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Crack the uncommon code with standardization

Healthcare Security and Emergency Management, October 1, 2004

The Hospital Association of Southern California (HASC) recognized that standardized emergency codes could make a difference in hospitals after a September 1999 shooting at West Anaheim (CA) Medical Center left three workers dead.

A man became upset over his mother's death and blamed the hospital staff for her deterioration. She received hip replacement surgery at the facility months earlier. Hours after her death, he reappeared at the hospital with a gun and shot a nurse, a pharmacist, and a maintenance director.

"Since everyone knew this person, no one thought this could happen," says Aviva Truesdell, senior vice president of AllHealth Security, the hospital association's security subsidiary and staff executive of the HASC safety committee.

When staff members saw the gun, they instinctively called the emergency code for a violent patient, Truesdell says. "When you call a code for a violent person, there's a team that usually responds to subdue the person. There's a different response code for someone with a weapon," she says.

That response involves evacuating people from the area. At the time, the medical center didn't have a specific emergency code for a person with a weapon. The shooter, a 47-year-old Vietnamese refugee, later admitted he shot the staff workers, although they weren't responsible for the care of his mother. In 2003, the shooter was convicted of first-degree murder and received the death sentence.

Following the incident, Truesdell and other HASC members wondered whether standardized codes could have prevented this tragedy.

Code invention

After the shooting, HASC decided standardized emergency codes throughout the region could benefit employees the most. "Many people work in different hospitals, like nurses who travel from one hospital to another," Truesdell says.

"Everyone has to go through new employee orientation, but it gets confusing if one hospital uses a specific code and another hospital uses a different code."

While visiting a hospital, Truesdell experienced code confusion firsthand. "The hospital called a code orange, which California hospitals typically use for a hazmat spill," she says, noting it was actually the hospital's infant abduction code.

To prevent emergency code confusion and possibly reduce tragedies, HASC focused on standardizing emergency codes in southern California hospitals, using its safety and security committee.

Common code

HASC sent a survey to all 442 hospitals in California requesting a list of codes, their purpose, and code names. Three healthcare doctoral candidates from a nearby university compiled the survey responses from more than 200 hospitals.

Despite the large response, only a few common codes among hospitals existed, making it difficult to find common ground. "There really wasn't a majority of common codes," Truesdell says. "Hospitals were just all over the map."

The survey revealed that over 90% of hospitals used "code red" to indicate a fire and "code blue" to indicate a medical emergency. However, there were 47 different codes to indicate an infant abduction and 61 different codes for a combative person. HASC also discovered that few hospitals had a code for someone carrying a weapon. "Not only did hospitals have to add this code, but it required training for proper response," Truesdell says.

Ultimately, HASC decided to use the most common colors and established 11 emergency codes for the most common or significant security events.

Disseminating the information

Once HASC determined the 11 emergency codes, the tough job of establishing a response protocol lay ahead. The entire process took almost a year.

HASC created general policies and procedures that hospitals could adapt for each code and compiled the information in a book, which included references to Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) standards, as well as relevant state or national policies. HASC published and sent a hard copy of the book and a customizable CD-ROM to every hospital in California.

Hospitals embrace codes

HASC waited to see whether area hospitals would respond to the recommended changes. Since HASC is the hospital industry's association, and not a rulemaking body, nothing required hospitals to change their codes.

Initially, not all hospitals jumped on the standardized emergency code recommendation. Many hospitals waited until the JCAHO surveyed their facilities before adopting code changes, Truesdell says.

For two years following the code release, HASC followed up with hospitals that still didn't convert. "We continuously did surveys to find out whether the change had an impact," Truesdell says. HASC's final survey on code adoption in 2002 showed that 89% of 86 responding hospitals had adopted the majority of the changes. "We had a phenomenal response," Truesdell says, noting this was the highest rate of voluntary adoption of any of HASC's security projects

As a result of Southern California's success, hospitals and their associations across the United States have followed HASC's model for standardized emergency codes. Truesdell still receives phone calls from other hospitals and associations in the country about the standardized system. HASC even posted its book and CD online at www.hasc.org/PDFs/Code_Book/CodeBook.pdf for other facilities to use.