R E V I E W S & A N A LY S E S Standardized Emergency Codes May Minimize “Code Confusion” Susan C. Wallace, MPH, CPHRM INTRODUCTION Patient Safety Analyst Emergency code terms, used to notify staff in a healthcare facility about an event that Edward Finley, BS Data Analyst requires immediate action, vary significantly from facility to facility in Pennsylvania, Pennsylvania Patient Safety Authority which can cause confusion for healthcare providers.1 (For the purpose of this article, emergency code terminology will be referred to as “emergency codes” or “codes.”) This variation may lead to code confusion and cause a potential delay in care, a patient safety ABSTRACT event, or confusion for healthcare providers who work in more than one facility.2,3 Emergency code terminology (i.e., terms A survey by the Northeast Pennsylvania Regional Task Force’s Health, Medical and used to notify staff in healthcare facili- EMS Committee and a search of the Pennsylvania Patient Safety Reporting System ties about an event that requires im- (PA-PSRS) database for reports involving emergency codes revealed that from July 2004 mediate action) varies significantly through the end of 2013, Pennsylvania healthcare facilities used 80 different emergency in Pennsylvania. For example, an codes. These codes were grouped by analysts into 37 categories that varied significantly emergency code for an adult medi- in their purpose. For example, “code green” was used in different facilities to report a cal emergency at different healthcare patient needing a rapid response, a combative person, a missing patient, a stroke, a fall, facilities could be announced as a and an “all clear.” “code blue,” “code rescue,” “code A literature search showed that hospital associations in more than 25 states have recom- stat,” or “code 99.” Analysis of events mended standardized emergency codes for their respective healthcare facilities. Several reported to the Pennsylvania Patient hospital associations have advocated using “plain language” codes based on recommen- Safety Authority from July 2004 through dations from government agencies such as the US Department of Homeland Security.4 2013 and a northeast Pennsylvania hospital survey found 80 different codes To help promote consistency for patient safety, Pennsylvania healthcare facilities may that were grouped into 37 categories. consider developing standardized emergency codes. This voluntary code standardization Over 25 hospital associations have could reduce terminology variations, increase awareness and knowledge of healthcare recommended standardized codes and professionals working in multiple facilities, and promote transparency of code meanings. definitions for healthcare facilities in their states. More recently, several associa- METHODS tions have endorsed “plain language” To understand the range of codes and the possible complications associated with them codes based on recommendations from in Pennsylvania, Pennsylvania Patient Safety Authority analysts queried the PA-PSRS government agencies such as the US database for all relevant events reported from July 2004 through December 2013, using Department of Homeland Security. To keywords such as “code” and “condition.” help promote consistency for patient safety and decrease “code confusion,” Using text mining (IBM SPSS Modeler 16.0), analysts were able to identify relevant it is suggested that Pennsylvania health- terms through keyword proximity to other terms associated with emergency conditions care facilities develop a standardized in the descriptions of unsafe conditions and patient safety events, such as letters, num- emergency code system. This volun- bers, colors, and other descriptive nouns (e.g., Armstrong, stroke, manpower), and to tary code standardization could lead eliminate irrelevant terms, such as patient conditions, “barcode,” “codeine,” and elec- to the reduction of code terminology tronic health record codes. Further analysis of the data was performed using terms that variations, increase awareness and could be associated with emergency code events, such as “wrong,” “mistake,” “delay,” knowledge of healthcare staff working in and “not called.” This was done to review if any events occurred when announcing an multiple facilities, and promote transpar- emergency code that compromised the safety of the patient. ency of code meanings. (Pa Patient Saf In addition, Stephanie A. Gryboski, MS, manager, emergency management, Geisinger Advis 2015 Mar;12[1]:1-6.) Health System, and chair of the Northeast Pennsylvania Regional Task Force’s Health, Corresponding Author Medical and EMS Committee, which consists of about 80 members, conducted a survey Susan C. Wallace in January 2014 to ascertain the differences in the code terms used in each of the com- mittee’s healthcare facilities. Authority analysts reviewed the survey and incorporated the answers of the 34 respondents into the results found in the PA-PSRS database. Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 1 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S RESULTS (e.g., code 99, code 222), colors (e.g., code In another example, “code yellow” meant Types of Codes orange, code green), words (e.g., code tri- a bomb threat in one facility and meant Examination disclosed 80 emergency codes age), or names (e.g., Dr. Quick). patient fall, internal/external emergency, (in 37 categories) contained in PA-PSRS and hazardous material spill in three other For example, there were over 15 different reports and the hospital survey from facilities. See Figures 1 and 2 for treemap emergency codes used by Pennsylvania Pennsylvania healthcare facilities. These representations of the number of codes healthcare facilities to identify a combat- codes were used in 154 combinations used for specific conditions (Figure 1) ive person, including “code gray,” “Dr. of terminology and intended meanings. and the number of different conditions Armstrong,” “code manpower,” “code 12,” Analysts then categorized the terms as let- associated with distinct codes, by category “code control,” and “code green.” ters (e.g., code R, code STEMI), numbers (Figure 2). Figure 1. Number of Distinct Codes by Condition Infant/ (1) Pediatric medical (1) (1) (1) (1) (1) (1) Bomb threat (7) Rapid response (7) emergencies (6) child Fall (4) (1) Disruptive/combative person (15) abduction (1) (1) (1) (1) (4) Adult medical Hazardous material (1) (1) (1) (1) emergencies spill (6) Lockdown (3) Weather STEMI Active shooter (6) (15) Patient event(2) alert(2) elopement/missing Stroke(8) Emergency internal/external (15) Patient Trauma alert Newborn (12) Decontamination Fire (4) Emergency assist/ requiring OR unresp- team (7) onsive C-section (6) lift (3) intervention (2) (2) Note: Based on reports submitted to the Pennsylvania Patient Safety Authority from July 2004 through 2013 and a survey by the Northeast Pennsylvania Regional Task Force. The 16 conditions with only one distinct code were as follows: all clear, biological incident, blood needed, change in patient behavior, emergency department baby delivery, emergency MS15067 department predivert/high census, emergency patient, hostage incident, labor and delivery requiring blood, medical gas system emergency, oxygen shut down, patient/family care concern, power failure, radiation incident, therapeutic hypothermia, and unusual event. Figure 2. Number of Conditions Associated with Distinct Codes, by Category Brown (3) Zero (2) (1) (1) (1) (1) Gray/grey (4) (1) (1) (1) (1) (1) (1) (1) (1) White (7) (1) (1) Silver (7) Rescue (2) (1) (1) (1) Man- (1) (1) (1) STAT (3) Blue (3) (1) Pink (5) power (1) (1) Adam (2) (1) (1) (1) (1) (1) (1) (1) Orange (9) (2) Lock- (1) (1) Black (3) down (1) (1) (1) (1) (1) (1) (1) (1) (1) (2) (1) (1) Purple (7) Green (7) 99 (6) Red (6) (1) (1) Yellow (10) (1) (1) (1) (1) 9 (1) 4 (3) (2) (1) (1) (1) (1) (1) (1) (1) (1) (1) Color Letter(s) Name Number Word Note: Based on reports submitted to the Pennsylvania Patient Safety Authority from July 2004 through 2013 and a survey by the Northeast Pennsylvania Regional Task Force. Fifty-nine distinct codes were used once for various conditions, as follows: – Color (n = 5): crimson, gold, lavender, neon, rainbow – Letter(s) (n = 16): A, condition A, condition C, condition O, D, H, L, MET, NBC, O/OB, O2, PALS, PCI, PERT, R, Z – Name (n = 4): Dr. Armstong, Dr. Gray, Dr. Quick, Dr. Strong – Number (n = 12): 1, 2, 3, 6, 12, 30, 44, 45, 68, 77, 88, 222 MS15068 – Word (n = 22): alpha, AWOL, baker, chill, control, elopement, fall alert, hazmat, heart/heart alert, ice alert, lake, lift, MI alert, rapid response, STEMI, stork, stroke/alert, team, team delta, triage, wintergreen, wireless Page 2 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority Code Events Pennsylvania. Additional emergency codes its 2000 guidelines, as a result of a tragedy Analysis of the event reports identified used by hospitals that were not associated occurring after an emergency code was 12 instances in which there was confusion with a specific event reported through broadcast on an overhead speaker.2 when announcing an emergency code. No PA-PSRS—and some types of emergency In 1999, the West Anaheim Medical harm was reported for any of these events, conditions and terms identified in the Center announced a code meant for a but the potential for harm from delays in Northeast Pennsylvania Regional Task violent/combative person after a man care or incorrect response team activation Force’s survey (e.g., medical gas system entered the hospital carrying a gun. could be significant. emergency)—would not be collected in Following established response protocols, the PA-PSRS reports submitted to the several hospital employees proceeded to Examples representative of events caused Authority, as they would be categorized as the area where the gunman was located, by code confusion are as follows: Infrastructure Failures. unaware that the man was armed with Operator called a “[Code] Team” a gun. The man opened fire and killed instead of a “Code Green.” The three Standardization of Codes to three hospital employees.6 warning bells were not used prior to Decrease Confusion calling the code. The room number A year after the tragedy, HASC adopted Over 25 state hospital associations have standardized healthcare emergency codes was not entered on the text pager. recommended voluntary adoption of stan- (see Table 1). The association recently The patient had an unresponsive dardized emergency codes on a state level. published its fourth edition of Health episode. Unable to arouse. “Code As of 2014, Maryland is the only state that Care Emergency Codes: A Guide for Code Red” called by mistake, then “Code approved regulations (in 2003) mandat- Standardization, which is aimed at assist- Blue” called immediately. Patient ing hospitals to adopt and implement ing healthcare staff respond in a uniform responded well. uniform code terminology as part of their way to situations that may occur in and Infant delivered and required resusci- emergency or disaster plans.5 around the hospital.2 tation. Code pink button pushed but The Hospital Association of Southern After rollout of the voluntary emergency code blue paged overhead by operator. California (HASC) was one of the first to codes, a 2011 survey of California hos- propose voluntary standardization with pitals showed improved consistency in DISCUSSION An emergency code system notifies staff in healthcare facilities about an event that Table 1. Standardized Code Names Recommended by the Hospital Association of requires immediate action. The intent is Southern California to relay urgent information in a timely, CODE NAME EVENT TYPE understandable manner and elicit the proper staff response. Blue Adult medical emergency Agency workers such as nurses; clinical Gray Combative person staff such as physicians; first responders Green Patient elopement such as police, firemen, and paramedics; Orange Hazardous material spill/release and nonclinical staff such as environ- mental services and security professionals Pink Infant abduction may work at several facilities and may Purple Child adduction be particularly confused when having Red Fire to remember several discrepant sets of Silver Person with a weapon and/or active shooter and/or emergency code definitions. A lack of hostage situation standardization increases the potential for Triage external External disaster misunderstanding and delayed or inap- propriate responses during serious and Triage internal Internal disaster urgent situations.4 White Pediatric medical emergency It is likely that the examples identified Yellow Bomb threat by the analysts underrepresent the actual Source: Hospital Association of Southern California. Health care emergency codes: a guide for code number of emergency codes used in standardization [online]. 2014 May [cited 2014 Jun 19]. http://www.hasc.org/hospital-emergency-codes Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 3 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S emergency response activation. Of the “color codes” at any of the five.3 In a let- and this can cause confusion. Plain lan- 240 hospitals that responded to the 2011 ter to Minnesota healthcare facilities, he guage helps to fulfill IHA’s commitment survey, 75% or more reported using the stated, “I don’t think this level of igno- to safety and transparency. See Table 2 for HASC-recommended emergency codes for a rance is unique to me. The clear language the plain-language codes recommended majority of their codes. About 80% of survey policy offers a more practical and sustain- by IHA. respondents separated the codes for a vio- able approach.”3 National recommendations. The US lent/combative person (i.e., code gray) and a The Iowa Hospital Association (IHA) Department of Homeland Security person with a weapon (i.e., code silver).7 recommends the use of plain language Federal Emergency Management Agency Review of codes recommended by several instead of a color system.10 Kirk Norris, (FEMA) and the US Department of state hospital associations shows that president and chief executive officer, IHA, Health and Human Services advocate the there are inconsistencies among state states that alerts like “code blue,” “code use of plain language for all emergency code systems. Healthcare workers who pink,” and “code yellow” have been in communications. FEMA states, “It is travel between states need to know differ- existence for many years, but there is no important that responders and incident ent code systems even if the healthcare uniform standard as to what they mean managers use common terminology. facilities adhere to state-recommended standardized codes. HASC plans to Table 2. Standardized Plain-Language Emergency Codes Recommended by the Iowa recommend its code designations for all Hospital Association healthcare systems on a national level, according to Darren Morgan, chair, EVENT TYPE PLAIN-LANGUAGE CODE HASC Safety and Security Committee.8 Facility Evacuation Evacuation + location + action required Use of Plain Language to Fire Fire alarm + location + action required Clarify Meaning Weather State recommendations. In an effort to increase safety and better communica- Severe weather Weather alert + descriptor + action required tion among staff, patients, and visitors, Security several hospital associations, including Abduction or elopement Missing person + descriptor + action Colorado,9 Florida,4 Iowa,10 Minnesota,3 required Missouri,11 and Wisconsin,12 have rec- Acts of violence Active shooter + location + action required ommended the use of plain language. Violent intruder + location + action required Plain-language systems, instead of sys- tems based on colors, letters, names, or Bomb threat Bomb threat + location + action required numbers, communicate information in Combative patient/person or Security assistance requested + location + a manner that is easily understood by show of force action required listeners, which may include patients and Disaster (internal or external) Internal emergency + descriptor + activate visitors in addition to staff.3 (e.g., hazardous agent, chemical incident command system spill, power outage) A facility using plain language would External emergency + descriptor + activate announce the alert category, the specific incident command system code description, and the location of the Medical emergency. For example, the announcer Mass casualty Mass casualty + descriptor would state: “medical emergency, cardiac Medical emergency Medical emergency + location arrest, room 123.” Obstetrics (OB) team activation OB team + location The Minnesota Hospital Association (MHA) Patient Safety Committee pub- Rapid response team activation Rapid response team + location lished a plain-language implementation Stroke team activation Stroke team + location guide. Steve Mulder, MD, chair of the Trauma team activation Trauma team + location committee, stated that he served on the Source: Iowa Hospital Association. Plain language emergency codes: implementation guide [online]. medical staff of five different hospitals [cited 2014 Jun 19]. http://www.ihaonline.org/iMIS15/Images/IHAWebPageDocs/publications/ during his career and never knew all the Plain%20Language%20Document.pdf Page 4 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority There simply is little or no room for mis- codes,” Grace said. “Such an approach is there was an array of codes used, Gryboski understanding in an emergency situation. guided by NIMS [the National Incident said. The committee would favor a uni- The use of plain language in emergency Management System] to reduce confusion form statewide system, she said. response is a matter of public safety, espe- and delays that can be experienced when cially the safety of first responders and codes are used during a crisis.” Implementation those affected by the incident.”13 Gryboski, of the Northeast Pennsylvania A transition to new emergency codes The US Department of Homeland Regional Task Force, leads emergency requires commitment, consensus, compre- Security requires plain language for management training for 8 hospitals, hensive education, and training. Several multiagency, multijurisdictional, and 5 helicopter transports, 78 clinic and hospital associations provide consensus multidisciplinary events, such as major outpatient facilities, and 2 research cen- on terminology, training guides, policies disasters and exercises.3 There is no ters across the state.14 She advocated for and procedures, emergency code posters, requirement at the federal government uniformity of emergency codes for the and competency tests.15 Training is recom- level (or known state requirement) that facilities she manages and all Pennsylvania mended for all staff, including physicians, mandates the use of plain language in healthcare facilities. as well as external emergency responders; a daily operations inside of a single organi- commitment from leadership is necessary. Uniformity of codes is important for zation, such as a healthcare facility. patients and staff safety, she said. “It is confusing for staff who go from one facil- CONCLUSION Uniformity Sought in ity to another, and also for patients who There are no national or statewide stan- Pennsylvania go to different hospitals, when emergency dard definitions for emergency codes,15 Pennsylvania does not have a statewide codes have different meaning,” she said. and a variety of emergency codes, some- standardized emergency codes system, It is not only about the healthcare times with conflicting meanings, are used according to Thomas L. Grace, RN, PhD, facilities, because the response needed to throughout Pennsylvania’s healthcare vice president, emergency preparedness, handle emergencies often requires help facilities. More than 25 state hospital Hospital and Healthsystem Association of from others, such as the fire and police associations have recommended standard- Pennsylvania (HAP).1 departments and other external emer- izing emergency codes within their states. “While PA DOH [the Pennsylvania gency responders, she said. Federal organizations and several state Department of Health] and HAP have organizations recommend the use of plain The answers to the Northeast Pennsylvania language. Standardizing hospital emer- not implemented specific guidance Regional Task Force’s survey showed the on the topic of emergency codes, our gency codes can benefit hospital employees lack of uniformity in the use of codes and external emergency responders, as well emergency preparedness staff have among these facilities. Some of the codes, encouraged facilities to consider use of as patients, by reducing code confusion such as “code red” and “code blue,” were and aiding staff in providing the correct plain English announcement in place of common, but for a combative person, response to emergencies. NOTES 1. Hospital and Healthsystem Association 4. US Department of Homeland Security. 7. California Hospital Association. Hospital of Pennsylvania. E-mail to: Pennsylvania National incident management system emergency code standardization survey: Patient Safety Authority. Pennsylvania [online]. 2008 Dec [cited 2014 Jun 19]. survey report [online]. 2011 Sep [cited emergency codes. 2014 Aug 21. http://www.fema.gov/pdf/emergency/ 2014 Jun 19]. http://www.hasc.org/ 2. Hospital Association of Southern Califor- nims/NIMS_core.pdf general-information/hospital-emergency- nia. Health care emergency codes: a guide 5. Md. Code Reg. 10.07.01.33 (2003). Uni- code-standardization-survey for code standardization [online]. 2014 form emergency codes. Also available 8. Morgan, Darren (Chair, Hospital Associa- May [cited 2014 Jun 19]. http://www. at http://www.dsd.state.md.us/comar/ tion of Southern California Safety and hasc.org/hospital-emergency-codes comarhtml/10/10.07.01.33.htm Security Committee). E-mail to: Pennsylva- 3. Minnesota Hospital Association. Plain 6. Leonard L, Gottlieb J, Warren PM. Gun- nia Patient Safety Authority. 2014 Jun 6. language emergency overhead paging: man kills 3 in Anaheim hospital [online]. 9. Colorado Hospital Association. Colorado implementation toolkit [online]. [cited Los Angeles Times 1999 Sep 15 [cited Hospital Association emergency code 2014 Jun 19]. http://www.mnhospitals. 2014 Jun 19]. http://articles.latimes. implementation guide [online]. [cited 2014 org/Portals/0/Documents/ptsafety/ com/1999/sep/15/news/mn-10258 Jun 19]. http://www.cha.com/Documents/ overhead-paging-toolkit-2011.pdf Focus-Areas/Patient-Safety/Emergency- Code-Implementation-Guide.aspx Vol. 12, No. 1—March 2015 Pennsylvania Patient Safety Advisory Page 5 ©2015 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 10. Iowa Hospital Association. Plain language 12. Wisconsin Hospital Association. Wis- 14. Gryboski, Stephanie A. (Manager, Emer- emergency codes: implementation guide consin hospital standardized alert code gency Management, Geisinger Health [online]. [cited 2014 Jun 19] http://www. recommendations [online]. [cited 2014 System). Conversation with: Pennsylvania ihaonline.org/iMIS15/Images/IHAWeb Jun 19]. http://www.wha.org/data/ Patient Safety Authority. 2014 May 29. PageDocs/publications/Plain%20 sites/1/emergencyprep/Standardized 15. ECRI Institute. Public address system Language%20Document.pdf AlertCodeRecommendations.pdf emergency codes. Healthc Risk Control 11. Missouri Hospital Association. Standard- 13. Federal Emergency Management Agency. 2012 May;Suppl A:Safety and security 16. ized, plain language emergency codes: NIMS and use of plain language [online]. implementation guide [online]. 2013 Apr NIMS alert. 2006 Dec 19 [cited 2014 Jun [cited 2014 Jun 19]. http://web.mhanet. 19]. http://www.fema.gov/pdf/emer com/uploads/media/2013_Emergency_ gency/nims/plain_lang.pdf Code_Implementation_Manual.pdf Page 6 Pennsylvania Patient Safety Advisory Vol. 12, No. 1—March 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 1—March 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. 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