BCMCH Emergency Codes

Module 1: Introduction to Emergency Codes at BCMCH

• Objective: To provide staff with a comprehensive understanding of the purpose, structure, and importance of the Emergency Code System at BCMCH.

• • 1.1. What are Emergency Codes? (Definition and Purpose)

    • Definition: A standardized system of color-coded and/or named alerts used within a healthcare facility to communicate critical information rapidly and discreetly during emergencies. Emphasize that codes are not intended to alarm patients or visitors unnecessarily but rather to trigger specific actions by trained staff.

    • Purpose:

      • Rapid Communication: Enable prompt communication of emergencies throughout the hospital, eliminating ambiguity.

      • Efficient Response: Facilitate a coordinated and effective response by designated teams.

      • Resource Mobilization: Trigger the deployment of appropriate resources (personnel, equipment, supplies) to the location of the emergency.

      • Safety and Security: Ensure the safety of patients, staff, visitors, and the facility itself.

      • Minimize Disruption: Minimize disruption to normal hospital operations while addressing the emergency.

      • Standardized Actions: Establish clear protocols and procedures for different types of emergencies.

• • 1.2. The History and Evolution of Emergency Codes

    • Brief history of how hospital emergency codes evolved over time in the healthcare industry.

    • Explain that the codes used today were established to improve patient safety, coordination, and efficiency.

• • 1.3 Benefits of Using Emergency Codes at BCMCH

    • 1.3.1. Enhanced Patient Safety: How codes contribute to quicker response times and appropriate interventions during patient emergencies.

    • 1.3.2. Improved Staff Preparedness: Regular training and drills improve staff readiness and confidence in responding to emergencies.

    • 1.3.3. Effective Communication: Standardized codes ensure that all staff members understand the nature of the emergency and their roles.

    • 1.3.4. Resource Optimization: Codes facilitate the efficient allocation of resources (personnel, equipment, supplies) to the area where they are most needed.

    • 1.3.5. Compliance with Regulations: Adherence to established codes demonstrates compliance with regulatory standards and accreditation requirements.

• • 1.4. Overview of All Emergency Codes Used at BCMCH (Code List and Descriptions)

    • Provide a detailed list of all emergency codes currently used at BCMCH. For each code:

      • Code Name

      • Color/Symbol

      • Detailed description

      • Triggers: The specific events or conditions that warrant activating the code.

      • Responding Team(s): Primary and secondary responding teams.

      • Brief Action Plan Summary: Key actions to be taken upon code activation.

      • Policy on the code

• • 1.5 Maintenance and Updates of the Emergency Code System

    • 1.5.1. Control and Authority

      • Explain the authority over the codes.

    • 1.5.2. Amendment and Review Procedure

      • Explanation of the process for adding new codes, modifying existing codes, or removing obsolete codes.

      • Who is responsible for initiating and approving code changes?

    • 1.5.3. Communication of Updates

      • How are changes to the code system communicated to all staff members? (e.g., email announcements, intranet postings, training sessions)

    • 1.5.4 Amendment sheet

      • Amendment sheet, to be updated (as and when amendments received) and referred for details of amendments issued.

    • 1.5.5 Review
      * The manual is reviewed at least once a year and is updated as relevant to the hospital policies and procedures.

  • 1.6. Distribution List

    • Provide detail that list includes all holders of the controlled copy of this Manual

• Training Methods:

  • Interactive Lecture

  • PowerPoint Presentation with Visual Aids (Code Posters, Diagrams)

  • Group Discussion

  • Q&A Session

Module 2: Announcing Emergency Codes Effectively

• Objective: To ensure that all staff members can confidently and accurately announce emergency codes using the BCMCH-approved procedure.

  • 2.1. Importance of Proper Code Announcement

    • 2.1.1. Alerting Responding Teams: Explain how the code announcement is the primary means of notifying responding teams.

    • 2.1.2. Prompting Action: The announcement triggers specific actions by staff members in the area.

    • 2.1.3. Providing Location Information: Accurate location information is crucial for a swift and effective response.

    • 2.1.4. Maintaining Discretion: Code announcements are designed to be discreet, minimizing alarm for patients and visitors.

• • 2.2. The Step-by-Step Code Announcement Procedure

    • 2.2.1. Step 1: Dial 7070

      • Emphasize that 7070 is the dedicated emergency code announcement line.

      • Confirm it is a landline.

      • Explain that dialing 7070 automatically activates the hospital's public address (PA) system for emergency announcements.

    • 2.2.2. Step 2: Wait for Connection (Very Brief Pause)

      • Explain the PA system will be activated immediately.

    • 2.2.3. Step 3: Announce the Code Only

      • The announcement is made by the designees.

      • No personal dialogue should be made.

    • 2.2.4. Step 4: Code Announcing Format

      • The code name in a firm voice.

      • Clear enunciation

      • Example- CODE RED

    • 2.2.4 Step 5: Floor

      • Announce only the name of the floor

      • Example- 2nd Floor

    • 2.2.4 Step 6: Department/Area

      • Announce only the name of the department/Area

      • Example- ICU

    • 2.2.4 Step 7: Bed No./Room No. (if applicable)
      * Example- ICU Bed 12

• • 2.3. Key Considerations for Effective Code Announcements

    • 2.3.1. Clarity:

      • Speak clearly and enunciate each word distinctly.

      • Avoid mumbling or speaking too quickly.

    • 2.3.2. Accuracy:

      • Verify the location and code information before making the announcement.

      • Repeat the information if necessary to ensure understanding.

    • 
      

    • 2.3.3. Consistency:

      • Follow the standardized announcement format.

      • Use consistent terminology for locations and codes.

    • 2.3.4 Calmness:

      • Try to remain calm, even under pressure

      • A calm voice reassures others.

• • 2.4. Practice Scenarios: Mock Code Announcements

    • 2.4.1. Small Group Practice:

      • Divide participants into smaller groups.

      • Provide each group with a scenario card describing a specific emergency and location.

      • Have each member of the group take turns announcing the code using the 7070 procedure.

      • Group members provide feedback to each other on clarity, accuracy, and tone.

    • 2.4.2. Large Group Practice:

      • Select participants to announce codes to the entire group.

      • Provide immediate feedback on their performance.

• Training Methods:

  • Demonstration

  • PowerPoint Presentation with Audio Examples

  • Role-Playing

  • Mock Code Announcement Exercises

  • Individual Feedback

Training Module: Code Red (Fire Emergency)

• Objective: To equip all BCMCH staff with the knowledge and skills necessary to respond effectively and safely during a fire emergency.

  • 1. What is Code Red? (Definition and Scope)

    • Definition: Code Red is the emergency code used to signal a fire or suspected fire within the BCMCH facility.

    • Scope: The Code Red protocol applies to all areas of the hospital, including patient care units, administrative offices, support services, and external buildings on the BCMCH campus.

• • 2. Understanding Fire Hazards and Safety Precautions

    • 2.1. Common Fire Hazards in a Hospital Setting:

      • Electrical Equipment (faulty wiring, overloaded outlets)

      • Oxygen-Rich Environments

      • Flammable Liquids (cleaning solutions, alcohol-based hand sanitizers)

      • Cooking Equipment (in cafeterias or kitchens)

      • Smoking Materials (in designated areas only)

• • • 2.2. Fire Prevention Measures:

      • Regular Equipment Maintenance

      • Proper Storage of Flammables

      • No Smoking in Unauthorized Areas

      • Training on Fire Safety Procedures

      • Ensure Fire Exits are Clear and Accessible.

      • Reporting and Addressing Fire Hazards Promptly.

• • 3. The RACE Acronym (Initial Response)

    • 3.1. Rescue:

      • Prioritize Immediate Danger: If safe to do so, immediately rescue any patients or individuals who are in immediate danger from the fire.

      • Safe Evacuation: Help them to evacuate the area safely and efficiently, using appropriate techniques and equipment (e.g., wheelchairs, stretchers, etc.).

      • Do not use elevators.

    • 3.2. Alarm:

      • Activate Fire Alarm: Pull the nearest fire alarm pull station to activate the building's fire alarm system. This will alert the fire department and other staff members to the emergency.

      • Code Announcement: Announce Code Red using the 7070 procedure, providing clear and concise location information:

        • "Code Red, [Floor], [Department/Area], [Room Number/Specific Location]" (repeated three times)

    • 3.3. Confine:

      • Close Doors and Windows: Close all doors and windows in the affected area to contain the fire and prevent it from spreading.

      • Seal Off Area: If possible, seal off the area with fire-resistant materials or barriers to further restrict the fire's spread.

    • 3.4. Extinguish/Evacuate:

      • If Trained and Safe: If you are trained in using fire extinguishers and the fire is small and contained, attempt to extinguish the fire using the appropriate type of extinguisher.

      • Evacuate If Necessary: If the fire is too large, spreading rapidly, or you are not trained to use a fire extinguisher, evacuate the area immediately. Follow the evacuation plan and assist others in evacuating.

• • 4. The PASS Acronym (Fire Extinguisher Use)

    • 4.1. P (Pull): Pull the pin on the fire extinguisher.

    • 4.2. A (Aim): Aim the nozzle at the base of the fire.

    • 4.3. S (Squeeze): Squeeze the handle to release the extinguishing agent.

    • 4.4. S (Sweep): Sweep the nozzle from side to side at the base of the fire until it is extinguished.

    • Important Note: Only attempt to extinguish small, contained fires if you have been trained and feel confident in your ability to do so safely. Your safety and the safety of others are always the top priority.

  • 5. Evacuation Procedures

    • 5.1. Evacuation Plan Overview: Review the hospital's evacuation plan, including designated evacuation routes, assembly points, and procedures for accounting for all patients, staff, and visitors.

    • 5.2. Assisting Patients with Evacuation: Demonstrate techniques for safely evacuating patients with varying levels of mobility, including using wheelchairs, stretchers, and manual carries.

    • 5.3. Vertical vs. Horizontal Evacuation:

      • Horizontal Evacuation: Move patients and staff to a safe area on the same floor, away from the fire.

      • Vertical Evacuation: If horizontal evacuation is not possible, evacuate to a safe area on a different floor, using stairs only (never elevators).

    • 5.4. Maintaining Order and Control:

      • Communicate clearly and calmly to direct people to the nearest safe exit.

      • Prevent panic by maintaining order and control during the evacuation.

    • 5.5 Accounting for everyone.

  • 6. Roles and Responsibilities

    • 6.1. Immediate Responders: Those who discover the fire, responsible for:

      • Activating Fire Alarm

      • Announcing Code Red

      • Attempting to Extinguish (if trained and safe)

      • Initiating Rescue and Evacuation

    • 6.2. Fire Safety Team: Fire Safety personnel or designated staff members responsible for:

      • Assessing the Situation

      • Coordinating Fire Suppression Efforts

      • Overseeing Evacuation

      • Communicating with Fire Department

    • 6.3. Nursing Staff: Nursing staff members are responsible for:

      • Assisting with Patient Evacuation

      • Administering Medications and Treatments

      • Maintaining Patient Records

      • Providing Emotional Support to Patients

    • 6.4. Security Personnel: Security personnel are responsible for:

      • Controlling Access to Affected Areas

      • Assisting with Evacuation

      • Maintaining Order and Security

    • 6.5. Engineering Staff: Responsible for shutting off electric and gas

  • 7. Communication with Fire Department

    • 7.1 Designee informs designees from fire department.

  • 8. Shutting down the Fire and Code Red CLEAR

    • 8.1 Once fire is shut down a Code Red CLEAR is made manually

  • 9. Line of Authority

    • 9.1. Authority during Code Red

    • Engineering Representative

    • CNO

    • Operations

    • Security Officer

    • PRO

    • Nurse Manager/ Supervisor of concerned area

• Training Methods:

  • Interactive Lecture with Multimedia (Videos, Images, Animations)

  • Fire Safety Demonstration (Fire Extinguisher Use, Evacuation Techniques)

  • Hands-on Practice with Fire Extinguishers (Controlled Environment)

  • Tabletop Evacuation Exercise

  • Mock Code Red Drill (Realistic Simulation)

  • Review of BCMCH Fire Safety Policies and Procedures

  • Q&A Session

• Assessment:

  • Written Exam (Knowledge of Fire Safety, RACE, PASS)

  • Practical Assessment (Fire Extinguisher Use, Evacuation Skills)

  • Participation in Mock Code Red Drill

  • Review of BCMCH Fire Safety Policies and Procedures

• Materials Needed:

  • Presentation Slides

  • Fire Safety Handouts (RACE, PASS, Evacuation Map, Emergency Contacts)

  • Fire Extinguisher (Training Model)

  • Smoke Simulator (Optional)

  • Tabletop Map of BCMCH

  • Scenario Cards for Tabletop Exercise

  • Evaluation Forms

Training Module: Code Pink (Infant/Child Abduction)

• Objective: To equip all BCMCH staff with the knowledge, skills, and awareness necessary to prevent and respond effectively to infant or child abduction attempts.

  • 1. What is Code Pink? (Definition and Scope)

    • Definition: Code Pink is the emergency code used to signal that an infant or child is missing and potentially abducted from the BCMCH facility. This code is intended to initiate a coordinated search and security response.

    • Scope: The Code Pink protocol applies to all areas of the hospital, including:

      • Maternity Units (Labor and Delivery, Postpartum)

      • Neonatal Intensive Care Unit (NICU)

      • Pediatric Units

      • Emergency Department

      • Waiting Areas

      • All other areas of the hospital, including external entrances and exits.

• • 2. Risk Factors and Vulnerabilities

    • 2.1. Understanding the Abductor Profile:

      • Discuss typical characteristics and motives of potential abductors (e.g., maternal instinct gone wrong, desire for a child, mental health issues).

      • Emphasize that abductors can be male or female, may appear normal, and may attempt to blend in with staff or visitors.

    • 2.2. Hospital Vulnerabilities:

      • Inadequate Security Measures

      • Staff Inattentiveness

      • Open Access to Units

      • Lack of Visitor Control

      • Poor Patient/Visitor Identification

      • Failure to Follow Security Protocols

    • 2.3. Patient-Related Risk Factors:

      • Young or Inexperienced Parents

      • Socially Isolated Patients

      • Patients with Mental Health Issues

      • Patients with Language Barriers

• • 3. Prevention Strategies and Security Measures

    • 3.1. Access Control and Visitor Management:

      • Restricting Access: Limiting access to maternity and pediatric units through secured doors, access codes, or badge access systems.

      • Visitor Badging: Implementing a visitor badging system to track and identify visitors.

      • Staff Identification: Requiring all staff to wear visible identification badges with photos.

      • Challenge Unknown Individuals: Encouraging staff to politely challenge individuals who are not wearing proper identification or who appear suspicious.

    • 3.2. Infant/Child Identification and Security:

      • Matching Identification Bands: Using matching identification bands for the infant/child and parents/guardians, with unique identification numbers.

      • Electronic Tagging (if available): Implementing an electronic tagging system with alarms to alert staff if an infant/child is removed from the unit without authorization.

      • Footprinting and Photography: Taking footprints and photographs of infants upon admission for identification purposes.

    • 3.3. Patient and Family Education:

      • Educating parents/guardians about the importance of infant/child security and abduction prevention measures.

      • Providing information about hospital protocols and procedures.

      • Encouraging parents/guardians to be vigilant and report any suspicious activity.

    • 3.4. Constant surveillance (CCTV)

  • 4. Recognition of Suspicious Behaviors and Situations

    • 4.1. Suspicious Individuals:

      • Loitering or Unnecessary Presence in Units

      • Asking Questions About Infants/Children

      • Exhibiting Overly Friendly or Inappropriate Behavior

      • Carrying Large Bags or Containers

      • Attempting to Circumvent Security Measures

    • 4.2. Suspicious Situations:

      • A Visitor Taking an Infant/Child from a Room without Authorization

      • A Parent/Guardian Leaving the Unit and Requesting a Staff Member to Watch the Infant/Child

      • An Infant/Child Crying Unattended in a Public Area

      • Unusual or Unexplained Activity near Exit Points

    • 4.3 Key Questions:

      • Why is a visitor going to the ward?

      • Who has come to visit

      • Is the visit needed for the well being of the patient?

• • 5. Initial Response and Code Activation

    • 5.1. Immediate Actions:

      • If you suspect an infant/child abduction is in progress, immediately:

        • Attempt to politely but firmly stop the individual.

        • Ask for identification and the purpose for removing the infant/child.

        • If there is any doubt, prevent the individual from leaving and call for security assistance.

      • If you witness an abduction or the individual flees:

        • Note the individual's appearance, clothing, and any distinguishing features.

        • Note the direction of travel.

        • Immediately activate Code Pink

    • 5.2. Activating Code Pink:

      • Dial 7070 from any BCMCH landline.

      • Announce the Code Pink using the approved format:

        • "Code Pink, [Floor], [Department/Area], Description of the infant or child and description of the abductor. "

      • Repeat the announcement three times.

  • 6. Security Procedures

    • 6.1. Lockdown Procedures:

      • Security personnel will immediately initiate lockdown procedures to secure the hospital.

      • All entrances and exits will be monitored.

      • Staff will be stationed at key points to observe and question individuals.

    • 6.2. Search Procedures:

      • Security personnel will conduct a systematic search of the hospital, including:

        • Patient Rooms

        • Waiting Areas

        • Restrooms

        • Stairwells

        • Elevators

        • Storage Areas

        • Exterior Grounds

      • Staff members will be asked to assist in the search, focusing on their assigned areas.

    • 6.3. Lockdown drill is mandatory

  • 7. Roles and Responsibilities During Code Pink

    • 7.1. Security Personnel:

      • Controlling access to the hospital.

      • Conducting the search.

      • Interacting with law enforcement.

    • 7.2. Nursing Staff:

      • Assisting with the search.

      • Providing information about the missing infant/child.

      • Supporting the family.

      • Caring for other patients.

    • 7.3. Administrative Staff:

      • Managing communication with media and external agencies.

      • Providing administrative support to the search efforts.

    • 7.4 Staff

      • Follow the Id card policy

  • 8. PREVENTIONS of the incidence

    • 8.1 Apply ID Band, follow the hospital policy

  • 9. IN-PATIENT INFANT SAFETY & LEGALITY

    • 9.1. During the absence of patient attenders they should be informed about the baby safety and baby identification

• Training Methods:

  • Interactive Lecture with Real-Life Case Studies

  • Video Demonstrations of Suspicious Behaviors and Response Techniques

  • Role-Playing Exercises (Challenging Suspicious Individuals, Responding to an Abduction)

  • Tabletop Search Exercise (Using a Map of BCMCH)

  • Mock Code Pink Drill (Simulated Abduction Scenario)

  • Review of BCMCH Code Pink Policy and Procedures

  • Q&A Session with Security Personnel

  • Quiz to check the effectiveness

• Assessment:

  • Written Exam (Knowledge of Code Pink Procedures, Suspicious Behaviors, Risk Factors)

  • Practical Assessment (Role-Playing, Search Techniques)

  • Participation in Mock Code Pink Drill

• Materials Needed:

  • Presentation Slides

  • Code Pink Handouts (Procedures, Risk Factors, Search Checklist, Contact List)

  • Visitor Badges

  • Sample Identification Bands

  • Map of BCMCH

  • Scenario Cards for Role-Playing and Search Exercise

  • Evaluation Forms

Training Module: Code RRT (Rapid Response Team)

• Objective: To empower all BCMCH staff with the knowledge and ability to recognize early signs of patient deterioration and activate the Rapid Response Team effectively, improving patient outcomes and reducing preventable adverse events.

  • 1. What is Code RRT? (Definition and Purpose)

    • Definition: Code RRT (Rapid Response Team) is an emergency code used to summon a specialized team of healthcare professionals to the bedside of a patient who is showing early signs of clinical deterioration, before a full-blown emergency (like cardiac arrest) occurs.

    • Purpose:

      • Early Intervention: Provide timely assessment and intervention for patients at risk of adverse events.

      • Prevent Code Blue Events: Prevent preventable cardiac arrests, strokes, and other life-threatening conditions.

      • Improve Patient Outcomes: Improve patient outcomes by addressing deteriorating conditions early on.

      • Reduce Unplanned Transfers to ICU: Reduce the need for emergency transfers to the ICU by providing prompt and effective care on the general ward.

      • Empower Staff: Empower bedside nurses and other staff members to escalate concerns about patient condition.

      • Reduce False Code Blue Numbers

• • 2. The Rationale for Rapid Response Teams

    • 2.1. Recognizing Subtle Deterioration: Patients often exhibit subtle changes in their condition hours before a major adverse event.

    • 2.2. Importance of Early Recognition: Early recognition and intervention can prevent a cascade of events leading to life-threatening complications.

    • 2.3. Empowering Bedside Staff: The RRT system empowers bedside nurses and other staff members to voice their concerns about a patient's condition and request expert assistance.

    • 2.4. Patient Safety Culture: Activating the RRT is not a sign of failure but a demonstration of a commitment to patient safety and proactive care.

• • 3. Activation Criteria: When to Call Code RRT

    • 3.1. Early Warning Score (EWS):

      • Explanation: The BCMCH RRT activation criteria are based on the Early Warning Score (EWS). The EWS assigns points to different physiological parameters, with higher scores indicating greater risk.

      • NOTE: RRTs are called in "IP areas only" as it needs an EWS score based escalation. For all Non IP areas, Initiate Code Blue only

• • • 3.2. Specific RRT Activation Criteria:

      • EWS Score ≥ 5

      • OR, any one of the following individual criteria:

        • Respiration Rate: <8 breaths/min or >25 breaths/min

        • Oxygen Saturation: <91% (Note: COPD patients with known chronic hypoxemia may have a lower target saturation; accepted oxygen saturation is 88-92% in this case. Documented COPD).

        • Temperature: <32.0°C or >39.1°C

        • Systolic Blood Pressure: <90 mmHg or >220 mmHg

        • Heart Rate: <40 beats/min or >131 beats/min

        • New Onset Chest Pain: Unexplained and concerning chest pain.

        • Pain Score: Greater than 7/10

        • Change in Level of Consciousness:

        • **Significant Fall in Urine Output: (Exception - ESRD).

• • • 3.3. When to Call the RRT even if the EWS is < 5 (using clinical judgment):

      • If your "gut feeling" is that something is not right with the patient, even if the objective criteria are not fully met, you are encouraged to call the RRT.

      • Examples of situations warranting RRT activation based on clinical judgment:

        • Sudden changes in mental status or behavior

        • Unexplained agitation or confusion

        • Difficulty breathing or increased work of breathing

        • Seizures

        • Any other concerning sign or symptom that raises a clinical concern.

• • 4. Announcing Code RRT

    • 4.1. Procedure: Follow the same 7070 protocol as other codes:

      • Dial 7070 from a BCMCH landline.

      • Announce Code RRT using the approved format:

        • "Code RRT, [Floor], [Department/Area], [Bed Number/Room Number]" (repeated three times)

• • • 4.2. Key Information to Provide:

      • Specific Reason for Calling the RRT: Clearly state the primary reason you are concerned about the patient (e.g., "Low oxygen saturation," "New onset chest pain," "Change in mental status").

      • Vital Signs: Provide the most recent set of vital signs, including heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature.

      • Pertinent Medical History: Briefly mention any relevant medical history or current medications.

• • 5. What Happens When Code RRT is Activated

    • 5.1. RRT Activation: The RRT will be immediately activated upon receiving the Code RRT announcement.

    • 5.2. RRT Response Time: The RRT will aim to arrive at the patient's bedside within 5 minutes.

    • 5.3. RRT Composition: The RRT typically consists of:

      • HDU doctor

      • Shift supervisor

      • Respiratory therapist

      • Primary nurse

    • 5.4. RRT Assessment and Intervention:

      • The RRT will conduct a thorough assessment of the patient's condition.

      • The RRT may initiate interventions, such as:

        • Oxygen therapy

        • Medication administration

        • Fluid resuscitation

        • Airway management

        • Cardiac monitoring

        • Ordering diagnostic tests

        • Consulting with the attending physician

• • • 5.5. Escalation of Care:

      • Based on the assessment, the RRT may recommend:

        • Continued monitoring on the general ward

        • Transfer to a higher level of care (e.g., ICU)

        • Other appropriate interventions

• • 6. Roles and Responsibilities During Code RRT

    • 6.1. Primary Nurse Responsibilities:

      • Recognize patient deterioration (using EWS and clinical judgment).

      • Activate Code RRT promptly.

      • Bring the crash cart and attach the monitor.

      • Remain at the bedside to provide information to the RRT upon arrival, including events leading to the activation of code, previous assessment, Diagnosis and Patient history, current vitals, deterioration, Any recent abnormal Lab values and Any test or procedure that might lead to the event

• • • 6.2. Shift Supervisor Responsibilities:

      • Respond immediately to the code.

        • Assess the situation especially with regards to activities of the nursing staff and provide additional assistance if needed.

      • Organize the information and communicate to the physician concerned if necessary.

      • If circumstances warrant, take the necessary steps to transfer the patient to ICU.

      • Communication with the family.

      • To coordinate postcode RRT analysis

    • 6.3. Respiratory Therapist Responsibilities:

      • Responsible for initial and ongoing respiratory assessment.

      • Basic airway management such as administering supplemental oxygen and airway clearance.

      • Noninvasive positive pressure ventilation if required and ABG analysis. Coordinate with the ICU consultant and arrange for the transfer to ICU if necessary.

    • 6.4. Team members will be trained in BLS and ACLS

• 7. Communication with Team Members

  • 7.1. Code RRT should follow a course of easy communication.

• Training Methods:

  • Interactive Lecture with Case Studies

  • Video Demonstrations of Patient Deterioration

  • Role-Playing Exercises (Recognizing Deterioration, Calling Code RRT, Providing Information to the RRT)

  • EWS Calculation Practice

  • Review of BCMCH Code RRT Policy and Procedures

  • Q&A Session

• Assessment:

  • Written Exam (Knowledge of RRT Activation Criteria, EWS Calculation)

  • Practical Assessment (Role-Playing)

  • Scenario-Based Simulation

• Materials Needed:

  • Presentation Slides

  • Code RRT Handouts (Activation Criteria, EWS Chart, Code Announcement Procedure, Contact List)

  • Case Study Scenarios

  • Role-Playing Guidelines

  • EWS Calculation Worksheets

  • Evaluation Forms
    I hope it is what you are looking for!

• Additional Considerations:

  • Visual Aids: Use visual aids such as posters and infographics to reinforce the RRT activation criteria and code announcement procedures.

  • Mock Code Drills: Conduct regular mock code drills to provide staff with hands-on practice in responding to RRT activations.

     *   Ongoing Education: Provide ongoing education and training on the RRT system to ensure that staff members remain up-to-date on the latest procedures and best practices.

NOTE: RRTs are called in "IP areas only" as it needs an EWS score based escalation. For all Non IP areas, Initiate Code Blue only

Training Module: Code Blue (Cardiac Arrest)

• Objective: To equip all BCMCH staff with the knowledge, skills, and confidence needed to effectively respond to a Code Blue (cardiac arrest) situation, maximizing the patient's chance of survival and positive outcomes.

  • 1. What is Code Blue? (Definition and Scope)

    • Definition: Code Blue is the emergency code used to signal that a patient is experiencing cardiac arrest (cessation of heart function) or respiratory arrest (cessation of breathing) and requires immediate medical intervention.

    • Scope: The Code Blue protocol applies to all areas of the hospital, including:

      • Patient Care Units

      • Waiting Areas

      • Diagnostic Areas

      • Treatment Areas

      • Public Areas

      • External Buildings on BCMCH campus

• • 2. Understanding Cardiac and Respiratory Arrest

    • 2.1. Causes of Cardiac Arrest:

      • Heart Attack (Myocardial Infarction)

      • Arrhythmias (Ventricular Fibrillation, Ventricular Tachycardia)

      • Electrolyte Imbalances

      • Drug Overdose

      • Trauma

      • Drowning

      • Hypoxia (Lack of Oxygen)

• • • 2.2. Causes of Respiratory Arrest:

      • Airway Obstruction

      • Drug Overdose

      • Neurological Conditions (Stroke, Seizures)

      • Trauma

      • Pneumonia

      • Asthma

• • • 2.3. Recognition of Cardiac and Respiratory Arrest:

      • Unresponsiveness (Patient does not respond to stimuli)

      • Absence of Breathing or Gasping Respirations

      • Absence of a Pulse (in the carotid artery)

      • Sudden Collapse

      • Change in color

• • 3. Initial Response and Code Activation

    • 3.1. Immediate Actions:

      • If you witness a patient collapse or exhibit signs of cardiac or respiratory arrest:

        • Immediately assess the patient for responsiveness, breathing, and pulse.

        • If the patient is unresponsive, not breathing, or has no pulse, call for help and activate Code Blue

• • • 3.2. Activating Code Blue:

    • Dial 7070 from any BCMCH landline.

    • Announce Code Blue using the approved format:

      • "Code Blue, [Floor], [Department/Area], [Bed Number/Room Number]" (repeated three times).

• • • 3.3 Provide information about the victim.

  • 4. Basic Life Support (BLS) Procedures

    • 4.1. Chest Compressions:

      • Positioning: Place the patient supine (on their back) on a firm surface.

      • Hand Placement: Place the heel of one hand in the center of the patient's chest (lower half of the sternum), and place the other hand on top of the first.

      • Compression Depth: Compress the chest at least 2 inches (5 cm) but no more than 2.4 inches (6 cm) in adults.

      • Compression Rate: Perform compressions at a rate of 100-120 compressions per minute.

      • Allow Complete Chest Recoil: Allow the chest to fully recoil between each compression.

• • • 4.2. Rescue Breaths:

      • Open the Airway: Use the head-tilt/chin-lift maneuver to open the patient's airway. If a spinal injury is suspected, use the jaw-thrust maneuver.

      • Seal and Breathe: Pinch the patient's nose closed and create a tight seal over their mouth with your mouth.

      • Deliver Breaths: Give 2 rescue breaths, each lasting about 1 second, and watch for chest rise.

      • Ratio: The compression-to-ventilation ratio is 30:2 (30 compressions followed by 2 breaths).

• • • 4.3. BLS Survey

    • The BLS survey is used in all cases of cardiac arrest In the respiratory arrest case you learned the basics of airway assessment and management of a patient in respiratory arrest with a pulse In this case you will assess and a patient without a pulse and used the AED

  • 5. Advanced Cardiac Life Support (ACLS) Procedures (For Qualified Personnel)

    • 5.1. Airway Management:

      • Advanced Airway Devices: Use of oropharyngeal airway (OPA), nasopharyngeal airway (NPA), laryngeal mask airway (LMA), or endotracheal intubation to secure the airway.

      • Suctioning: Clearing the airway of secretions or vomitus using suction equipment.

• • • 5.2. Cardiac Monitoring:

      • Applying ECG Electrodes: Place ECG electrodes to monitor the patient's heart rhythm.

      • Identifying Arrhythmias: Recognize common cardiac arrest rhythms (Ventricular Fibrillation, Ventricular Tachycardia, Asystole, Pulseless Electrical Activity).

• • • 5.3. Defibrillation:

      • Defibrillator Use: Using a defibrillator to deliver an electrical shock to terminate ventricular fibrillation or pulseless ventricular tachycardia.

      • Energy Levels: Administering the appropriate energy levels for defibrillation based on the defibrillator type and patient condition.

      • Safety Precautions: Ensuring safety for all personnel during defibrillation by calling "Clear!" and verifying that no one is touching the patient or the equipment.

• • • 5.4. Medication Administration:

      • Epinephrine: Administering epinephrine to stimulate heart function and increase blood pressure.

      • Amiodarone: Administering amiodarone to treat certain arrhythmias.

      • Other Medications: Using other medications as indicated by the ACLS guidelines.

• • • Roles and Responsibilities During Code Blue

      • 5.1 Emergency physician

        • Team leader: direct overall patient care

        • Manage the code

        • Medication

        • Defibrillation

        • Other procedures: intubation, compressions

        • Evaluate Code Blue procedures

        • Effectiveness of chest compression

        • Effectiveness of assisted respirations

        • Rhythm/ pulse check

        • Document in the medical record

      • 5.2 Emergency nurse

        • Maintains airway/oxygenation/ventilation

        • Applies monitor leads/ defibrillator pads

        • Starts Intravenous access

        • Administer medications

        • Administers electrical shock (ACLS trained)

        • Assist with intubation procedures

        • Completes CPR record

      • 5.3 Primary nurse

        • Recognize cardiac arrest

        • Sudden onset of unresponsiveness

        • No breathing or no normal breathing

        • Absent carotid pulse

        • Activate code blue team

        • Initiate chest compressions

      • 5.4 Secondary nurse

        • Place backboard under patient

        • Initiate CPR 30:2

        • Administer ventilations with 100% o2 with Bag/valve/mask

      • 5.5 ROLES OF THE SUPPORT PERSONNEL

        • Bring emergency resuscitation cart

        • Obtain supplies from CPR Cart/Ward Stock

        • Attach cardiac monitor leads

        • Ensure patient intravenous access

        • Prepare suction

      • MICU NURSE

        • Support in airway

        • Maintain and support in intravenous access and medications

      • *Nursing supervisor

        • Coordinate the entire code blue event

        • Arrange beds in specific ICU's

        • Helps and monitor staff in recording the code blue sheet

        • range post code blue meeting

        • *Ensures strict infection control practices during the code

        • *Ensures that post code blue form is sent to CPR committee chairman within 24 hours

      • SECURITY SUPERVISOR

        • Crowd control

• Visuals to assist with Code Blue

  • AED posters

  • Chart with code blue team personnel in strategic places

• Ethical considerations
  * Documentation and handover are important things.

  • • Additional Considerations:*

      • Visual Aids: Use visual aids such as posters and infographics to reinforce the Code Blue activation procedures.

      • Mock Code Drills: Conduct regular mock code drills to provide staff with hands-on practice in responding to Code Blue activations.     

• Ongoing Education: Provide ongoing education and training on the Code Blue system to ensure that staff members remain up-to-date on the latest procedures and best practices.

• Training Methods:

  • Interactive Lecture with Multimedia (Videos, Simulations)

  • Hands-on Practice with CPR Mannequins

  • AED Demonstration and Practice

  • ACLS Skills Stations (Airway Management, Medication Administration)

  • Mock Code Blue Drills (Realistic Simulation with Simulated Patients)

  • Review of BCMCH Code Blue Policy and Procedures

  • Ethics Discussion

  • Q&A Session with ACLS-Certified Instructors

• Assessment:

  • Written Exam (Knowledge of BLS/ACLS Guidelines, Code Blue Procedures)

  • Practical Assessment (CPR Skills, AED Use, Airway Management)

  • Participation in Mock Code Blue Drills

  • Documentation and Ethical considerations

• Materials Needed:

  • Presentation Slides

  • BLS and ACLS Handouts (Algorithms, Drug Dosages, Equipment Instructions)

  • CPR Mannequins

  • AED Training Unit

  • Airway Management Equipment (OPA, NPA, LMA)

  • Simulated Medications

  • Code Blue Checklist

  • Scenario Cards for Mock Code Blue Drills

  • Evaluation Forms

Training Module: Code Stroke (Stroke Emergency)

Objective:
To ensure that all BCMCH staff can recognize the signs and symptoms of stroke, rapidly activate the Code Stroke protocol, and facilitate timely delivery of life-saving treatment to stroke patients.

1. Introduction to Code Stroke

• 1.1 What is Code Stroke?

  • Definition: Code Stroke is an emergency code that activates a rapid-response protocol for patients presenting with symptoms suggestive of an acute stroke, requiring immediate assessment and intervention to minimize brain damage.

  • Scope: The Code Stroke protocol applies to all areas of the hospital, including:

    • Emergency Department (ED)

    • Patient Care Units

    • Waiting Areas

    • Diagnostic Imaging

    • All other areas of BCMCH.

2. Understanding Stroke

• 2.1 Types of Stroke:

  • Ischemic Stroke: Caused by a blockage of a blood vessel in the brain (most common type).

    • Thrombotic: A clot forms in an artery within the brain.

    • Embolic: A clot forms elsewhere in the body and travels to the brain.

  • Hemorrhagic Stroke: Caused by bleeding in the brain.

    • Intracerebral Hemorrhage: Bleeding within the brain tissue.

    • Subarachnoid Hemorrhage: Bleeding in the space between the brain and the surrounding membrane.

• 2.2 Importance of Time: "Time is Brain!"
  Brain cells die rapidly during a stroke, emphasizing the critical need for prompt diagnosis and treatment.

• 2.3 Goal of Rapid Treatment
  Fast treatment means a high likelihood of patient survival and reduced disability.

3. Recognizing Stroke Symptoms: The BE FAST Acronym

• If you observe ANY of the following symptoms, suspect stroke and act immediately:

  • B (Balance): Sudden loss of balance or coordination.

  • E (Eyes): Sudden vision changes in one or both eyes (blurring, double vision, loss of vision).

  • F (Face): Face drooping (uneven smile). Ask the person to smile.

  • A (Arm): Arm weakness or numbness (difficulty raising one arm). Ask the person to raise both arms.

  • S (Speech): Speech difficulty (slurred speech, difficulty understanding). Ask the person to repeat a simple sentence.

  • T (Time): TIME to call Code Stroke immediately if any of these symptoms are present. "Time is Brain!"

• 3.7 Reinforcing the Importance of Time
  The faster the diagnosis and treatment, the better the chance of survival and recovery for the patient.

4. Activation of Code Stroke

• 4.1 Immediate Actions:

  • If you suspect a patient is having a stroke, immediately assess for BE FAST symptoms.

  • If any of the BE FAST symptoms are present, activate Code Stroke.

• 4.2 Steps for Activating Code Stroke:

  • Dial 7070 from any BCMCH landline.

  • Announce Code Stroke using the approved format:

    • "Code Stroke, [Floor], [Department/Area], [Bed Number/Room Number], describe patient symptoms" (repeated three times).

5. Code Stroke Team Response

• 5.1 Team Composition: The Code Stroke Team typically consists of:

  • Emergency Physician: Leads the team, performs initial assessment, orders diagnostic tests, and makes treatment decisions.

  • Neurologist (if available): Provides expert consultation and guidance on stroke management.

  • Radiologist: Interprets brain imaging studies (CT scan, MRI).

  • Nursing Staff: Assists with patient assessment, medication administration, and monitoring.

  • Radiology Technician: Performs CT scan and other imaging studies.

  • Laboratory Staff: Performs blood tests to assess patient's condition.

6. Initial Assessment and Diagnostic Testing

• 6.1 Rapid Neurological Assessment:

  • The Code Stroke Team will perform a rapid neurological assessment to determine the severity and location of the stroke.

  • This assessment typically includes evaluating:

    • Level of consciousness

    • Speech

    • Motor function

    • Sensory function

    • Reflexes

• 6.2 Diagnostic Imaging:

  • CT Scan: A CT scan of the brain is the primary diagnostic test to determine if the stroke is ischemic or hemorrhagic and to rule out other conditions.

  • Other Imaging Studies: Additional imaging studies, such as MRI or angiography, may be performed to further evaluate the brain and blood vessels.

• 6.3 Laboratory Testing:

  • Lab tests will also be performed to assess patient's condition and help guide treatment.

7. Treatment Options

• Treatment decisions depend on the type of stroke, time of symptom onset, and patient condition.

• 7.1 Ischemic Stroke:

  • Thrombolytic Therapy (tPA): Medication (tissue plasminogen activator) to dissolve blood clots. Must be administered within a limited time window (typically 4.5 hours).

  • Endovascular Therapy: Procedures (e.g., mechanical thrombectomy) to remove clots from large arteries.

• 7.2 Hemorrhagic Stroke:

  • Blood Pressure Control: Crucial to prevent further bleeding.

  • Surgical Intervention: May be needed to remove blood clots or repair damaged blood vessels.

• 7.3 General Management:

  • Medication and ongoing monitoring to manage symptoms and prevent complications.

8. Documentation is Important

• Accurate and timely documentation of assessment findings, time of symptom onset, Code Stroke activation details, and treatments administered is critical.

9. Training Details

• 9.1 Training Methods:

  • Interactive Lecture with Case Studies

  • Video Demonstrations of Stroke Symptoms and Assessment Techniques

  • Role-Playing Exercises (Recognizing Stroke Symptoms, Activating Code Stroke, Performing Neurological Assessment)

  • Review of BCMCH Code Stroke Policy and Procedures

  • Mock Code Stroke Drill (Simulated Patient Scenario)

  • Q&A Session with Stroke Specialists

  • Handouts

  • Visual demonstrations

• 9.2 Assessment:

  • Written Exam (Knowledge of Stroke Symptoms, Code Stroke Activation, Treatment Options)

  • Practical Assessment (Neurological Assessment Skills, Role-Playing)

  • Participation in Mock Code Stroke Drill

• 9.3 Materials Needed:

  • Presentation Slides

  • Code Stroke Handouts (BE FAST Acronym, Stroke Assessment Checklist, Code Announcement Procedures, Contact List)

  • Video Examples of Stroke Symptoms

  • Scenario Cards for Role-Playing and Mock Code Stroke Drill

  • Neurological Assessment Tools

  • Evaluation Forms 

Training Module: Code White (Physical Assault)

Objective:
To equip BCMCH staff with the knowledge, skills, and strategies to effectively manage aggressive and potentially violent individuals, ensuring the safety of patients, staff, and visitors while minimizing the risk of injury.

1. Introduction to Code White

• 1.1 What is Code White?

  • Definition: Code White is the emergency code used to signal that a situation involving an aggressive, hostile, or potentially violent individual is occurring within the BCMCH facility, requiring immediate assistance from security and other trained personnel.

  • Scope: The Code White protocol applies to all areas of the hospital, including:

    • Patient Care Units

    • Waiting Areas

    • Emergency Department

    • Reception Areas

    • Administrative Offices

    • External Grounds

2. Understanding Aggression and Violence in Healthcare Settings

• 2.1 Contributing Factors to Aggression:

  • Medical Conditions: Delirium, dementia, head injuries, psychiatric disorders.

  • Substance Abuse: Intoxication, withdrawal.

  • Pain and Discomfort: Uncontrolled pain, fear of medical procedures.

  • Emotional Distress: Anxiety, frustration, grief, anger.

  • Environmental Factors: Overcrowding, long wait times, lack of privacy.

• 2.2 Stages of Escalation:

  • Anxiety: Increased restlessness, fidgeting, pacing.

  • Verbal Aggression: Yelling, shouting, swearing, threats.

  • Physical Aggression: Pushing, shoving, hitting, kicking.

  • Violence: Use of weapons, serious physical harm.

3. De-escalation Techniques (Before Code White Activation)

• These techniques are used to prevent escalation when possible.

• 3.1 Communication Strategies:

  • Active Listening: Pay attention to what the individual is saying, both verbally and nonverbally.

  • Empathy: Acknowledge and validate the individual's feelings.

  • Respect: Treat the individual with respect and dignity, even if their behavior is challenging.

  • Calm Tone and Demeanor: Speak in a calm, reassuring tone of voice and maintain a non-threatening posture.

  • Clear and Simple Language: Use clear, simple language that is easy to understand.

  • Avoid Arguing: Do not argue or try to reason with the individual.

  • Set Limits: Clearly and calmly set limits on unacceptable behavior.

• 3.2 Environmental Management:

  • Reduce Stimulation: Minimize noise, distractions, and overcrowding in the environment.

  • Provide Space: Give the individual adequate personal space.

  • Remove Potential Weapons: Remove any objects that could be used as weapons from the immediate vicinity.

4. Activation of Code White

• Key Principle: Your safety and the safety of others is paramount. If you feel unsafe or unable to manage the situation using de-escalation, activate Code White.

• 4.1 When to Activate Code White:

  • When de-escalation techniques fail to calm the individual.

  • When there is an immediate threat of physical harm to patients, staff, or visitors.

  • When the individual is exhibiting violent behavior (e.g., hitting, kicking, throwing objects).

  • When you feel unsafe or unable to manage the situation on your own and require backup.

• 4.2 Steps for Activating Code White:

  • Dial 7070 from any BCMCH landline.

  • Announce Code White using the approved format:

    • "Code White, [Floor], [Department/Area], [Specific Location], description of the aggressive behaviour" (repeated three times).

    • Describe the individual and their behaviour to the best of your knowledge (e.g., "male, red shirt, yelling and hitting walls").

5. Security Response and Intervention

• 5.1 Security Team Arrival:

  • Security personnel will respond to the Code White location as quickly as possible.

  • They will assess the situation upon arrival and take appropriate action to ensure safety.

• 5.2 Security Intervention Techniques:Verbal De-escalation: Security personnel will also attempt to de-escalate the situation through communication.

  • Physical Restraint (if necessary): Using approved physical restraint techniques as a last resort to control the individual and prevent harm to themselves or others.

  • Use of Force (if necessary): Using reasonable force to defend themselves or others from imminent harm, in accordance with policy.

• 5.3 Legal and Ethical Considerations & Documentation:

  • Understanding the legal and ethical guidelines for managing aggressive individuals, including the use of restraint and force, is critical.

  • Thorough and accurate documentation of the incident, including behaviors observed, interventions attempted (de-escalation), time of Code White activation, security response, and any physical interventions used, is mandatory. Documentation should clearly outline what was done and why, adhering to policy guidelines on what should and shouldn't be documented regarding such interventions.

6. Roles and Responsibilities During Code White

• 6.1 Staff Member Activating Code White (or present):

  • Ensure your own safety and the safety of those around you.

  • Provide a clear and concise report to security personnel upon their arrival.

  • Assist with de-escalation efforts as directed by security, if safe to do so.

  • Document all observations and actions taken before and during the incident.

• 6.2 Security Personnel:

  • Respond to the Code White location promptly and safely.

  • Assess the situation and take appropriate action to ensure safety.

  • Communicate effectively with staff members and the individual.

  • Use de-escalation techniques or physical intervention as necessary, in accordance with training and policy.

  • Document all interventions thoroughly and accurately.

• 6.3 Nursing Team Member (or primary caregiver):

  • Liaise with the patient/individual (if appropriate and safe) to identify needs or triggers.

  • Attempt to calm the patient/individual using learned techniques, if safe.

  • Provide relevant information about the patient/individual to the security team (e.g., medical history, reasons for distress, communication needs).

  • Assist security and other staff as directed and when safe.

7. Training Details

• 7.1 Training Methods:

  • Interactive Lecture with Real-Life Case Studies

  • Video Demonstrations of Aggressive Behavior, De-escalation Techniques, and Response

  • Role-Playing Exercises (De-escalation scenarios, Setting Limits, Calling Code White)

  • Practical Training in Self-Protection and Disengagement Techniques (Mandatory/Optional based on role)

  • Review of BCMCH Code White Policy and Procedures

  • Legal and Ethical Discussion specific to managing aggression

  • Q&A Session with Security and/or Management

• 7.2 Assessment:

  • Written Exam (Knowledge of Contributing Factors, Stages of Escalation, De-escalation Techniques, Code White Activation Criteria, Legal and Ethical Considerations, Documentation Requirements)

  • Practical Assessment (Role-Playing performance, Demonstration of Self-Protection/Disengagement Techniques)

  • Scenario-Based Simulation

• 7.3 Materials Needed:

  • Presentation Slides

  • Code White Handouts (Policy Summary, De-escalation Tips, Legal Guidelines Summary, Code Announcement Format, Contact List)

  • Video Examples of Aggressive Behavior and Effective/Ineffective Responses

  • Scenario Cards for Role-Playing and Simulation

  • Training Equipment for Practical Techniques (e.g., mats, protective pads)

  • Evaluation Forms 

Training Module: Code Grey (Psychiatric Patient Agitation)

Objective:
To equip BCMCH staff with the knowledge, skills, and sensitivities necessary to manage agitated and potentially aggressive patients with mental health conditions, ensuring a safe and therapeutic environment while respecting patient rights and dignity.

1. Introduction to Code Grey

• 1.1 What is Code Grey?

  • Definition: Code Grey is the emergency code used to signal a situation involving a patient exhibiting agitation, aggression, or other behaviors indicative of a mental health crisis that requires immediate intervention by trained personnel.

  • Scope: The Code Grey protocol applies to all areas of the hospital where a patient with a mental health condition may become agitated, including:

    • Emergency Department

    • Patient Care Units (Medical, Surgical, Mental Health, etc.)

    • Waiting Areas

    • Admissions/Discharge Areas

    • Any other location within BCMCH.

2. Understanding Mental Health Crises and Agitation

• 2.1 Common Psychiatric Conditions Leading to Agitation:

  • Schizophrenia

  • Bipolar Disorder (Manic Phase)

  • Major Depressive Disorder with Psychotic Features

  • Anxiety Disorders, Panic Attacks

  • Post-Traumatic Stress Disorder (PTSD) flashbacks

  • Substance-Induced Psychosis or Withdrawal

  • Dementia or Delirium

• 2.2 Triggers for Agitation:

  • Medication Non-Compliance or Side Effects

  • Changes in Routine or Environment

  • Sensory Overload (Noise, Crowds, Lights)

  • Lack of Sleep

  • Dehydration or Hunger

  • Pain or Physical Discomfort

  • Underlying Medical Conditions (e.g., infection, hypoxia)

  • Personal Stressors, Fear, or Paranoia

• 2.3 Signs and Symptoms of Agitation:

  • Increased restlessness, pacing, fidgeting

  • Verbal hostility, irritability, yelling, swearing

  • Threatening language or gestures

  • Physical tension, clenched fists, rigid posture

  • Difficulty focusing or following instructions

  • Suspiciousness or paranoia

  • Rapid speech or flight of ideas

3. De-escalation Techniques (Prior to Code Grey Activation)

• These techniques aim to calm the patient and prevent escalation.

• 3.1 Creating a Therapeutic Environment:

  • Quiet and Calm Space: Move the patient to a quiet, private area if possible and safe.

  • Reduce Stimulation: Minimize noise, bright lights, distractions, and overcrowding. Aim for a safe and peaceful environment.

  • Non-Threatening Posture: Approach the patient in a calm, non-threatening manner, avoiding sudden movements, direct prolonged eye contact initially, or standing directly over them.

  • Provide Adequate Personal Space: Maintain a safe distance.

• 3.2 Communication Strategies:

  • Calm and Respectful Tone: Use a calm, reassuring, and respectful tone of voice. Address the patient by name (if known) if appropriate.

  • Active Listening: Pay attention to what the patient is saying (verbally and nonverbally). Try to understand their concerns or the source of their distress.

  • Empathy: Acknowledge and validate the patient's feelings ("I can see you're upset," "That sounds frustrating").

  • Clear and Simple Language: Use simple, clear language. Avoid jargon, complex explanations, or arguing.

  • Redirection: Attempt to gently redirect the patient's attention away from the source of their agitation towards a calmer topic or activity.

  • Offering Choices: Provide the patient with limited, reasonable choices when possible to give them a sense of control (e.g., "Would you like water or juice?", "Would you prefer to sit here or by the window?").

  • Avoid Escalation: Do not engage in aggressive, confrontational, or punitive behavior. Avoid challenging delusions or arguing facts directly while the patient is highly agitated.

• 3.3 Collaboration with the Patient:

  • Involve the patient in problem-solving or developing a plan to manage their agitation, if they are able.

  • Offer support and reassurance.

  • Inquire about past coping strategies or things that have helped them calm down in similar situations.

4. Activation of Code Grey

• Key Principle: Activate Code Grey when de-escalation is not working and there is a risk of harm to the patient, staff, or others, or when you feel unable to manage the situation safely on your own.

• 4.1 When to Activate Code Grey:

  • When de-escalation techniques are ineffective in calming the patient despite sustained effort.

  • When the patient presents an immediate threat of physical harm to themselves or others (e.g., making direct threats, picking up objects to throw).

  • When the patient's agitation is escalating rapidly and significantly despite your efforts.

  • When you feel unsafe or unable to manage the situation on your own and require immediate assistance from trained personnel.

• 4.2 Steps for Activating Code Grey:

  • Dial 7070 from any BCMCH landline.

  • Announce Code Grey using the approved format:

    • "Code Grey, [Floor], [Department/Area], [Bed Number/Room Number], brief description of patient's behavior" (repeated three times).

    • Example: "Code Grey, 3rd Floor, 3rdPVT, Room 3, patient is yelling and pacing aggressively."

5. Response Team and Intervention

• 5.1 Response Team Composition:

  • Psychiatrist or Psychiatric Nurse Practitioner (if available or on-call)

  • Registered Nurse (often the primary caregiver and/or charge nurse)

  • Security Personnel

  • Other staff members as needed (e.g., attending physician, social worker, additional trained nursing staff).

• 5.2 Roles of Response Team Members:

  • Psychiatrist/Psychiatric Nurse Practitioner: Assess the patient's mental state, identify potential underlying causes, make treatment decisions, including medication management.

  • Registered Nurse: Continue monitoring the patient, attempt further de-escalation, administer prescribed medications (oral or intramuscular), monitor vital signs and patient response, assist with documentation.

  • Security Personnel: Ensure safety and security for all present, create a safe perimeter, provide a calm and reassuring presence if appropriate, and assist with physical restraint if deemed necessary and appropriate by clinical lead.

• 5.3 Intervention Strategies:

  • Continued De-escalation: The response team will collaboratively continue to attempt de-escalation, leveraging the specific skills of mental health professionals if present.

  • Medication Management: Administering rapid tranquilization medication (oral or intramuscular) as prescribed to help calm the patient and reduce agitation.

  • Seclusion or Restraint (if necessary): Using seclusion (placing the patient alone in a safe, secure room) or physical restraint (using approved manual or mechanical methods) as a last resort to ensure the safety of the patient and others, only when less restrictive measures have failed or are deemed inappropriate for the level of risk.

    • Principle of Least Restrictive Intervention: Staff should attempt less restrictive measures before implementing more restrictive interventions like seclusion or restraint. Measures should only be taken after other options have been considered or ruled out.

6. Safety Considerations During Code Grey

• 6.1 Personal Safety: Always prioritize your own safety and the safety of colleagues and other patients. Do not attempt to intervene alone if you feel unsafe. Wait for the response team.

• 6.2 Safe Distance: Maintain a safe distance from the patient, especially if they are agitated or exhibiting physical tension. Be aware of your surroundings and potential escape routes.

• 6.3 Communication: Communicate clearly and effectively with other staff members during the incident. Designate a leader if needed.

• 6.4 Environmental Scan: Quickly assess the environment for potential weapons or hazards.

• 6.5 Restraint Techniques: If physical restraint is necessary, use only approved BCMCH techniques and follow all relevant policies and procedures strictly. Proper training is essential before participating in restraint.

7. Documentation

• Detailed and accurate documentation is crucial. This should include:

  • Observations of patient behavior leading to Code Grey activation.

  • Time agitation began and escalated.

  • De-escalation techniques attempted and the patient's response.

  • Time Code Grey was activated.

  • Time the response team arrived.

  • All interventions implemented (medication, seclusion, restraint), including times, rationale, and effectiveness.

  • Monitoring of the patient's condition throughout the incident and post-intervention.

  • Any injuries sustained by the patient or staff.

8. Ethical Considerations

• Managing agitated patients requires balancing the need for safety with the patient's rights and dignity.

• Use the least restrictive interventions possible.

• Ensure interventions are therapeutic, not punitive.

• Respect the patient's autonomy and privacy as much as the situation allows.

• Debriefing after the incident can help staff process the event and identify areas for improvement while respecting patient confidentiality.

9. Training Details

• 9.1 Training Methods:

  • Interactive Lecture with Case Studies (Real-Life Examples)

  • Video Demonstrations of Agitated Patient Behavior and Effective/Ineffective De-escalation Techniques

  • Role-Playing Exercises (Practice De-escalation, Setting Limits, Calling Code Grey, Responding as a Team)

  • Practical Training in Safe Physical Intervention/Restraint Techniques (Mandatory for staff who may be involved in physical interventions)

  • Review of BCMCH Code Grey Policy and Procedures, including legal/ethical guidelines.

  • Guest Speaker: Mental Health Professional (Psychiatrist, Psychiatric Nurse, Social Worker) to provide clinical context.

  • Q&A Session

• 9.2 Assessment:

  • Written Exam (Knowledge of Mental Health Conditions, Triggers, Signs, De-escalation Techniques, Code Grey Procedures, Documentation Requirements, Ethical/Legal Principles)

  • Practical Assessment (Role-Playing performance in de-escalation scenarios, Demonstration of safe physical intervention techniques if applicable)

  • Participation and performance evaluation during Mock Code Grey Drills.

• 9.3 Materials Needed:

  • Presentation Slides

  • Code Grey Handouts (BCMCH Policy Summary, De-escalation Tips, Communication Guidelines, Code Announcement Format, Contact List)

  • Video Examples of Agitated Patient Behavior and Management

  • Scenario Cards for Role-Playing and Simulation

  • Training Equipment for Physical Intervention Techniques (e.g., mats, protective gear)

  • Sample Forms for Documentation

  • Evaluation Forms

10. Program Implementation & Maintenance

• Visual Aids: Use visual aids such as posters and infographics in key staff areas to reinforce the Code Grey activation procedures and BE FAST principles.

• Mock Code Drills: Conduct regular mock code drills to provide staff with hands-on practice in responding to Code Grey activations in a simulated environment.

• Ongoing Education: Provide ongoing education and training on the Code Grey system, including updates to policies, new de-escalation strategies, and refresher training on physical techniques, to ensure staff members remain skilled and up-to-date. 

Training Module: Code Yellow (Mass Casualty Incident - MCI)

Objective:
To prepare BCMCH staff to effectively respond to a Mass Casualty Incident (MCI), ensuring that resources are allocated efficiently, patient care is prioritized, and the hospital can function effectively during a crisis.

1. Introduction to Code Yellow

• 1.1 What is Code Yellow?

  • Definition: Code Yellow is the emergency code activated when BCMCH faces or anticipates a Mass Casualty Incident (MCI). An MCI is any event that overwhelms the hospital's normal resources, resulting in a significant disparity between the number of patients and the available resources to care for them. Generally, an incident involving more than 11 patients indicates a Code Yellow situation requiring activation.

  • Scope: The Code Yellow protocol applies to all areas of the hospital and involves a coordinated response across all departments to manage the surge in patients and the strain on resources.

2. Understanding Mass Casualty Incidents

• 2.1 Types of MCIs:

  • External Disasters: Natural disasters (earthquakes, floods, hurricanes), transportation accidents (plane crashes, train derailments), mass shootings, explosions, acts of terrorism.

  • Internal Disasters: Fire within the hospital, major infrastructure failure (loss of power, water, or communication systems), hazardous materials spill impacting the facility.

• 2.2 Key Challenges of MCIs:

  • Surge Capacity: Managing a sudden and large influx of patients simultaneously.

  • Resource Scarcity: Limited availability of staff, beds, equipment, and supplies relative to demand.

  • Communication Breakdown: Difficulty coordinating communication between different departments, external agencies (EMS, police, fire), and within the command structure.

  • Emotional Stress: High levels of stress and anxiety among staff, patients, and families, impacting decision-making and performance.

• 2.3 Nature of MCIs:

  • Each incident is unique. Adaptability, critical thinking, and remaining level-headed under pressure are crucial for a successful team response.

• 2.4 Importance of Time:

  • "Time is of the essence." Efficient and rapid decision-making, triage, and intervention are paramount and should be a constant focus for everyone involved.

3. The Hospital Incident Command System (HICS)

• 3.1 Introduction to HICS:

  • HICS is a standardized, flexible management system used to provide a clear chain of command and organizational structure during an emergency response, including MCIs. It ensures coordinated efforts across the hospital.

• 3.2 Key Roles and Chain of Command within BCMCH HICS (Examples):

  • Incident Commander: (Often CEO / Chief Medical Officer or designated hospital administrator) - Overall responsibility and authority for the incident.

  • Operations Chief: (e.g., Chief ED Physician for clinic operations, COO for administrative operations) - Manages all tactical operations.

  • Planning Chief: Collects, evaluates, and disseminates incident information.

  • Logistics Chief: Manages resources (personnel, equipment, supplies).

  • Finance/Administration Chief: Tracks costs and manages administrative aspects.

  • Public Information Officer (PIO): Manages communications with the media and public.

  • Specific Operational Roles/Units often managed under the Operations Chief:

    • Triage Team Leader (Often ED Physician or experienced ED Nurse)

    • Treatment Officer (Physician)

    • Morgue/Patient Identification Officer (e.g., GDM)

    • Nurse Managers (Coordinate nursing resources on floors/units)

    • Floor/ICU/OT Coordinators

    • Key Department Leads (e.g., Front Office, CSSD, Housekeeping, IT/Biomedical, Pharmacy, Lab/Blood Bank)

  • Chain of Command: Follow the established HICS chain of command for reporting and decision-making.

4. Activation of Code Yellow

• 4.1 Criteria for Activation:

  • Receipt of notification from external agencies (EMS, police, fire department) about a mass casualty event impacting BCMCH.

  • A sudden influx of a large number of patients (generally >11) into the Emergency Department that overwhelms normal capacity.

  • A significant internal event that threatens the hospital's ability to provide care (e.g., fire, major utility failure affecting patient care areas).

  • Declaration by the Hospital Administrator or designated authority (e.g., Incident Commander).

• 4.2 Activating Code Yellow:

  • Dial 7070 from any BCMCH landline.

  • Announce Code Yellow using the approved format:

    • "Code Yellow, [Type of Incident, e.g., External MCI / Internal Fire], [Location/Area Affected, e.g., Emergency Department / 4th Floor], [Estimated Number of Patients, if known]" (repeated three times).

    • Example: "Code Yellow, External MCI, Emergency Department, Approximately 25 Patients."

5. Communications During Code Yellow

• 5.1 Receiving Initial Notification: Information typically comes from external agencies or internal sources to switchboard/communications and designated leadership.

• 5.2 Internal Confirmation: Designated leadership confirms the incident and criteria for Code Yellow activation are met.

• 5.3 Hospital-wide Announcement: Code Yellow is announced via the overhead paging system following the approved format.

• 5.4 Mobilizing Key Personnel: Responsible personnel (Incident Commander, HICS team members, department heads) are contacted using pre-determined call lists and communication trees.

• 5.5 Communication Methods: Utilize all available and reliable means of communication (pagers, internal phone system, radios, runners) as standard systems may be overwhelmed or fail. Code Yellow procedures should promote easy and clear communication flow.

6. Triage Principles and Procedures

• 6.1 Triage Definition: Triage is the critical process of sorting patients based on the severity of their injuries, likelihood of survival, and the resources required, to prioritize care when resources are limited. This is often performed rapidly upon patient arrival.

• 6.2 Triage Categories (START or similar method):

  • Immediate (Red): Patients with life-threatening injuries who require immediate intervention to survive (e.g., severe bleeding, airway obstruction, shock).

  • Delayed (Yellow): Patients with serious injuries who require prompt treatment but can wait for a short period without immediate risk of death (e.g., significant fractures, stable abdominal injuries).

  • Minimal (Green): Patients with minor injuries ("Walking Wounded") who can walk, are stable, and are able to assist themselves or others (e.g., sprains, minor cuts).

  • Expectant (Black): Patients with injuries so severe or prognosis so poor that they are unlikely to survive, even with maximum treatment efforts. Care is focused on comfort; resources are prioritized for patients in other categories who have a higher likelihood of survival.

• 6.3 Triage Procedures:

  • Tag patients immediately upon entry with the appropriate triage color tag.

  • Ensure the tag number is recorded and followed for tracking.

  • Patients with official disaster badges or specific HICS roles are to be given priority access to designated areas.

  • Staff involved in direct patient care must have access to personal protective equipment (PPE) like gloves and masks.

  • Gloves should be changed per patient to prevent cross-contamination.

  • Ensure Disaster Kits (containing basic triage supplies, tags, etc.) are readily accessible.

7. Surge Capacity Management

• Strategies to manage the overwhelming demand for resources:

• 7.1 Staffing:

  • Activating Emergency Staffing Plans: Calling in off-duty staff, using call lists.

  • Cross-Training: Utilizing staff from different departments or specialties to assist where needed based on skills.

  • Volunteer Management: Coordinating credentialed and untrained volunteers effectively.

  • Identify personnel with specific skills (e.g., interpreters, mental health support).

• 7.2 Bed Management:

  • Expediting Discharge: Rapidly assess and discharge stable patients.

  • Creating Temporary Bedding Areas: Setting up treatment areas in non-traditional spaces (hallways, waiting rooms, conference rooms, etc.).

  • Transferring Patients: Transferring stable patients to other facilities if feasible and safe.

• 7.3 Resource Allocation:

  • Prioritizing Resources: Allocate limited medications, equipment, and supplies based on triage category and clinical need.

  • Inventory Management: Implement rapid systems for tracking and distributing available resources.

• 7.4 Pharmacy: Manage rapid dispensing and inventory of critical medications.

• 7.5 Lab and Blood Bank: Prioritize urgent testing and manage blood product inventory and distribution.

• 7.6 Other Operational Areas: Ensure key departments like ICU, OT, CSSD, Housekeeping, IT/Biomedical, Security, etc., are functioning efficiently under the HICS structure.

8. Staff Expectations

• All BCMCH staff members are part of the Code Yellow response plan.

• Staff are responsible for knowing the Code Yellow procedure and their potential role.

• Be prepared to be flexible and adaptable, potentially working outside of your usual role or area.

• Maintain a focus on time efficiency and effective communication.

• Prioritize your own safety and the safety of your colleagues.

9. Demobilization

• The demobilization process begins when the incident is under control and the immediate surge is managed. It involves systematically winding down the emergency response, accounting for personnel and resources, and returning to normal operations. This process should follow an established plan communicated clearly.

10. Training Details

• 10.1 Training Methods:

  • Interactive Lecture with Scenarios

  • Tabletop Simulation Exercises (Focus on Triage, Resource Allocation, Communication flow)

  • Review of BCMCH Code Yellow Policy and Procedures

  • Guest Speakers: Emergency Management Experts, experienced MCI responders (EMS, ED Physicians)

  • Q&A Session

• 10.2 Assessment:

  • Written Exam (Knowledge of Triage Principles, HICS structure, Code Yellow Activation, Surge Capacity Management strategies)

  • Participation and performance evaluation during Tabletop Simulation Exercises

  • Scenario-Based Analysis and Decision-Making exercises

• 10.3 Materials Needed:

  • Presentation Slides

  • Code Yellow Handouts (BCMCH Policy Summary, Triage Flowcharts/Algorithms, HICS Organization Chart example, Communication Plan overview, Resource Inventory checklists)

  • Tabletop Simulation Materials (Maps of the hospital, Patient Cards with injury descriptions, Resource Cards, Communication Logs)

  • Emergency Contact Lists for key personnel

  • Evaluation Forms

NOTE: Every disaster is unique and may not fit neatly into a textbook. Adaptability, decisive action, effective time management, and clear communication are paramount for an effective Code Yellow response. Team members should be quick to assess, ready to act, and follow the established command structure. 

Training Module: Code Brown (Blood/Body Fluids/Chemical Spillage)

Objective:
To equip all BCMCH staff with the knowledge and skills necessary to respond effectively and safely to incidents involving blood, body fluids, or chemical spills, minimizing the risk of exposure and ensuring proper cleanup and disposal procedures are followed.

1. Introduction to Code Brown

• 1.1 What is Code Brown?

  • Definition: Code Brown is the emergency code used to signal an uncontrolled blood, body fluid, or chemical spill within the BCMCH facility that requires immediate attention and specialized cleanup and decontamination procedures.

  • Scope: The Code Brown protocol applies to all areas of the hospital where spills may occur, including:

    • Patient Care Units

    • Laboratories

    • Operating Rooms

    • Radiology

    • Phlebotomy Areas

    • Public Areas (Restrooms, Waiting Areas)

    • Any other area within BCMCH.

  • Activation Criteria: Code Brown is typically activated for spills exceeding a specific size/quantity, such as:

    • Blood/Body Fluids: Spills larger than approximately 10 cm in diameter.

    • Chemicals: Spills larger than approximately 5 Liters or any spill posing a significant hazard. Note: Any chemical spill where the responder is unsure of the substance or safe cleanup requires immediate expert intervention regardless of size.

2. Understanding Hazards Associated with Spills

• 2.1 Bloodborne Pathogens:

  • Hepatitis B (HBV)

  • Hepatitis C (HCV)

  • Human Immunodeficiency Virus (HIV)

• 2.2 Other Infectious Agents (potentially found in body fluids):

  • Bacteria (e.g., Staphylococcus aureus, Escherichia coli)

  • Viruses (e.g., influenza, norovirus)

  • Fungi

  • Other potentially infectious materials.

• 2.3 Chemical Hazards:

  • Corrosives (acids, bases causing burns)

  • Toxic Substances (chemotherapy drugs, concentrated disinfectants, medications)

  • Flammable Liquids (alcohol, solvents posing fire risk)

  • Irritants (cleaning solutions causing skin/respiratory irritation)

  • Reactive Substances (chemicals that may react violently with air, water, or other substances)

• 2.4 Legal and Regulatory Factors:

  • Failure to properly manage spills can lead to violations of occupational safety regulations (e.g., OSHA), potentially resulting in fines or legal action against the hospital. Proper protocols protect the institution.

• 2.5 Health Factors & Potential Outcomes:

  • Direct exposure (skin contact, inhalation, ingestion, sharps injury) can lead to:

    • Infections (from bloodborne or other pathogens).

    • Chemical burns, irritation, or systemic toxicity.

    • Respiratory problems (from inhaling fumes).

  • Improper cleanup leaves residual hazards, posing risks to subsequent staff, patients, and visitors.

3. Spill Prevention Measures

• 3.1 Safe Handling Practices:

  • Use appropriate Personal Protective Equipment (PPE) consistently when handling blood, body fluids, or chemicals.

  • Handle containers carefully to prevent spills or leaks.

  • Never overfill waste containers.

  • Follow proper labeling and storage procedures for all substances.

• 3.2 Containment Strategies:

  • Use spill trays or secondary containment vessels when transporting or storing liquids, especially hazardous ones.

  • Store containers in designated, secure areas, ideally with spill containment features.

• 3.3 Training and Education:

  • Provide staff with comprehensive and recurring training on spill prevention and response procedures (Code Brown).

  • Ensure staff are aware of the potential hazards associated with specific blood, body fluids, and chemicals in their work area.

  • Know the location and proper use of spill kits.

• Important Note: Despite prevention efforts, spills can and will occur. Be prepared to follow the proper cleanup procedure safely and effectively.

4. Initial Response to a Spill

• 4.1 Immediate Actions:

  • If you witness or discover a spill:

    • Ensure Personal Safety: Do not approach if there is a risk of exposure to hazardous fumes, fire, or unknown chemicals. Leave the area immediately if the hazard is unknown or appears significant.

    • Evacuate Others: Alert people in the immediate vicinity of the spill to move away from the area.

    • Contain the Area: If safe to do so (and only for minor, known spills), attempt to contain the spill using available materials (e.g., blocking with absorbent pads).

    • Attend to Injured/Exposed Persons: If a person is injured or exposed, prioritize their immediate safety and care (e.g., flushing exposed skin/eyes with water).

• 4.2 When to Activate Code Brown:

  • Activate Code Brown if the spill meets the activation criteria (size/quantity) OR if you are unsure of the substance OR if you feel unsafe managing the spill on your own.

• 4.3 Steps for Activating Code Brown:

  • Dial 7070 from any BCMCH landline.

  • Announce Code Brown using the approved format:

    • "Code Brown, [Floor], [Department/Area], [Type of Spill - Blood, Body Fluid, Chemical - specify type if known], [Approximate Quantity/Size of Spill]" (repeated three times).

    • Example: "Code Brown, 4th Floor, Lab, Blood Spill, Approximately 20 centimeters."

    • Example: "Code Brown, 2nd Floor, Pharmacy, Chemical Spill, Unknown quantity, Strong Odor."

5. Roles and Responsibilities During Code Brown Response

• Various trained personnel respond to a Code Brown depending on the nature and location of the spill. Key personnel may include:

  • Safety Officer / Safety Committee Member: Provides expertise on chemical hazards, ensures proper protocols are followed, leads response for major chemical spills.

  • Infection Control (HIC) Officer / HIC Team: Provides expertise on bloodborne pathogens and other infectious risks, advises on disinfection protocols.

  • Security: Secures the area to prevent unauthorized entry and ensures safety perimeter is maintained.

  • Charge Nurse / Unit Supervisor: Manages the affected patient care area, ensures patient safety, directs staff in the immediate vicinity.

  • Housekeeping Supervisor / Housekeeping Staff: Trained housekeeping staff are often the primary responders for standard blood/body fluid spills following established protocols.

  • Engineering Department: May be needed for spills involving plumbing, structural issues, or specific chemical systems.

  • Chief Medical Officer / Administrator On-Call: Notified for significant incidents or policy decisions.

6. Spill Kit Contents and Location

• Spill kits contain the necessary materials for safe cleanup. They should be readily accessible, clearly labeled, and their locations known by all staff.

• 6.1 Typical Spill Kit Contents Include:

  • Personal Protective Equipment (PPE):

    • Disposable Gloves (multiple pairs, e.g., Nitrile)

    • Eye Protection (Goggles or Face Shield)

    • Fluid-Resistant Gown or Apron

    • Mask (especially for potential aerosols or fumes)

    • Disposable Shoe Covers

  • Containment and Absorbent Materials:

    • Absorbent Pads, Rolls, or "Pillows"

    • Granular Absorbent (for chemical spills)

    • Paper Towels (for minor spills)

  • Cleanup Tools:

    • Disposable Scoop and Scraper/Brush

    • Disposable Wipes

  • Disinfection/Neutralization Materials:

    • Appropriate Disinfectant Solution (e.g., pre-mixed bleach solution 1:10 or 1:100, EPA-approved hospital disinfectant).

    • Specific neutralizing agents for chemical spills (depends on potential chemicals in the area).

    • Sodium dichloroisocyanurate (NaDCC) tablets (e.g., Presept) to create bleach solution.

  • Waste Disposal:

    • Biohazard Waste Bags (Red Bags)

    • Heavy-Duty Plastic Bags (for double bagging)

    • Chemical Waste Containers (specific types depending on chemicals)

  • Other:

    • Warning Signs ("Spill Area - Do Not Enter")

    • Basic Instructions/Flowchart for Spill Cleanup

• 6.2 Spill Kit Locations: Kits are strategically placed in areas with higher risk of spills (e.g., Labs, ED, OR, high-traffic patient areas, areas storing chemicals).

7. Containment and Cleanup Procedures

• General Steps (After activating Code Brown if needed, and ensuring personal safety):

• 7.1 Donning PPE: Always put on the appropriate PPE before approaching the spill.

• 7.2 Containment: Stop the spread. Create a perimeter around the spill using absorbent materials, working from the outside edge inward. For chemicals, use appropriate absorbents (often granular) to diking the area.

• 7.3 Cleanup:

  • Blood/Body Fluid Spills:

    • Cover the spill completely with absorbent material to soak up the liquid.

    • Carefully scoop or wipe up the saturated absorbent material, working from the outer edges towards the center. Place waste directly into the biohazard bag.

    • Disinfect the contaminated area. Use an appropriate disinfectant solution (e.g., fresh 1:10 bleach solution or EPA-registered disinfectant). Apply disinfectant and allow the required contact time as per product instructions.

    • Wipe the disinfected area clean with disposable towels and place them in the biohazard bag.

    • Note on Blood Bank: The Blood Bank should follow specific National AIDS Control Organization (NACO) Guidelines, which often mandate using a 1% Sodium Hypochlorite solution as a disinfectant for blood spills.

  • Chemical Spills (Major or Unknown):

    • Do NOT attempt to clean unless specifically trained for that chemical.

    • Follow the steps in Section 4.1 (Ensure Safety, Evacuate, Contain area if possible).

    • Wait for the trained response team (Safety Officer, Security, potentially HazMat if external agency called).

    • Provide information about the chemical (if known) and location.

  • Chemical Spills (Minor, Known, Trained Staff):

    • If the spill is small (< 5L, manageable) and you are trained and have the correct chemical spill kit:

      • Wear appropriate PPE (may require specific chemical-resistant gloves/suit).

      • Use the correct absorbent or neutralizing agent for the specific chemical. Follow kit instructions.

      • Carefully scoop/clean up the material.

      • Place contaminated materials into designated chemical waste containers.

• 7.4 Waste Disposal:

  • Place all contaminated cleanup materials (absorbent pads, wipes, PPE) into appropriate waste containers.

  • Blood/Body Fluid cleanup waste goes into Biohazard Waste Bags (Red Bags). Double Bagging the biohazard waste is recommended for secure containment before transporting.

  • Chemical cleanup waste goes into designated Chemical Waste Containers, labeled appropriately as per safety protocols.

8. Reporting and Documentation

• 8.1 Reporting the Spill:

  • Report the spill incident promptly to your immediate supervisor, the Charge Nurse, or the Infection Control department.

  • For significant spills, ensure notification is made to the Safety Officer and relevant HICS personnel if Code Brown was activated.

• 8.2 Documentation:

  • Complete an incident report form for all spills requiring cleanup beyond routine housekeeping.

  • Documentation is crucial for safety, tracking incidents, identifying trends, and providing a legal record.

  • Document the date, time, location, and type of spill (substance if known).

  • Describe the estimated quantity or size of the spill.

  • Detail the cleanup procedures followed (who, what materials used, disinfection steps).

  • Document any potential exposures, injuries, or required medical follow-up for staff or others.

9. Legal and Ethical Considerations

• Adherence to Code Brown protocol is essential for meeting legal requirements related to occupational safety and hazardous materials handling.

• Ethically, staff have a responsibility to manage spills safely to protect themselves, colleagues, patients, and visitors from harm.

• Proper training and availability of resources are key to fulfilling these obligations.

10. Training Details

• 10.1 Training Methods:

  • Interactive Lecture with Real-Life Scenarios and Case Studies

  • Video Demonstrations of Spill Cleanup Procedures (Blood/Body Fluid and Chemical Examples)

  • Hands-on Practice with Spill Kits (All participants should practice donning PPE and using kit contents for simulated spills).

  • Review of BCMCH Code Brown Policy and Procedures, including specific chemical spill protocols relevant to the trainee's area.

  • Q&A Session with Infection Control and Safety Experts.

• 10.2 Assessment:

  • Written Exam (Knowledge of Hazards, Prevention, Initial Response, PPE Requirements, Cleanup Procedures, Waste Disposal, Reporting, Legal/Ethical Considerations).

  • Practical Assessment (Demonstration of proper PPE donning/doffing and simulated Spill Cleanup Demonstration using a spill kit). Assess:

    • "What are the spill and what needs to happen?" (Identification and initial plan)

    • "How would the situation be controlled in a safe manner?" (Execution of containment/cleanup steps safely).

  • Scenario-Based Simulation (Participants walk through response steps for different spill types).

  • Review of Completed Documentation forms from simulations.

• 10.3 Materials Needed:

  • Presentation Slides

  • Code Brown Handouts (BCMCH Policy Summary, PPE Guide, Waste Disposal Guidelines, Spill Kit Inventory Checklist, Contact List for Safety/IC/Security)

  • Spill Kits (Practice Kits containing simulated PPE, absorbent materials, bags, instructions)

  • Simulated Spill Materials (e.g., Colored Water for blood/body fluid; Flour or harmless powder for chemical simulation).

  • Biohazard Waste Containers (practice)

  • Chemical Waste Containers (practice, appropriately labeled)

  • Sample Incident Report Forms

  • Evaluation Forms 

Training Module: Code Indigo (Failure of Sterilization Process: Recall of Failed CSSD Items)

Objective:
To ensure BCMCH staff understands the protocols for identifying, reporting, and managing a failure in the sterilization process, leading to a potential recall of CSSD (Central Sterile Supply Department) items.

1. Introduction to Code Indigo

• 1.1 What is Code Indigo?

  • Definition: Code Indigo is the emergency code activated when a failure in the CSSD sterilization process is detected. This indicates that medical devices or instruments processed in a specific batch or using a specific method may not be sterile and could pose a risk of infection to patients.

  • Scope: The Code Indigo protocol applies to:

    • All areas of the hospital using sterile supplies processed by CSSD (Operating Rooms, Patient Care Units, Clinics, Emergency Department, etc.).

    • It involves a coordinated response primarily from CSSD, Infection Control, Operating Room staff, and all other user departments.

  • Activation Trigger: Code Indigo is typically activated when there is confirmation or strong suspicion of a sterilization failure in a batch of items, often indicated by:

    • Failure of external or internal chemical indicators.

    • Positive biological indicator test results.

    • Detection of excessive moisture within sterile packs after processing.

    • Equipment malfunction alarms related to the sterilization cycle.

2. Understanding the Sterilization Process and its Importance

• 2.1 Sterilization Methods Used at BCMCH: (Include details specific to your facility)

  • [Example: Steam Sterilization (Autoclave) - describe process, typical cycles]

  • [Example: Low-Temperature Sterilization (e.g., Ethylene Oxide, Hydrogen Peroxide Plasma) - describe process, specific uses]

  • [Example: Chemical Sterilization (e.g., Glutaraldehyde, Peracetic Acid) - describe process, specific uses]

  • Proper sterilization is critical to prevent Healthcare-Associated Infections (HAIs) by ensuring medical devices are free from all forms of microbial life, including highly resistant spores.

• 2.2 Sterilization Indicators (Chemical and Biological):

  • Chemical Indicators: These are placed inside and/or outside sterilization packages. They change color or form when exposed to specific parameters of the sterilization process (e.g., temperature, time, sterilant concentration). An external indicator confirms the package went through the process; an internal indicator confirms conditions were met inside the package. A failure to change color indicates a potential problem.

  • Biological Indicators (BIs): These are the most reliable indicators of sterilization effectiveness. BIs contain resistant bacterial spores. After processing, the BI is incubated. If no microbial growth occurs, it confirms the sterilization process successfully killed even the most resistant organisms. Positive growth indicates a sterilization failure.

• 2.3 Reasons for Sterilization Failures:

  • Equipment Malfunction (e.g., autoclave not reaching required temperature/pressure, sterilant concentration issues).

  • Operator Error (e.g., improper loading allowing air pockets, incorrect cycle settings, errors in packaging).

  • Packaging Issues (e.g., damaged packaging allowing recontamination, using incorrect packaging materials).

  • Contamination of instruments before sterilization (e.g., residual bioburden).

  • Exposure to excessive moisture during or after the cycle, which can compromise the sterile barrier.

3. Detection and Reporting of Sterilization Failures/Concerns

• 3.1 Recognizing a Potential Failure or Compromise:

  • Observing an incorrect color change on chemical indicators (internal or external) after a sterilization cycle.

  • Receiving a positive biological indicator test result from the lab.

  • Discovering damaged or compromised packaging on a sterile item (tears, punctures, seals broken).

  • Finding excessive moisture or water stains on or inside a sterile package.

  • Equipment malfunction alarms, error messages, or documented cycle parameters outside of the norm.

  • Expired sterile packages (shelf life exceeded).

• 3.2 Reporting a Suspected Failure or Compromise:

  • Any staff member who identifies a potentially non-sterile item or suspects a sterilization failure must immediately:

    • Quarantine the item(s) and any associated items from the same batch if known.

    • Clearly label the item(s) as "Suspected Non-Sterile - Do Not Use."

    • Immediately notify the CSSD supervisor or designated CSSD personnel.

    • Provide clear and concise information about the nature of the suspected failure (e.g., item name/lot number, type of indicator failure, moisture noted, specific equipment/cycle involved).

• 3.3 Important CSSD Practices for Detection & Prevention:

  • Thoroughly inspect items and packaging before and after sterilization.

  • Regularly maintain and monitor sterilization equipment.

  • Document everything accurately in the CSSD log, including cycle parameters, biological and chemical indicator results, batch numbers, and date/time.

  • Ensure external indicators and batch numbers are correctly applied and recorded for every load processed.

  • Implement procedures for removing damaged, outdated, or malfunctioning equipment promptly. This saves costs in the long run by preventing failures and ensuring reliable sterilization.

4. Activation of Code Indigo

• 4.1 When to Activate Code Indigo:

  • Code Indigo is formally activated by the CSSD Supervisor or designated authority upon confirmation of a sterilization failure (e.g., positive biological indicator, confirmed equipment malfunction impacting a batch).

  • It may also be activated based on strong suspicion when the scope of potentially affected items is significant, pending further investigation.

• 4.2 Steps for Activating Code Indigo:

  • The CSSD supervisor or designated personnel will initiate the Code Indigo activation.

  • Dial 7070 from any BCMCH landline.

  • Announce Code Indigo using the approved format:

    • "Code Indigo, [CSSD], [Affected Sterilization Method, e.g., Steam/EtO], [Affected Batch Number/Date of Sterilization or Timeframe], [Brief description, e.g., Sterilization Failure - Potential Recall of Items]" (repeated three times).

    • Example: "Code Indigo, CSSD, Steam Sterilization, Batch Number 12345 / Processed Yesterday, Potential Recall of OR Items."

5. Recall Procedures

• 5.1 Identifying Potentially Affected Items:

  • CSSD staff, using sterilization logs and distribution records, will review all items processed in the affected batch and identify where those items were distributed throughout the hospital.

  • CSSD will generate a comprehensive list of affected items, including item names, kit names, tray numbers, lot/batch numbers, date/time of sterilization, and the locations where they were sent.

• 5.2 Notifying User Departments:

  • CSSD, in urgent coordination with the Infection Control department and potentially hospital leadership, will immediately notify all departments that may have received the affected items.

  • Notification will include:

    • Clear statement of Code Indigo activation and the reason (sterilization failure).

    • Detailed list of affected items (names, batch numbers, relevant dates).

    • Clear instructions for identifying, locating, and retrieving the items.

    • Instructions on proper handling and quarantine of the items.

    • Contact information for CSSD, Infection Control, or a designated point person for questions.

• 5.3 Retrieving Potentially Affected Items:

  • User departments (OR, ICUs, Clinics, etc.), upon receiving the notification, will immediately and thoroughly search their sterile supply inventory (including storage areas, carts, procedure rooms) for the affected items based on the provided list and batch numbers.

  • All identified items must be immediately removed from shelves, quarantined, and placed in a designated container clearly labeled "Non-Sterile - Do Not Use - Code Indigo Recall."

  • Follow the BCMCH policy on managing and returning non-sterile items.

  • Items should be returned to CSSD following specific instructions provided during the recall notification.

6. Roles and Responsibilities During Code Indigo

• 6.1 CSSD Supervisor / Staff:

  • Detect sterilization failures through monitoring and testing.

  • Initiate Code Indigo activation procedures.

  • Identify and list potentially affected items and their distribution locations.

  • Notify user departments (often in collaboration with Infection Control/Leadership).

  • Coordinate the recall process and manage the return of items.

  • Quarantine returned items and determine appropriate reprocessing or disposal.

  • Conduct a thorough investigation into the cause of the sterilization failure.

  • Liaise with equipment manufacturers if malfunction is suspected.

  • Document all actions taken during the investigation and recall.

• 6.2 Infection Control (HIC) Team:

  • Collaborate with CSSD on the scope and potential risk of the failure.

  • Assist in notifying user departments and providing guidance.

  • Provide expertise on potential patient exposure risk and necessary follow-up.

  • Monitor for any potential infections related to the sterilization failure.

  • Assist in the investigation from an infection prevention perspective.

• 6.3 User Departments (Nursing Staff, OR Staff, Clinic Staff, etc.):

  • Be vigilant for signs of potentially non-sterile items during routine work.

  • Immediately report any suspected issues to CSSD and their supervisor.

  • Understand the Code Indigo activation process.

  • Upon notification of a Code Indigo recall, immediately cease use of affected items.

  • Thoroughly search inventory and identify all affected items based on the provided list.

  • Quarantine affected items securely.

  • Return items to CSSD following recall instructions.

  • Be mindful of the correct interpretation of external sterilization indicators and batch numbers during routine stock checks.

• 6.4 Hospital Leadership/Management:

  • Support CSSD and Infection Control during the recall.

  • Assist in high-level communication if needed.

  • Ensure resources are available for the recall and investigation.

  • Approve communication regarding patient notification if deemed necessary by clinical/infection control risk assessment.

  • Provide assistance in informing higher-level managers as needed.

7. Documentation

• Accurate and complete documentation is critical for tracking, investigation, and legal/regulatory purposes.

• All steps of the detection, reporting, activation, recall, and investigation process must be documented in relevant logs (CSSD logs, incident reports, recall logs).

• Details should include dates, times, batch numbers, specific items, locations, personnel involved, actions taken, and communication records.

8. Ethics and Patient Safety Considerations

• Prompt identification and recall of non-sterile items are ethical imperatives to protect patient safety and prevent infections.

• Transparency and thoroughness in the recall process build trust.

• Decisions regarding patient notification after potential exposure will be made based on a comprehensive risk assessment guided by Infection Control and clinical leadership, balancing patient safety with the need for accurate information.

9. Additional Considerations

• Training Scope: Ensure that training on Code Indigo covers all personnel who handle or could encounter sterile items processed by CSSD, not just CSSD staff.

• Checklist: Develop and utilize a clear checklist for Code Indigo activation and recall procedures to ensure all critical steps are followed systematically.

• Escalation: Establish clear guidelines on when and how to escalate issues related to sterilization failures or difficulties during a recall to higher levels of management or relevant experts.

10. Training Details

• 10.1 Training Methods:

  • Interactive Lecture with Case Studies focusing on real or simulated sterilization failure scenarios.

  • Visual Examples of Sterilization Indicators (correctly and incorrectly processed) and various packaging defects (tears, moisture).

  • Role-Playing Exercises (Practicing reporting a suspected failure to CSSD, Practicing identifying and retrieving recalled items in a simulated storage area).

  • Review of BCMCH Code Indigo Policy and Procedures.

  • Q&A Session with CSSD Supervisor, Infection Control Expert, and potentially OR Nurse Manager.

  • Discussion on how to effectively inform and involve higher-level managers if the situation escalates.

• 10.2 Assessment:

  • Written Exam (Knowledge of Sterilization Processes, types of indicators and their interpretation, common reasons for failure, Code Indigo Activation criteria and procedures, Recall steps, roles/responsibilities, documentation requirements).

  • Practical Assessment (Ability to identify a potentially non-sterile item based on indicators/packaging, Ability to follow steps for quarantining/returning recalled items in a simulated setting).

  • Scenario-Based Simulation (Respond to a described situation involving a potential failure or recall notice).

  • Review of Sample Documentation completed during practical exercises.

• 10.3 Materials Needed:

  • Presentation Slides

  • Code Indigo Handouts (BCMCH Policy Summary, Quick Reference Guide for Activation/Recall, Item Identification Guide with photos of indicator issues/packaging defects, Contact List for CSSD/IC/Management).

  • Examples of Sterilization Indicators (correct and incorrect results, labeled).

  • Examples of Damaged or Moist Packaging.

  • Sample Recall Notices used by BCMCH.

  • Simulated Sterile Items with various indicators/packaging issues and batch numbers for practical exercises.

  • Designated Containers and Labels for "Suspected Non-Sterile" and "Code Indigo Recall" items.

  • Sample CSSD Logs and Incident Report Forms.

  • Evaluation Forms. 

Training Module: Code Purple (Adult Patient Missing)

Objective:
To equip BCMCH staff with the knowledge and skills to effectively respond when an adult patient is determined to be missing, initiating a coordinated search effort and prioritizing the patient's safety and well-being.

1. Introduction to Code Purple

• 1.1 What is Code Purple?

  • Definition: Code Purple is the emergency code activated when an adult patient is determined to be missing from their assigned location within the BCMCH facility, and there is significant concern for their safety or well-being due to their medical, cognitive, or mental health status.

  • Scope: The Code Purple protocol requires a coordinated search effort and applies to all areas of the hospital, including:

    • Patient Care Units (all types: Medical, Surgical, Mental Health, Rehab, etc.)

    • Waiting Areas

    • Treatment Areas (e.g., Dialysis, Therapy)

    • Diagnostic Areas (e.g., Radiology, Lab)

    • External Grounds (including entrances, exits, loading docks, surrounding property)

    • Parking Lots

    • Public Areas (Cafeteria, Gift Shop, Chapel)

    • Any other area within BCMCH.

2. Understanding the Risks and Causes of Missing Adult Patients

• 2.1 Potential Causes of Patients Going Missing/Eloping:

  • Cognitive Impairment: Confusion, disorientation due to delirium, dementia, head injury, or stroke.

  • Intentional Elopement: Patient desires to leave against medical advice (AMA), sometimes without formally notifying staff. This might be due to:

    • Desire for cigarettes, personal items, or external environment.

    • Feeling confined or anxious.

    • Misunderstanding their medical status or need for care.

  • 
    

  • Mental Health Crisis: Suicidal ideation, psychosis (delusions, hallucinations), panic attacks, or extreme agitation leading to impulsive departure.

  • Medication Effects: Adverse drug reactions causing confusion, restlessness, or impaired judgment.

  • Accidental Disorientation: Patients simply getting lost within the large facility structure.

  • Physical Limitations/Disability: Patients attempting to navigate the facility despite physical challenges, leading to falls or getting stuck.

  • Stress/Anxiety: Feeling overwhelmed by the hospital environment.

• 2.2 Risk Factors for Patients Going Missing:

  • Documented history of elopement attempts.

  • Cognitive impairment (diagnosis of dementia, delirium assessment positive).

  • Mental health diagnoses, especially with symptoms like agitation, paranoia, or suicidal thoughts.

  • Impaired judgment.

  • Lack of insight into their medical condition or need for hospitalization.

  • Recent medication changes or initiation of psychoactive drugs.

  • Advanced age, especially when combined with cognitive issues.

  • Language barriers or communication difficulties.

  • Lack of consistent family/caregiver presence or support.

  • Patients who are overly mobile and unsupervised.

  • Patients expressing a strong desire to leave.

• 2.3 Potential Negative Outcomes:

  • Harm to the patient (injury from falls, exposure to weather, inability to access necessary medical care or medication).

  • Increased medical complications or death.

  • Risk to public safety if the patient is disoriented or experiencing a mental health crisis outside the facility.

  • Significant distress for family and staff.

  • Legal and regulatory consequences for the hospital.

3. Initial Actions and Assessment (Before Code Activation)

• Key Principle: If a patient is not in their expected location, staff must immediately assess the situation and conduct a rapid initial search before activating the code if criteria are met.

• 3.1 Immediate Actions by Staff:

  • Check the Patient's Immediate Area: Look thoroughly in the patient's room (including closets, bathroom, under the bed) and the immediate surrounding area (hallway).

  • Inquire with Others: Ask other staff members in the area (nurses, physicians, CNAs, housekeepers, visitors) if they have seen the patient and note the last known time and location.

  • Review the Patient's Chart: Look for known risk factors for elopement, cognitive status, current medications, mobility level, and baseline behavior. Note their admitting diagnosis.

  • Attempt Contact with Family/Caregiver: Contact the patient's family or designated caregiver to inquire if they have heard from the patient or if the patient mentioned leaving. Gather essential identifying information and a recent photo if possible.

  • Gather Patient Identification Details: Obtain an accurate physical description of the patient, including:

    • Full Name and Medical Record Number

    • Age, Gender, Race

    • Height, Weight, Build

    • Hair Color, Eye Color

    • Clothing Last Worn (description and color are crucial)

    • Any distinguishing features (tattoos, scars, glasses, wheelchair/walker, specific gait, jewelry).

  • Check Nearby Common Areas: Briefly check obvious nearby locations like the unit's lounge, nourishment room, or quiet areas.

4. Activating Code Purple

• 4.1 When to Activate Code Purple:

  • After a thorough search of the patient's room, immediate unit area, and nearby common areas has been conducted, and the patient cannot be located.

  • When there is concern for the patient's safety due to their medical condition, cognitive status, mental health, or length of time missing.

  • When the patient has been missing for a predetermined amount of time (e.g., 15-30 minutes, as defined by BCMCH policy) after the initial check, regardless of perceived risk factors. Follow BCMCH policy strictly regarding activation criteria and timing.

• 4.2 Steps for Activating Code Purple:

  • Dial 7070 from any BCMCH landline.

  • Announce Code Purple using the approved format:

    • "Code Purple, [Floor], [Department/Area], [Patient Name], [Patient Description - key features like clothing, mobility aids]" (repeated three times).

    • Example: "Code Purple, 5th Floor, South Wing, Patient John Smith, Male, wearing blue pajamas, possibly using a walker."

  • Provide the description to the BCMCH operator and be prepared to provide it to responding personnel. This announcement alerts all hospital staff to be on the lookout.

5. Search Procedures

• Key Principle: The search must be systematic, expanding outwards from the last known location. All staff members are potentially involved in searching their areas.

• 5.1 Initial Search Area (Immediate Response):

  • Patient's room and adjacent rooms (if appropriate and safe).

  • Unit hallways, lounges, bathrooms, nourishment rooms.

  • Unit's stairwells (check landings on floors immediately above/below) and elevators.

  • Nearby common areas like waiting rooms, visitor lounges, cafeteria, gift shop, chapel.

  • Designated "safe spots" or known patient wandering areas.

• 5.2 Expanding the Search Area (Coordinated Response):

  • All internal hospital areas, methodically searching assigned zones.

  • Unused or Less-Frequently Visited Areas (storage rooms, mechanical rooms, basement areas, unoccupied clinical spaces - exercise caution, these can be unsafe).

  • External Grounds (hospital entrances, exits, loading docks, gardens, smoking areas).

  • Parking Lots.

  • Review CCTV footage from areas near the patient's room and potential exit points to identify the patient's direction and time of departure. This is a crucial and effective strategy led by Security.

  • Coordinate with Security to monitor entrances and exits.

• 5.3 Search Management:

  • Assign specific zones or areas to search teams or individuals to ensure no area is missed. A "Code Search Checklist" outlining areas to check can be helpful.

  • Follow the BCMCH policy checklist for systematic search procedures.

  • Check areas that match potential patient motivations (e.g., smoking areas if the patient is a smoker).

  • Maintain communication throughout the search regarding areas cleared and any findings.

6. Communication and Documentation

• 6.1 Communication Channels:

  • Utilize clear and consistent communication channels (overhead paging for initial alert, internal phone calls, radios, potentially designated runners) to keep all involved parties informed of the search progress and any sightings.

  • A designated communication hub or lead (often within Security or Nursing supervision) helps coordinate information flow.

• 6.2 Communication with External Agencies: Security typically liaises with local law enforcement if the patient cannot be found after an extensive internal/external search and there is ongoing concern for their safety, following BCMCH policy.

• 6.3 Communication with Family/Caregivers: Keep the patient's family or designated caregiver informed about the situation and the search efforts throughout the process. This should be done with sensitivity and empathy.

• 6.4 Required Documentation: Accurate and timely documentation is critical.

  • Patient Name and Medical Record Number.

  • Date and Time the Patient Was Last Seen (most accurate possible).

  • Location the Patient Was Last Seen.

  • Detailed Description of the Patient's Appearance, Clothing Last Worn, and Any Distinguishing Features.

  • Risk factors identified in the chart.

  • Date and Time Code Purple was Activated.

  • Areas Searched and by Whom.

  • Time the Patient Was Found (if applicable).

  • Location and Condition when Found.

  • Interventions taken.

  • Contact Information for Family/Caregivers and Law Enforcement (if involved).

  • Legal Confirmation & Proof: Thorough, accurate, and timely documentation serves as crucial legal proof that the hospital followed its established procedures to ensure patient safety. The role of Security in documenting search efforts and CCTV review is vital.

7. Roles and Responsibilities During Code Purple

• 7.1 Nursing Staff (Unit Staff):

  • Recognize the patient and their baseline behaviors, cognitive status, and risk factors.

  • Initiate immediate check of the patient's area and interview others.

  • Gather patient identification information and description.

  • Activate Code Purple if criteria are met.

  • Participate actively in the search of their assigned area and be prepared to assist in expanded search efforts as directed.

  • Communicate findings or lack thereof during the search.

  • Document initial assessment, actions taken, and participation in the search.

  • Ensure staff maintain vigilance and are present/aware during visits, especially with high-risk patients, to mitigate elopement opportunities. Staff should avoid leaving high-risk patients unattended with visitors if there's any concern.

• 7.2 Security Personnel:

  • Primary lead for coordinating and managing the comprehensive search efforts.

  • Monitor and potentially secure hospital entrances and exits as needed.

  • Review CCTV footage to track patient movement.

  • Liaise and communicate directly with local law enforcement if necessary, following BCMCH policy.

  • Ensure legal and safety perimeters are maintained during the search.

  • Crucial and indispensable role in Code Purple response.

• 7.3 Administrative Staff (Leadership/Management):

  • Support the search efforts by ensuring resources and communication channels are available.

  • Manage communication with media and external agencies (often the designated Public Information Officer).

  • Provide administrative support for documentation and follow-up.

  • Support the Incident Command System (HICS) structure if a larger emergency response is needed.

• 7.4 Other Staff (All BCMCH Personnel):

  • Be aware of the Code Purple announcement.

  • Be observant in your work area for the missing patient based on the description provided.

  • Immediately report any sighting or potential sighting to the designated contact (Security, Charge Nurse).

  • Follow directions from Security or leadership regarding search participation in your area.

• 7.5 Procedure Upon Finding the Patient:

  • Immediately assess the patient's condition and safety.

  • Provide any necessary immediate medical aid or comfort.

  • Notify the Charge Nurse/Supervisor, Security, and Attending Physician immediately of the patient's location and condition.

  • If the patient is deceased, follow established BCMCH procedures for handling a deceased person, notifying the Medical Officer on Call, Security, and adhering to all legal and procedural requirements with sensitivity.

8. Additional Considerations

• Universal Staff Training: Ensure all personnel working within BCMCH receive training on recognizing Code Purple, knowing their basic responsibilities, being observant, and how to report a sighting.

• Risk Assessment: Implement and utilize a standardized risk assessment tool for elopement upon patient admission and throughout their stay, updating as condition changes.

• Patient Identification: Encourage patients (if able) to wear hospital identification bands clearly.

• Environmental Controls: Review physical layout and consider security measures at exits if elopement is a frequent concern in specific areas. Ensure easy access points are known for searchers, but controlled for patient egress.

• Regular Drills: Conduct regular mock Code Purple drills to practice response procedures, communication, and search coordination.

• Collaboration with Law Enforcement: Understand the specific protocols and triggers for involving external law enforcement in the search for a missing patient.

9. Training Details

• 9.1 Training Methods:

  • Interactive Lecture with Case Studies examining real-life missing patient scenarios.

  • Video Demonstrations focusing on initial unit checks, communication during a search, and interactions with family/responders.

  • Role-Playing Exercises (Practicing initial assessment, calling Code Purple, interacting with a potential eloper if safe/appropriate, communicating with a distressed family member).

  • Tabletop Search Exercise using a map of BCMCH to plan and simulate search zones and reporting.

  • Review of BCMCH Code Purple Policy and Procedures in detail.

  • Q&A Session with Security personnel, Nursing Leadership, and potentially a Mental Health professional.

• 9.2 Assessment:

  • Written Exam (Knowledge of Code Purple definition/scope, Risk Factors/Causes of elopement, Initial Actions, Activation Criteria/Procedure, Search Techniques, Communication Requirements, Documentation Requirements).

  • Practical Assessment (Role-Playing performance in simulating initial response and/or communication during a Code Purple).

  • Scenario-Based Simulation (Responding to a described missing patient scenario, including identifying necessary actions and communication steps).

• 9.3 Materials Needed:

  • Presentation Slides

  • Code Purple Handouts (BCMCH Policy Summary, Risk Assessment Checklist example, Search Checklist/Zone Map example, Communication Plan overview, Contact List for Security/Leadership)

  • Map of BCMCH for Tabletop Exercise

  • Scenario Cards for Role-Playing and Simulation (including patient descriptions and risk factors).

  • Evaluation Forms.

Training Module: Code Green (Recall of Medications)

Objective:
To ensure BCMCH staff understands how to identify, manage, and implement a medication recall to prevent patient harm.

1. Introduction to Code Green

• 1.1 What is Code Green?

  • Definition: Code Green is the emergency code used to signal that a specific medication product has been recalled. A medication recall is the removal of a drug from the market due to safety issues, identified defects (quality issues), or regulatory violations. The recall can be initiated by the manufacturer, the FDA (or equivalent regulatory body), or internally by the hospital if a local issue is identified.

  • Scope: The Code Green protocol applies to all areas of the hospital where medications are stored, handled, or administered, including but not limited to:

    • Pharmacy (Central and Satellite locations)

    • Patient Care Units (all units)

    • Operating Rooms

    • Emergency Department

    • Clinics (Inpatient and Outpatient)

    • Any medication storage area (medication rooms, carts, automated dispensing cabinets, patient rooms).

2. Understanding Medication Recalls

• 2.1 Types of Medication Recalls (Based on Severity - FDA Classification):

  • Class I: The most serious type. A situation where there is a reasonable probability that using or being exposed to the recalled product will cause serious adverse health consequences or death.

  • Class II: A situation where using or being exposed to the recalled product may cause temporary or medically reversible adverse health consequences, or where the probability of serious adverse health consequences is remote.

  • Class III: The least serious type. A situation where using or being exposed to the recalled product is not likely to cause adverse health consequences.

  • Note: BCMCH may also issue internal "recalls" or alerts for locally identified quality issues, which would follow a similar protocol.

• 2.2 Reasons for Recalls:

  • Manufacturing Defects (e.g., incorrect tablet shape, foreign particles).

  • Contamination (e.g., microbial contamination, cross-contamination with other drugs).

  • Incorrect Labeling (e.g., wrong drug name, strength, or instructions on the label).

  • Incorrect Strength or Potency (too high, too low, or inconsistent).

  • Lack of Sterility (for injectable or sterile products).

  • Packaging Defects compromising integrity.

  • Regulatory Violations (failure to meet manufacturing standards).

  • Stability Issues (product degrades too quickly).

  • Discovery of serious adverse events linked to the product after market release.

3. Notification of Code Green Activation

• Key Principle: Rapid and clear notification is essential to stop the use of the recalled medication as quickly as possible.

• 3.1 How Notification Works:

  • Upon receiving notification of a recall (external source like manufacturer/FDA, or internal detection), the Head of Pharmacy and/or Medication Safety Officer will initiate the Code Green protocol.

  • An overhead announcement Code Green will be made via the 7070 system following the approved format.

  • Detailed information about the recalled medication will be circulated electronically via the hospital intranet, email, and potentially internal messaging systems (like the Electronic Health Record - EHR) by the Pharmacy or Medication Safety Officer.

  • This detailed notice will include:

    • Medication Name (Generic and Brand)

    • Dosage Form and Strength

    • Specific Lot Number(s) affected

    • Expiration Date(s) of affected lot(s)

    • Reason for the Recall (briefly, e.g., "Potential Contamination," "Incorrect Strength")

    • Severity of the Recall (Class I, II, or III)

    • Instructions for identifying, quarantining, and returning the medication.

    • Contact information for questions (Pharmacy).

• 3.2 Alerting Key Staff: Key staff, including nursing supervisors, unit managers, physician leads, and hospital administration ("higher ups"), will be made aware of the Code Green activation through designated communication channels.

4. Pharmacy Procedures

• Primary Responding Team: Head of Pharmacy, Medication Safety Officer.

• Secondary Responding Team: Clinical Pharmacists, Pharmacy Staff (Technicians, Pharmacists), Quality Personnel.

• 4.1 Actions by Pharmacy Staff:

  • Immediately remove all vials, packages, or doses of the recalled medication (matching the specific lot number(s)) from active inventory shelves in the main pharmacy and any satellite pharmacies.

  • Immediately remove all doses of the recalled medication (matching the specific lot number(s)) from automated dispensing machines (e.g., Pyxis, Omnicell) throughout the hospital. This is often a critical and rapid step.

  • Search other potential storage locations within Pharmacy (refrigerators, controlled substance storage, return bins).

  • Securely quarantine all identified recalled medication in a designated, separate area clearly labeled "RECALLED - DO NOT USE."

  • Prepare return documentation for the manufacturer or follow disposal protocols as instructed by the recall notice and BCMCH policy.

  • Ensure all pharmacy team members work efficiently and collaboratively to ensure rapid removal of affected stock and maintain overall patient safety.

5. Nursing Unit and Department Procedures

• Key Staff Involved: Charge Nurses, Staff Nurses, Physicians, Respiratory Therapists, other staff who handle medications on the unit/in the department.

• 5.1 Identifying and Removing Recalled Medications:

  • Upon notification of Code Green, staff on units and in departments (OR, ED, Clinics, etc.) must immediately review all medication storage areas within their area for the recalled medication product matching the specific details (name, strength, lot number, expiration date).

  • Check medication carts, automated dispensing machines (even though Pharmacy will also remove), patient-specific bins or drawers, supply closets, and refrigerators.

  • Immediately remove any recalled medication identified from active use or storage.

  • Securely quarantine the identified recalled medication in a designated location on the unit, clearly labeled "RECALLED - DO NOT USE," separate from active medications.

  • Follow instructions provided in the recall notice and by Pharmacy/BCMCH policy for comparing stock on hand to the recalled product details and arranging for the return of the recalled medication to the Pharmacy.

6. Communication and Documentation

• 6.1 Communication:

  • Communication must flow clearly from Pharmacy to all affected areas regarding the recall details and necessary actions.

  • Units must communicate back to Pharmacy regarding any recalled stock found and returned.

  • Communication regarding potential patient exposure or harm must be coordinated through Pharmacy, Attending Physicians, Clinical Pharmacists, and potentially Risk Management/Quality.

  • If a Class I recall occurs, a process for identifying patients who may have received the affected lot and notifying their physicians for assessment and potential patient communication will be initiated, often led by Pharmacy/Medication Safety/Risk Management.

• 6.2 Documentation:

  • Thorough and accurate documentation of the Code Green response is crucial for safety, quality improvement, and legal/regulatory compliance.

  • Pharmacy must document: Source of recall notification, time of Code Green activation, details of the recalled product, lot numbers affected, areas notified, quantities of recalled medication located and quarantined from all areas (Pharmacy and Units), return/disposal details, and any patient impact assessment undertaken.

  • Nursing units/departments must document: Time of notification, areas searched, any recalled medication found (name, strength, lot #, quantity), where it was found, and confirmation of quarantine/return to Pharmacy.

  • The audit log from automated dispensing machines (e.g., Pyxis) is a key tool for Pharmacy to identify where recalled medication lots were dispensed, which helps in assessing potential patient exposure. This log must be reviewed as part of the process.

  • An incident report may be required depending on the recall class and potential for patient harm.

  • This documentation is important and crucial for safety and legal standing.

7. Roles and Responsibilities During Code Green

• Head of Pharmacy / Medication Safety Officer: Initiate Code Green, issue notifications, lead the recall process investigation, coordinate with external entities (manufacturer), oversee stock removal and patient impact assessment.

• Pharmacy Staff (Pharmacists, Technicians): Execute rapid removal of recalled stock from Pharmacy and automated dispensing machines, manage quarantined stock, assist with unit support, participate in patient impact assessment under supervision.

• Clinical Pharmacists: Assist in assessing potential patient impact based on dispensed medication data, provide clinical guidance related to the recall.

• Quality / Risk Management: Provide oversight, assist with investigation, manage regulatory reporting, support patient communication decisions if necessary.

• Nursing Staff / Unit Personnel: Be aware of Code Green, identify and remove recalled medication from unit areas, quarantine stock, notify Pharmacy of findings, participate in patient monitoring as directed.

• All Staff: Be aware of the Code Green system, report any sighting of the recalled medication to Pharmacy or supervisor immediately.

8. Key Principles for an Effective Code Green

• Quality and Safety are Paramount: The entire process is driven by the need to protect patient safety and ensure the quality of medications used.

• Speed is Critical: The faster the recalled medication is identified and removed from use, the lower the risk of patient harm.

• Teamwork: Effective Code Green response relies on seamless collaboration between Pharmacy, Nursing, and all other hospital departments. Ensure all team members work well together.

• Accuracy: Correctly identifying the specific medication and lot number(s) is vital to avoid removing unaffected stock or missing affected stock.

• Documentation: Thorough documentation supports the safety process, investigation, and compliance. Utilize tools like automated dispensing system audit logs.

• Control: The process is designed to bring a potentially hazardous situation under control by removing the risk factor (the recalled medication). Training is to make sure that things will be under control.

9. Training Details

• 9.1 Training Methods:

  • Interactive Lectures with Case Studies discussing examples of past medication recalls and their impact.

  • Discussions on the best methods to efficiently search medication storage areas and identify specific lot numbers.

  • Review of BCMCH Code Green Policy and Procedures.

  • Practical exercises or demonstrations on how to read medication labels, identify lot numbers, and simulate searching a medication cart/storage area for a recalled product.

  • Review of sample recall notices and the information they contain.

  • Q&A Session with Head of Pharmacy, Medication Safety Officer, or Clinical Pharmacist.

  • Training should contain what is needed to make a code green effective by focusing on recognition, communication, searching, and documentation.

• 9.2 Assessment:

  • Written Exam (Knowledge of Code Green definition/scope, Recall Classes/Reasons, Notification Procedure, Roles/Responsibilities, Importance of Lot Numbers/Expiration Dates, Documentation Requirements).

  • Practical Assessment (Ability to correctly identify a specific medication by lot number from a selection of similar-looking medications, Demonstration of searching a simulated medication storage area, Correctly filling out sample documentation regarding found recalled medication).

  • Review of Sample Documentation: Assessment includes evaluating documentation quality and accuracy (checking for completeness, correct product/lot number, location, time). The use of audit logs from automated dispensing systems can also be discussed/assessed conceptually.

• 9.3 Materials Needed:

  • Presentation Slides

  • Code Green Handouts (BCMCH Policy Summary, Quick Reference Guide for Activation/Response, Sample Recall Notice template/examples, Medication Label reading guide focusing on lot/exp date, Contact List for Pharmacy/Medication Safety).

  • Sample Medication Packaging/Labels (with various names, strengths, lot numbers for identification exercises).

  • Simulated Medication Storage Area (cart, shelves) for practical search exercises.

  • Sample Documentation Forms (Recall Log, Unit Search Checklist).

  • Evaluation Forms. 

Training Module 4: Code Clear Procedures

Objective:
To ensure all BCMCH staff understand the proper procedures for announcing the "all clear" signal after an emergency has been resolved. This signals the return to normal operations, minimizes confusion, and prevents unnecessary anxiety.

1. What is a Code Clear and Why is it Important?

• Definition: A Code Clear is a specific announcement used to signal that the emergency situation associated with a previously activated emergency code (e.g., Code Red, Code White, Code Yellow) has been resolved, and it is safe for staff, patients, and visitors to return to normal activities and operations in the affected area or throughout the hospital, as appropriate.

• Importance:

  • Prevents Unnecessary Anxiety: Reassures patients, visitors, and staff that the immediate threat or crisis is over.

  • Avoids Confusion: Provides a definitive signal that the emergency response can stand down, clearing up uncertainty about the situation's status.

  • Allows Return to Normalcy: Enables staff to safely resume their regular duties and allows hospital operations to return to their normal state.

  • Prevents Resource Misallocation: Frees up staff and resources that were dedicated to the emergency response, making them available for routine care and operations.

  • Important Note: Following a Code Clear, it is expected that the environment should transition back to a state where all should be calm and orderly.

2. Who Can Authorize a Code Clear?

• Authorizing a Code Clear is a significant responsibility and is restricted to designated individuals within the hospital's emergency response structure. It signifies a high-level decision that the situation is definitively safe.

• This responsibility typically falls to individuals holding authority within the established Incident Command System (ICS) or BCMCH Emergency Management Plan for that specific type of incident. Authorized personnel may include:

  • The Incident Commander for the specific event (often the highest-ranking authority responding).

  • The Security Supervisor or Director of Security (especially for security-related codes like White or Purple).

  • The Nursing Supervisor or Administrator On-Call (especially for patient-related codes like Code Purple or Grey, or initial site control for others).

  • The Physician in Charge of the immediate response (e.g., ED Physician during Code Stroke, Psychiatrist during Code Grey).

  • It is the highest authorized individual or the designated authority for that specific emergency response who can call a Code Clear out.

3. The Code Clear Announcement Procedure

• Key Principle: The Code Clear announcement must be clear, concise, and follow the standard hospital procedure to be universally recognized. It directly relates back to the code that was initially activated.

• 3.1 How to Announce Code Clear:

  • Use the standard hospital emergency communication system.

  • Dial 7070 from any BCMCH landline.

  • State the "Code Clear" announcement clearly, identifying the original code that is now clear and, if necessary, the area where it occurred (though often Code Clear is hospital-wide unless specified).

  • Announce using the approved format:

    • "Code Clear, Code [Original Code Name, e.g., Red, White, Purple], Code Clear, Code [Original Code Name], Code Clear, Code [Original Code Name]."

    • Example: "Code Clear, Code Red, Code Clear, Code Red, Code Clear, Code Red."

    • If the emergency was confined to a specific area and the Code Clear is only for that area (check policy), the announcement might include the area, but this must be clearly defined in BCMCH policy.

4. Considerations Before Announcing Code Clear

• Declaring a Code Clear prematurely can be dangerous. The authorized individual must ensure several conditions are met before making the announcement.

• Has the Emergency Truly Ended? The immediate threat or crisis must be fully resolved.

  • (For Code Red/Fire): Fire is out, smoke is dissipated, area is safe to re-enter.

  • (For Code White/Physical Assault): Aggressive individual is contained, removed, or calmed; no immediate threat remains.

  • (For Code Purple/Missing Patient): Patient has been located, assessed, and is safely returned to care.

  • (For Code Yellow/MCI): The immediate surge of patients is managed, the HICS structure is standing down key response phases, and hospital capacity is returning to manageable levels.

  • (For Code Brown/Spill): The spill has been fully contained, cleaned, and decontaminated according to protocol.

  • (For Code Indigo/Recall): The affected items have been successfully recalled and quarantined from all potential use areas.

• Is the Area Safe? The affected area must be assessed and declared safe for re-entry by authorized personnel (e.g., Fire Department, Security, Safety Officer, Clinical Lead).

• Has Any Important Information Been Communicated? Ensure that all critical information regarding the resolution, any remaining precautions, or follow-up actions has been shared with the response teams and affected staff.

• Patient Safety and Well-being: Confirm the safety and well-being of patients involved or affected by the emergency.

  • Is the patient (if applicable, e.g., Code Purple, Code White incident patient) in good condition and safe?

  • Has necessary medical or psychological care been provided?

• Handover and Follow-up: If a specific patient incident led to the code, ensure that a proper handover of care is completed and the next steps for their care, monitoring, or security are clearly established. Is there the next person who can take over responsibility for the patient/situation?

• Documentation Initiated: While full documentation takes time, ensure the process for official incident reporting has been initiated by the appropriate personnel. Was initial documentation signed off?

• Resource Assessment: Confirm that resources used during the emergency (e.g., equipment from crash carts, spill kits) are being restocked or accounted for.

5. Post-Code Clear Actions

• The "all clear" doesn't mean work stops entirely. Several steps follow the announcement:

  • Return to Normal Operations: Staff return to their regular duties. Patients and visitors can move freely within safe areas.

  • Accountability: Ensure all staff involved in the response are accounted for and return to their assigned areas or check out if off-duty.

  • Restock Resources: CSSD, Pharmacy, Nursing units, etc., restock any supplies or equipment used during the emergency response (e.g., crash carts, spill kits, emergency medications).

  • Documentation Completion: Full incident reporting and documentation must be completed by all relevant staff according to BCMCH policy. This includes documenting the Code Clear time.

  • Debriefing: Conduct formal or informal debriefings among the response team and affected staff to review the event, identify lessons learned, recognize successes, and address any emotional impact. This is crucial for finding out who to get feedback from and improving future responses.

  • Equipment Review: Any equipment potentially damaged or involved in the incident is inspected and repaired or replaced.

  • Follow-up: Implement any necessary follow-up actions identified during the response or debriefing, such as changes to policy, additional training, or maintenance.

  • Support for Staff: Acknowledge that emergency responses can be stressful. Ensure staff know where to access support services if needed. Revisit all the things to find out who to get support from if needed. Looking after each other post-event is important.

  • Safety Remains Priority: Even though the immediate emergency is over, maintaining a safe environment for patients, staff, and visitors remains the number one important thing. Be aware of any residual hazards or emotional aftermath.

6. Training Details

• 6.1 Training Methods:

  • Interactive Lecture explaining the Code Clear concept, authorization, and procedure.

  • Discussion of Real-Life Examples or scenarios where Codes were cleared effectively or ineffectively.

  • Review of BCMCH Code Clear Policy and Procedures.

  • Discussion on the best procedure to follow after a Code Clear announcement, focusing on debriefing and follow-up.

• 6.2 Assessment:

  • Written Exam (Knowledge of Code Clear definition, who authorizes it, the announcement procedure, key considerations before announcing, and post-clear actions).

  • Mock Role-Playing (Participants practice announcing a Code Clear over a simulated system, or role-play the decision-making process leading to a Code Clear announcement).

  • Scenario-Based Simulation (Respond to a scenario where a code is resolving and determine if/when a Code Clear is appropriate and how to announce it). Assessment emphasizes that it should only be announced by the authority.

• 6.3 Materials Needed:

  • Presentation Slides.

  • Code Clear Handouts (BCMCH Policy Summary, Quick Reference Card for Code Clear Announcement Format, Checklist for Considerations Before Announcing Code Clear, Basic Post-Clear Steps).

  • Visual Aides showing the hospital communication system (if applicable for demonstration).

  • Scenario Cards for simulation/role-playing.

  • Evaluation Forms.

  • The procedure steps documented in handouts. 

Training Module 5: Patient Identification

Objective:

1. Why is Accurate Patient Identification Crucial?

• Accurate patient identification is the single most critical step in preventing medical errors and ensuring patient safety. It is the foundation upon which all safe patient care is built.

• 1.1 Preventing Medical Errors: Misidentification can lead to severe consequences, including:

  • Medication Errors: Administering the wrong medication, wrong dose, or wrong route to the wrong patient.

  • Transfusion Errors: Transfusing incompatible blood or blood products to the wrong patient, potentially causing life-threatening reactions.

  • Surgical Errors: Performing surgery on the wrong patient, wrong body part, or wrong side.

  • Diagnostic Errors: Performing tests (lab, imaging) on the wrong patient, resulting in inaccurate results, delayed diagnosis, or inappropriate treatment for both the misidentified patient and the correct patien

• 1.2 Ensuring Patient Safety: Accurate identification directly protects the patient from receiving inappropriate care or treatment.

• 1.3 Regulatory Compliance and Accreditation: Adherence to strict patient identification protocols is a fundamental requirement set by regulatory bodies and for hospital accreditation. Failure to comply can result in sanctions.

• 1.4 Legal Considerations: Failure to follow proper patient identification procedures that results in patient harm can have significant legal consequences for the staff involved and the hospital. Legal action may occur if patient safety protocols are not followed.

2. BCMCH Patient Identification Policy and Procedures

• Key Principle: Patient identity must be verified using at least two (and at BCMCH, we use three specific identifiers) before any procedure, treatment, or administration of medication/blood products. This is a non-negotiable safety step.

• 2.1 The Three Acceptable BCMCH Patient Identifiers:
  To ensure accuracy, BCMCH policy mandates the use of three specific identifiers. These are:

  • Full Name of the Patient

  • UHID Number (Unique Hospital Identification Number)

  • Date of Birth and/or Address (Clarification: While the user input listed Date of Birth and/or Address, standard practice and likely BCMCH policy uses Full Name, UHID/MRN, and Date of Birth as the primary three. If Address is the third BCMCH identifier, state it clearly. Assuming Name, UHID, DOB are standard, we will proceed with that structure as most likely BCMCH policy)

• 2.2 When to Verify Patient Identity: Patient identity must be verified using the three acceptable identifiers immediately before:

  • Medication Administration (including IV fluids and parental nutrition)

  • Blood and Blood Product Transfusion

  • Specimen Collection (Blood, Urine, Tissue, etc.)

  • Diagnostic Testing (X-ray, CT Scan, MRI, ECG, etc.)

  • Treatment Administration (e.g., therapy, wound care, respiratory treatments)

  • Initiating or Modifying Intravenous Lines or Infusions

  • Surgical or Invasive Procedures

  • Transferring a Patient to Another Area

  • Any Procedure or intervention where misidentification can cause harm.

• 2.3 Steps for Verifying Patient Identity:

  • Step 1: Ask the Patient

    • Whenever possible, directly ask the patient to state their full name and date of birth. Do not ask yes/no questions like "Are you John Smith?"

  • Step 2: Compare with Identification Band

    • Compare the information stated by the patient with the information on their patient identification band. Ensure the identification band is present, legible, and securely attached.

  • Step 3: Compare with Medical Record/Order

    • Compare the information stated by the patient and on the identification band with the information on the medication order, treatment order, test requisition, or in the patient's Electronic Health Record (EHR).

  • Step 4: Ensure All Three Match

    • Ensure that all three identifiers (Full Name, UHID Number, and Date of Birth) match correctly across all three sources (Patient Statement, ID Band, Medical Record/Order) before proceeding with any intervention. Make this procedure clear and unambiguous for all staff.

• 2.4 Patient Identification Band:

  • Ensure all inpatients have a current and correct identification band applied upon admission.

  • Verify the information on the band is accurate (matches chart).

  • The ID band should remain on the patient at all times during their hospitalization.

  • If an ID band is missing, illegible, or incorrect, a new one must be obtained and applied immediately.