DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER

“Towards Patient Safety in Surgery”Promote customer delight. Avoid complaints at all times!

Hospital Alert Codes

A Lecture to OMMC StaffJanuary 26, 2012

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

Harvey Balucating, MD, DPBS

Ariel T. Celzo, MD




Backgrounder:

Last January 8 to 9, 2012, OMMC was on Code White Alert because of the Black Nazarene Feast.

OMMC had a share of about 20 patients coming from the Feast.

(10 – Surgery; 7 – IM; 2 Pedia; 1 – OB-GYN)




Question I ask / we ask:

What usually happens during an activation of a Code White Alert in a hospital setting?




Question I ask / we ask:What usually happens during an activation of a Code White

Alert in a hospital setting?

My perception and observations:

Stand-by is oftentimes confined to just knowing “We are on Code White Alert.

“We are on Code White Alert. Be ready for any emergency or disaster. Be ready to come to the hospital when called for.”







Staff on stand-by inside the hospital would just have a mental stance of being physically ready to respond to an emergency when called for without doing other response preparations like supplies and space preparations.







Staff on stand-by outside the hospital would also just have a mental stance of waiting for a call and will just go to the hospital when called without a set response time to be physically present in the hospital.







There is usually no structured and comprehensive way of doing things to ensure effective alertness or readiness and effective response when the alert code is elevated to a response code.






ROJoson’s in-depth analysis – January 8 to 14, 2012 (trigger: Black Nazarene Feast)

Primer• Hospital Level • Department Level

Goal: Promote structured and comprehensive way of doing things to ensure effective alertness or readiness and effective response when the alert code is elevated to a response code.



Primer on Hospital Alert Codes

What are hospital emergency and disaster codes?

Hospital emergency and disaster codes are codes, usually using colors, being used in hospitals worldwide to

• convey essential information quickly to staff during times of potential and actual emergencies and disasters

• prevent stress or panic among patients and visitors in the hospitals during response to actual emergencies and disasters




What are the uses of hospital emergency and disaster codes?

Hospital emergency and disaster codes are being used for two purposes:

• to convey need to be alert or ready

• to convey type of emergency or disaster occurring in the hospital that needs a corresponding response




How are hospital emergency and disaster codes classified?

Hospital emergency and disaster codes can be classified into

- alert codes - response codes





Hospital alert codes are mainly used in anticipation of surge of patients from an emergency or disaster occurring outside the hospital.

Can also be used for anticipated emergencies and disasters involving the hospital itself, such as when there is a forecast typhoon.





Response codes are mainly used in response to emergencies and disasters occurring within the hospital such as fire, earthquake, flood, and sudden cardiopulmonary arrest of patients, staff, and guests.

However, they can also be used in response to external

emergencies and disasters.





For alignment purposes,

the recommendation is for all hospitals to adopt the alert codes being used by DOH hospitals, as long as the word “Alert” is incorporated in the code, like so, Code White Alert, Code Blue Alert, and Code Red Alert.





Color codes without the word “Alert” being used in hospitals shall be considered as response codes.

Response codes can make use of colors also.

If there are two similar colors being used in the alert and response codes, the presence of “Alert” makes for the distinction.





Examples

Code Red is a response code in cases of fire in the hospital. Code Red Alert is an alert code for more manpower and

supplies in preparation for an anticipated extensive surge of patients.

Code Blue is a response code in case of sudden cardiopulmonary arrest in the hospital.

Code Blue Alert is an alert code.




What are the conditions in which the different alert codes can be adopted?

DOH

Conditions in which Code WHITE Alert can be adopted:• Strong possibility of a military operation within the area/region, e.g., coup

attempt• Any planned mass action or demonstration within the catchment area• Forecast typhoons (Signal No. 2 up) the path of which will affect the area• National or local elections and other political exercises• National events, holidays, or celebrations in the area with potential for mass

casualty incidents• Any emergency with potential 10-50 casualties (deaths, injuries)• Any other hazard that may result in emergency• Unconfirmed report of reemerging diseases, e.g., bird flu, SARS





DOH

Conditions in which Code BLUE Alert can be adopted:• When 20-50 casualties (red tags) are suddenly brought to the hospital.• Any internal emergency/ disaster in the hospital which brings down their

operating capacity (i.e., vital areas) to 50% or which would require evacuation of patients and setting up of a Field Hospital.

• For conditions other than mass casualty incidents, the influx of patients is beyond the capacity of the hospital to handle.

• Confirmed/documented report of reemerging diseases (SARS, human to human avian flu) within the catchment area.





DOH

Conditions in which Code RED Alert can be adopted:• When more than 50 (red tag) casualties are suddenly brought to the

hospital.• An emergency wherein the services of the hospital is paralyzed since

50% of the manpower are themselves victims of the disaster.• Hospital is structurally damaged requiring evacuation and/or transfer of

patients.• Conditions requiring mandatory quarantine of hospital and its personnel

(e.g., SARS, avian fl u); uncontrolled human to human transmission of SARS/avian flu within the catchment area.




What are the general sequential steps in the activation and deactivation of alert codes?

•Monitoring of news of potential emergency and disaster that may create a surge of patient incident or event in the hospital.

•Assessment of the potential incident or event with a determination on what alert code to activate.

•Securing of permission for activation of an alert code from the Hospital Director by the Hospital Disaster Control Director.





•Activation of an alert code approved by the Hospital Director to be implemented through the Hospital Disaster Control Director.

•Surveillance for occurrence of actual emergency and disaster with corresponding response.

•Maintenance of readiness of out-of-hospital stand-by staff such that they proceed promptly to the hospital when needed.





•Securing of permission for deactivation of an alert code from the Hospital Director by the Hospital Disaster Control Director.

•Deactivation of an alert code approved by the Hospital Director to be implemented through the Hospital Disaster Control Director.




What are main targets of readiness in the alert codes of the hospitals?

Having

enough manpower and enough supplies

to handle anticipated surge of patients to the hospital.




What are recommended guidelines in ensuring manpower readiness under each code alert?

• Determine the composition of the Hospital Alert Teams as well as Department Alert Teams.

• Determine which teams and who should be physically present and which teams and who can be on stand-by outside the hospital in each alert code.





• Use the checklist on essential steps in responding to a surge of patient emergency as a guide to determine who, how many staff, and what teams should be available and made readily available when needed.

Essential steps in responding to surge of patients Who How many staff

Teams

Declaration of disaster Creation of an incident command Notification of

Disaster Control Officer

Chair, Disaster Preparedness Committee Hospital Director Concerned Division and Department Heads

Mobilization and organization (task assignment and authorization) of staff

Mobilization of ancillary services (laboratory, x-ray, pharmacy, etc)

Control of disaster

Triage

Treatment Referrals / Transport Traffic control Patient log Relatives Information Area Press conference

Decongestion and post-disaster reconstruction Post-disaster evaluation and reporting





• Use the following checklist as a guide in determining who, how many staff, and what teams should be available and made readily available when needed.

Hospital / Department Alert Teams Who /Person-in-charge

How many staff Teams / Person-in-charge

Administrative TeamCorporate Communication Team

Medical TeamNursing TeamInstitutional Worker TeamSecurity TeamTelephone Service TeamAdmitting TeamInformation TeamAmbulance

Emergency RoomOperating Room

Record TeamPharmacyDietaryFinance

Others





Use the following manpower stand-by monitoring sheet as a guide:

XYZ Hospital / Department Alert Team Members Stand-by Monitoring SheetAlert Code: White / Blue / Red (encircle one)Date and Time of Activation: Name of Event / Incident:

Name of Consultants / Residents / Interns / Staff

Cellphone Nos. / Residence (City)

Time SMS on Activation / Deactivation

Time SMS response (copied / noted)

Whereabout / Time

Remarks




What are the recommended guidelines on communication system that will ensure adequacy and prompt response of manpower?

The primary communication device shall be the cellphone as this is readily available and will facilitate documentation of all activities that transpire which in turn will facilitate evaluation, particularly, on activation and deactivation messages and responses and whereabout messages of members of the surgical teams.

The cellphone can be complemented with telephones and other means of communication.

Templates for text messages shall be used.




What are examples of templates of SMS messages that can be used during the activaiton and deactivation of alert codes?

Templates for SMS (text) messages:

Messages - Types Templates with Examples

Announcing activation of alert code

Code (COLOR) Alert; Date; Time; Event – Hospital Director / Hospital Disaster Control Director

Ex: Code WHITE Alert; January 9, 2012; 1300H; Black Nazarene Feast – HD / HDCD

Repeating announcement of activation of alert code

Txt # - Code (COLOR) Alert; Date; Event – Hospital Director / Hospital Disaster Control Director

Ex: Txt 2 - Code WHITE Alert; January 9, 2012; 1300H; Black Nazarene Feast – HD / HDCD







Announcing deactivation of alert code

Deactivation - Code (COLOR) Alert; Date; Time; Event – Hospital Director / Hospital Disaster Control Director

Ex: Deactivation - Code WHITE Alert; January 9, 2012; 1300H; Black Nazarene Feast – HD / HDCD

Responding to announcement of activation of alert code

Noted or Copy. Whereabout

Ex:

Noted. Am now at home in Malabon.

Copy. Am now in Mall of Asia.







Responding to announcement of deactivation of alert code

Noted or Copy.

Requesting update on whereabouts of members of surgical team on stand-by:

Whereabout Update #?

Ex:

Whereabout Update 1?

Whereabout Update 2?







Updating status of alert code

Code Update # - still or now Code (COLOR) Alert; Date; Time; Hospital Director / Hospital Disaster Control Director

Ex:

Code update 1 – still Code WHITE Alert; jan9; 2000H; HD / HDCD

Code update 2 – now Code BLUE Alert; jan 10, 2000H; HD / HDCD




What are recommended guidelines in ensuring there are enough supplies to handle anticipated surge of patients to the hospital?

Determine the supplies needed for each level of alert code.Use the following supplies monitoring sheet as a guide:

XYZ Hospital / Department Supplies Stand-by Monitoring SheetIn Emergency Room / Operating Room / Other Departments (specify)

Alert Code: White / Blue / Red (encircle one)Date and Time of Activation: Name of Event / Incident:

Item Quantity Needed Current Quantity

Remarks

Red Blue White

Hospital / Department Alert Teams Supplies Needed Other Logistics Needed

Administrative Team

Corporate Communication Team

Medical Team

Nursing Team

Institutional Worker Team

Security Team

Telephone Service Team

Admitting Team

Information Team

Ambulance

Emergency Room

Operating Room

Record Team

Pharmacy

Dietary

Finance

Others




What are the ultimate criteria to be used in evaluating an alert code activation?

The minimum criteria to be used during the evaluation will be

adequacy and response time (to be in the Hospital) of manpower on stand-by outside the hospital and the

adequacy of prepared supplies based on a must-have list.




What are the general parameters and criteria that can be used in evaluating a hospital alert code system?

• Presence of policies and procedures on alert code system

• General steps followed during activation and deactivation• • Specific guidelines and instructions followed during

activation and deactivation

• Presence of exercises at least once a year





• Presence of evaluation after every activation of an alert code (see evaluation checklist)

• Presence of continual review and improvement activities





• During actual activation of an alert code:

• Presence of adequate manpower on alert stand-by based on activated alert code

• Response time (being in the hospital) of at least 80% of manpower on stand-by outside the hospital within 30 minutes

• Presence of adequate prepared supplies based on activated alert code




What is an example of a checklist that one can be used in evaluaitng the quality of an alert code activation and deactivation?

XYZ Hospital Alert Code Activation and DeactivationEvaluation Checklist

Alert Code: White / Blue / Red (encircle one)Date and Time of Activation: Name of Event / Incident:

Required-activity Statements for Evaluation Yes / No Remarks (areas for improvement)

1 The alert code was activated by the Hospital Disaster Control Director with the approval of the Hospital Director.

2 All members of the Hospital / Department Alert Teams were texted announcing the activation of the alert code.

3 The alert code was texted within 30 minutes after a decision to activate the code right away or it was texted promptly (within 30 minutes) at a time determined by the Hospital Director / Hospital Disaster Control Director.


4 The texted message activating the alert code was concise with inclusion of names of the Hospital Director / Hospital Disaster Control Director, official date and time of start of alert, and the object or trigger of the alert.

5 All members of the Hospital / Department Alert Teams receiving the activation text replied with “copy” or “noted” and current exact whereabouts, within 30 minutes after the code activation text was sent.

6 There was a repeat texting of the code activation until at least 80% of the members of the Hospital / Department Alert Teams replied with “copy” or “noted” and current exact whereabouts. This was achieved within 60 minutes after the code activation text was first sent.


7 There was an update report on the status of the alert code at least one every 8 hours from time of activation to time of deactivation or at a shorter interval as deemed necessary by the Hospital Disaster Control Director.

8 There was a repeat texting inquiring on the whereabouts of the members of the Hospital / Department Alert Teams who are staying outside the hospital at least every 8 hours from time of activation to time of deactivation or at a shorter interval as deemed necessary by the Hospital Disaster Control Director.

9 There were update reports on whereabouts of members of the Hospital / Department Alert Teams who were on stand-by outside the Hospital at least every 8 hours from time of activation to time of deactivation or at a shorter interval as deemed necessary by the Hospital Disaster Control Director.


10 The preparation for securing the supplies prescribed within each alert code was completely done within 60 minutes from the official time of activation of the code. Completely means complete in quantities based on the list prescribed under each alert code.

11 The Hospital Disaster Control Director coordinated with hospital administration and other departments, Emergency Room, Operating Room, and Anesthesiology, in particular, in the preparation and implementation of plans for the Hospital’s readiness for the anticipated emergency / disaster.

12 All the members of the Hospital / Department Alert Teams who were on stand-by outside the Hospital were able to arrive to the Hospital within 30 minutes after elevation of a lower code alert to a higher level such as from Code White to Code Blue or Code Red.


13 The alert code was deactivated by the Hospital Disaster Control Director with the approval of the Hospital Director.

14 All members of the Hospital / Department Alert Teams were texted announcing the deactivation of the alert code.

15 The deactivation message was texted within 30 minutes after a decision to deactivate the code.


16 The texted message deactivating the alert code was concise with inclusion of name of the Hospital Disaster Control Director, official date and time of stand-down and the object or trigger of the alert.

17 All text messages from start of the activation of the alert code to stand-down (deactivation) were preserved in the cellphones of all the members of the Hospital / Department Alert Teams for purposes of documentation, monitoring and evaluation.

18 There was an evaluation of the alert code activation within 72 hours after deactivation.


19 Areas of improvement were identified during the evaluation.

20 Action plans for areas of improvement were formulated within 7 days after the evaluation.




What’s next for OMMC?

Formulation of Policies and Procedures on OMMC Alert Code System

Completion of ALL Departments’ Alert Codes

Exercise on Code White Alert



Department of Surgery Alert Code System

Code White AlertCode Blue AlertCode Red Alert

Indication for activation of alert codes

Presence of events 5 kms outside OMMC in which surge of patients is anticipated.

Anticipated surge of 10 patients – Code White Alert 20 patients – Code Blue Alert30 patients – Code Red Alert



Department of Surgery Alert Code System

Surgical Teams Consultants, residents, and interns

Team 1Team 2 Team 3

10 patients – Code White Alert – 1 Team physically present20 patients – Code Blue Alert – 2 Teams physically present30 patients – Code Red Alert - 3 Teams physically present



Manpower Alert



Directory of Residents:



Directory of Consultants:



Directory of Residents:



Directory of Clerks and Interns:



Supplies on Stand-by

ER

OR



CODE WHITE: SUPPLIES NEEDED FOR 10 PATIENTS (INDIVIDUAL PATIENT)

Wound Suturing Kit Individual Pack Available in the Dept. Available in the Hospital

NSS 500mL/ bottle 1/ patient 5 0

Xylocaine 5mL/ ampule

2/patient - 10

Syringe 5cc 1/patient 5 0

Syringe 3cc 1/patient - 5

Hypodermic Needle 1/patient - 5

Gauze(4 x 4 inches) 10/patient 30 20

Antiseptic (Betadine 60mL/ bottle)

1/patient - 5

Silk 4.0 cutting 2/patient 10 0



CODE WHITE: SUPPLIES NEEDED FOR 10 PATIENTS (INDIVIDUAL PATIENT)

Wound Suturing Kit Individual Pack Available in the Dept. Available in the Hospital

Suturing Instruments 1/patient 10 0

Sterile Gloves 7.0 2/patient 10 5

Plaster 1 inch 1/patient 10 0

Anti-Tetanus serum 1,500u/ampule

3/patient - 15

Tetanus Toxoid 0.5mL/ampule

1/patient - 5



Indigent Patient Help Box



Name of Items Starting Balance(January 01,2012)

In / From(January 01,2012)

Out / To(Date)

Values Running Balance(January 18,2012)

Macroset 2 2 0 2Chest tube fr 28 1 1 0 1Sterile gloves 6.5 5 5 0 5Sterile gloves 7 5 5 0 5Mosquito curve 1 1 0 1Bandage scissors 1 1 0 1Metzenbaum scissors

1 1 0 1

Mixter 2 2 0 2Debakey 2 2 0 2Needle Holder 2 2 0 2Iris scissors 1 1 0 1IV cannula g18 2 2 0 2Blade 10 5 5 0 5Blade 11 5 5 0 5Silk 4-0 cutting 5 5 0 5



Name of Items Starting Balance(January 01,2012)

In / From(January 01,2012)

Out / To

(Date)

Values

Running Balance(January 18,2012)

Silk 4-0 round 5 5 0 5Silk 3-0 round 5 5 0 5Silk 2-0 round 5 5 0 5Silk-0 cutting 3 3 0 3Vicryl 2-0 round 5 5 0 5Vicryl 4-0 cutting 5 5 0 5ET tube size 8 1 1 0 1ET tube size 7.5 1 1 0 1PNSS 1L 1 1 0 1Cefuroxime 750 mg vial 5 5 0 5Diclofenac 75 mg amp 5 5 0 5Tramadol 50 mg amp 5 5 0 5Ranitidine 50 mg amp 5 5 0 5Midazolam 5 mg vial 3 3 0 3




What’s next for OMMC?

Formulation of Policies and Procedures on OMMC Alert Code System

Completion of ALL Departments’ Alert Codes

Exercise on Code White Alert



WebsitesPrimer on Hospital Alert Codeshttps://sites.google.com/site/hospitalsafetypromotion/

primer-on-hospital-alert-codes

OMMC Surgery Alert Codeshttps://sites.google.com/site/ommcsurgerysafetypromoon/

Queries: [email protected]

DEPARTMENT OF SURGERY OSPITAL NG MAYNILA MEDICAL CENTER “Towards Patient Safety in Surgery”

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