Emergency codes and how they are called

When something goes wrong in a hospital, the first few minutes decide a great deal. A fire that is reported within a minute can be contained in one room; a fire noticed ten minutes later may fill a corridor with smoke. A patient in cardiac arrest who gets help in two minutes has a far better chance than one who waits five. Emergency codes exist to get the right people moving in the right direction as fast as possible, with as few words as possible. This lesson explains the codes used at Northbridge, how to call one, what you are expected to do when you hear one, and why many hospitals are changing the way codes are announced.

What an emergency code does

An emergency code is a short, standard announcement that tells everyone in the building three things: what kind of emergency is happening, where it is, and, by implication, what they should do. Each type of code is linked to a procedure. When a fire is announced, staff on the affected unit carry out the fire procedure, staff on nearby units prepare to receive patients, the fire response team goes to the location, and everyone else stays put, closes doors and keeps corridors clear. One announcement sets off dozens of coordinated actions.

Codes also save time when time matters most. A worker who finds a fire does not need to explain the situation to a dozen departments; one call to the emergency number reaches the switchboard, which announces the code, notifies the response team and calls the fire department.

The codes at Northbridge

For many years, US hospitals used color codes too, but the colors were not standard: Code Red meant fire in most hospitals, but Code Orange might mean a hazardous spill in one hospital and a mass casualty incident in the next. Staff who worked in two hospitals, and traveling nurses, could misread a code with serious results. Many states, through their hospital associations, have since adopted plain-language emergency alerts, and Minnesota hospitals have moved the same way. Northbridge uses a plain-language system in which every announcement starts with one of three alert types:

• Facility alert: fire, evacuation, hazardous material spill, utility failure, severe weather, mass casualty incident and similar events.
• Security alert: violent person, active shooter, missing patient, infant or child abduction, bomb threat, lockdown.
• Medical alert: cardiac arrest (still called Code Blue by staff), rapid response, medical emergency in a public area, stroke, and similar calls.

After the alert type comes a plain description and the location, and sometimes an instruction. For example: Facility alert, fire, 4 West, room 412, staff follow fire procedures. Or: Security alert, active shooter, main lobby, run, hide, fight; avoid the main lobby. The descriptions use everyday words, so visitors, contractors and new staff understand them without a code card.

Color codes or plain language?

The argument for color codes is that they are short and discreet. A color code can be announced without alarming patients and visitors, which matters for events such as a violent patient or a missing child, where panic or a crowd could make things worse. Codes are also deeply familiar to experienced staff.

The argument for plain language is that it is understood by everyone. Visitors, contractors, students and agency staff may not know the codes, and in an active attacker event, the people most at risk are often visitors in public areas who have no idea what Code Silver means. Studies and reviews of real events have found staff confusing codes, especially when hospitals use different colors for the same event. Agencies and professional groups, including emergency nursing organizations, now generally support plain-language alerts, sometimes keeping a small number of familiar medical codes such as Code Blue.

Northbridge keeps a short internal list of terms staff may still hear from older staff or other hospitals, so that a nurse who hears Code Red from a visiting physician understands it, but all overhead announcements use the plain-language format.

How to call a code

At Northbridge, any worker who sees an emergency calls the internal emergency number, 5555, from any hospital phone. On a mobile phone, staff call the switchboard number printed on the back of their badge. For a fire, the worker also pulls the nearest fire alarm, which sends the signal to the switchboard and the fire department automatically.

The switchboard operator needs four things, in this order:

• What: the type of emergency, using the code or plain words if you are not sure of the code.
• Where: the exact location, with building, floor, unit and room number or a landmark, such as cafeteria, near the cashiers.
• Details: anything the responders need to know, such as a person with a knife, a spill of 1 gal (about 4 L) of formalin, or a resident who left 20 minutes ago wearing a blue coat.
• Who: your name and the number you are calling from, so the operator can call back.

The caller then stays on the line until the operator has repeated the information back, unless doing so would put them in danger. The operator announces the code overhead, usually three times, sends it to the pagers and phones of the response team, and calls outside services, such as the fire department or police, as the procedure requires. When the emergency is over, the person in charge tells the switchboard, which announces an all clear for the code and the location. Until the all clear, staff keep following the procedure.

Northbridge's switchboard uses a script to build each announcement from the information the caller gives, so that every announcement has the same parts in the same order.

# Build a standard overhead announcement (plain language)
ALERT_TYPE = {
    "fire": "Facility alert", "evacuation": "Facility alert",
    "hazardous spill": "Facility alert", "utility failure": "Facility alert",
    "active shooter": "Security alert", "missing patient": "Security alert",
    "violent person": "Security alert",
    "cardiac arrest": "Medical alert", "rapid response": "Medical alert",
}

def announce(kind, location, instruction=""):
    text = f"{ALERT_TYPE[kind]}, {kind}, {location}"
    if instruction:
        text += f", {instruction}"
    return " ... ".join([text] * 3)

print(announce("fire", "4 West, room 412", "staff follow fire procedures"))
print(announce("active shooter", "main lobby",
               "run, hide, fight; avoid the main lobby"))
print("All clear, fire, 4 West")

Facility alert, fire, 4 West, room 412, staff follow fire procedures ... Facility alert, fire, 4 West, room 412, staff follow fire procedures ... Facility alert, fire, 4 West, room 412, staff follow fire procedures
Security alert, active shooter, main lobby, run, hide, fight; avoid the main lobby ... Security alert, active shooter, main lobby, run, hide, fight; avoid the main lobby ... Security alert, active shooter, main lobby, run, hide, fight; avoid the main lobby
All clear, fire, 4 West

What to do when you hear a code

Hearing a code is as important as calling one. For each code, the plan sets out three kinds of response:

• The unit where the emergency is: staff carry out the procedure for that code, starting with the steps that protect life.
• The response team: designated people go to the location, such as the fire response team, the Code Blue team, the Code White team or security.
• Everyone else: staff stay in their area unless assigned, keep phones and elevators free, keep corridors and doors clear, prepare to help or receive patients, and listen for updates. They do not go to look.

Curious staff who go to the scene of a code are a real problem. At a cardiac arrest in a crowded corridor, extra people block the team and the equipment. At a fire, they can be cut off by smoke. At a violent incident, they become extra targets. Northbridge's rule is simple: go only if it is your role, or if you are asked.

Each unit at Northbridge has a code flip chart near the nursing station, with one tabbed page for each code, showing the steps for that unit and the roles for each shift. Staff also carry a code card on their badge. The flip chart for 4 West lists, for example, who closes doors during a fire, who checks the oxygen zone valve, who brings the evacuation sleds, and who meets the fire response team at the elevator.

Mass notification and the limits of the overhead page

Overhead announcements are only one way to spread an alert. They cannot be heard in every room, they are often switched off or turned down in intensive care units, operating rooms and patient rooms at night, and they mean nothing to staff who are off site. Hospitals therefore use several channels together:

• Overhead paging in public areas and units.
• Pagers, phones and secure messaging apps for response teams and managers.
• Mass notification systems that send texts, calls and emails to all staff, including those at home, for events such as calling in extra staff.
• Visual alerts, such as strobe lights and screens, for areas where sound is a problem and for people who are hard of hearing.
• Desktop alerts that pop up on hospital computers.

Northbridge tests its mass notification system every month by sending a short message that staff must acknowledge. The first test after the system was set up showed that 27 of every 100 phone numbers were wrong or out of date. Staff are now reminded to update their contact information twice a year, and managers check it during the annual performance review.

Codes beyond the main hospital

Maple Court uses the same alert system as the hospital, which matters because the two buildings share staff and a response team. At night, Maple Court has far fewer staff in each household than the hospital has on a unit, so its procedures say exactly which hospital teams come through the connecting corridor for each alert, and how long they should take. Fires and evacuations in particular depend on that help, because a handful of night staff cannot move 24 residents alone.

Northbridge Home Health staff work in clients' homes, where there is no switchboard and no response team. Their emergency procedure is to call 911 for any fire, medical emergency or threat, get themselves to safety, and then call the home health coordinator, who starts the agency's own response and checks on other staff working nearby. Their phones carry a short emergency card with the same what, where, details and who format, because a caller who is frightened often forgets to give an address.

Talking to patients and visitors during a code

Patients and visitors hear codes too, and an unexplained announcement can be frightening, especially for people who are already unwell or anxious. Staff should answer questions calmly and honestly without adding detail that could cause panic: there is a situation on another floor and the team is dealing with it; we will tell you if we need you to do anything. During a fire or evacuation, the message is short and clear: stay in your room with the door closed, or come with me now. Staff should never say that a code is just a drill unless they know it is.