Hospital_emergency_codes. 2. Gates DM. The epidemic of violence against healthcare workers [editorial] Occup Environ Med 2004;61: 649-650. 3. National Institute for Occupational Safety and Health. Violence. Occupational Hazards in Hospitals. DHHS (NIOSH) Publication No. 2002-101, April 2002. Available from: URL: http://www.cdc.gov/ niosh/2002-101.html. 4. A Healthcare Association of Southern California Publication. Healthcare Facility Emergency Codes: A Guide for Code Standardization. 2000. Available from: URL: http://www.hasc. org/download.cfm?IDZ7377.
Volume 5, Number 1
Editorial
The Many Codes for a Disaster: A Plea for Standardization Margaret M. McMahon, RN, MN, CEN, FAEN
T
he use of special code words announced overhead to communicate emergency situations is fairly standard in most American hospitals. What are not standard, though, are the terms used for these emergencies. While the terms may vary, some such as Code Red for fire and Code Blue for a cardiac arrest are relatively easy to decipher. Even a Code Blue, though, is not consistently applied. Some facilities use numbers such as Code 99 or 707 to indicate a cardiac arrest. An alternative, in an effort to minimize patient and visitor anxiety, are terms such as ‘‘Doctor Heart’’ for a cardiac arrest, ‘‘Doctor Trip’’ for a visitor fall, and ‘‘Doctor White’’ for a HAZMAT incident. Others use alphabet codes, such as Code A being a cardiac arrest. This is somewhat confusing in that Code A, Code Alpha, or Code Amber are also used to indicate child abduction, consistent with the nationwide ‘‘Amber Alert’’ system. In Texas, however, a Code Amber is used to indicate a theft or armed robbery. A Code Pink is used both to indicate a child abduction and a pediatric cardiac arrest. Codes used for a disaster include Code Amber, Code Orange, or a Code Triage. A bomb threat may be called a Code White, a Code Yellow, or a Code R-1. Finally, the term Code Green,
Disaster Manage Response 2007;5:1-2. 1540-2487/$32.00 Copyright Ó 2007 by the Emergency Nurses Association. doi:10.1016/j.dmr.2006.12.001 January-March 2007
used by many facilities to indicate that the emergency is now over, is used in other facilities to indicate that a physician or service is urgently needed, e.g., a STAT call. A study of hospital codes by the Hospital Association of Southern California revealed that while 90% of the hospitals used Code Blue to indicate cardiac arrest, there were 47 different codes for an infant abduction and 61 different codes for a combative person.1 As a clinician working in several facilities simultaneously, with each using different terminology, I found the lack of standardized codes to be both annoying and frightening. Given both the nursing shortage and the increased number of emergency codes, this inconsistency is a now a larger safety issue for staff and patients alike. Nursing shortages have resulted in widespread use of agency and pool nurses who come from all over the country or work at a number of facilities across several state lines. The use of service contracts for other hospital services also increases the potential for a number of transient workers. Orientation for temporary staff is brief at best, with a great deal of information to process. I suspect that, with the exception of a cardiac arrest and fire, most other codes are not easily remembered by temporary staff, and that regular staff might have some difficulty as well. Much energy has been directed at the issue of ‘‘failure to rescue’’da term used to denote an adverse patient event that was potentially avoidable. I wonder if any of these events result
from delays in activating the appropriate code or dialing the operator rather than the special emergency number. Another concern is staff safety. The increase in violent acts against health care workers has been identified by the National Institute of Occupational Health and Safety and by many researchers.2,3 The Hospital Association of Southern California began exploring emergency codes after an investigation into the shooting death of a hospital employee by an armed visitor suggested that confusion existed regarding the correct code to use. The organization has been instrumental in standardizing emergency codes throughout the state of California and has made its manual, Healthcare Facility Emergency Codes: A Guide for Code Standardization,4 available for download at http://www.HASC.org. The State of New Jersey has also developed state-wide standardization of hospital emergency codes. The implications of inconsistent terminology on disaster response became very clear during a recent meeting involving colleagues from several adjoining states. One of the participants was discussing a Code Orange in her facility; however, the context didn’t make sense to me, since a Code Orange is a HAZMAT incident in my state. After a few minutes, it became clear that a Code Orange in her facility was a disaster, not a HAZMAT incident. The differences in terminology have implications for planning, communication, and operations during an actual event.
Disaster Management & Response/McMahon 1
DMR Responders to a large-scale disaster will most likely come from a number of different states, if not nations. Patient and worker safety hinge on our ability to communicate emergency situations clearly. While the newly revised Hospital Incident Command System guidance does not dictate standardization of emergency codes, it emphasizes the need to use clear language to describe an event, especially to external resources. Instead of communicating a code, simply state what the nature of the situation, e.g., disaster, HAZMAT, armed individual, etc. While
2 Disaster Management & Response/McMahon
this may not address the issue of inconsistency of internal codes, at least external responders will have a clear understanding of the issue. I challenge each of us to become involved in efforts to standardize hospital emergency codes within our respective states with hopes for national standardization as well; your life as well as those of your patients and colleagues may well depend on it.
References 1. Wikipedia, the free encyclopedia. Hospital Emergency Codes [online;
cited 2006 Nov 15] Available from: URL: http://en.wikipedia.org/wiki/ Hospital_emergency_codes. 2. Gates DM. The epidemic of violence against healthcare workers [editorial] Occup Environ Med 2004;61: 649-650. 3. National Institute for Occupational Safety and Health. Violence. Occupational Hazards in Hospitals. DHHS (NIOSH) Publication No. 2002-101, April 2002. Available from: URL: http://www.cdc.gov/ niosh/2002-101.html. 4. A Healthcare Association of Southern California Publication. Healthcare Facility Emergency Codes: A Guide for Code Standardization. 2000. Available from: URL: http://www.hasc. org/download.cfm?IDZ7377.
Volume 5, Number 1