St. Joseph s General Hospital, Vegreville EMERGENCY RESPONSE CODE GREY Shelter in Place / Air Exclusion

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St. Joseph’s General Hospital, Vegreville

EMERGENCY RESPONSE CODE GREY

Shelter in Place / Air Exclusion

EMERGENCY RESPONSE CODE GREY ALGORITHM

S u p er vi so r / D esi g n at e re c e iv in g n o ti c e S ite A d m in is tr a ti o n (o n -si te) / D esi g n at e S w itc h b o a rd / D esi g n at e F a c ilit ie s Mai n ten an c e an d E n g in e e ri n g

Notice received from Emergency Personnel of hazardous air quality and advised to Shelter In Place

Notify Site Administration / Designate

Upon receipt of notification of incident:

• Consult with Medical Officer of Health and Facilites Maintenance to

determine actions, based on risk considering:

- Measures to minimize / prevent air movement into the building - Access / egress (Site Lockdown) - Evacuation (Code Green)

• Notify Switchboard / Designate to activate site Code Grey response –

“Code Grey – Air Exclusion Procedures”

• Determine need to establish Site Command Post to coordinate actions and communications to staff • Ensure notification to Covenant Health E/DM, Leadership, Communications,

• E/DM to notify AHS E/DM for further escalation as required i.e. RAAPID

In consultation with engaged parties determine when event has concluded:

• Advise Switchboard / Designate to

announce “Code Grey – Air Exclusion Procedures All Clear” three (3) times

Upon receiving notification of Code Grey, advise all staff:

“Code Grey – Air Exclusion Procedures”

three (3) times

Notify:

• St. Joseph’s General Hospital Facilities Maintenance on-call

When directed by Site Administrator/Designate announce:

“Code Grey – Air

Exclusion Procedures All Clear” three (3) times

In consultation with Site Administration / Designate determine actions, based on risk including measures to minimize / prevent air movement into the building

Site specific actions may include:

• Identifying alternate sources / alternatives to medical air

• Supporting air quality monitoring

In consultation with engaged parties determine when event has concluded:

• Prepare for phased start up of HVAC and HEPA filter systems

This template was reviewed and approved by Covenant Health Emegency / Disaster Management June 2015

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EMERGENCY RESPONSE CODE GREY ALGORITHM

Si te A d m in is tr a ti o n / D esi g n at e U n it / Pr o g ra m Su p e rv is o rs w ith in A ffe c te d S ite

In consultation with Site Administration / Designate

• Initiate Site Lockdown sealing exterior doors and windows where practical; close interior fire doors

• Assign staff and post signage at entrances / exits (See Appendix 1)

• Encourage staff and patients to remain indoors until “All Clear” is announced

Remain engaged with Site Administration / Designate, requesting additional resources / personnel, if needed.

In consultation with Site Administration / Designate determine actions to support patients and staff, based on risk

Assist staff to implement Air Exclusion and Lockdown Procedures (See below Actions)

Unit / Program specific actions may include:

• Identifying alternative therapies to those involving medical air

• Determine staffing plan for future shifts

When “All Clear”

announced determine supports required to patients and staff.

• Consult with Site Administration / Designate to convey recovery plan for Unit / Program

This template was reviewed and approved by Covenant Health Emegency / Disaster Management June 2015

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S ta ff A c ti o n s w h e n N o ti fi e d o f C o d e G re y

UNDER THE EXPLICIT DIRECTION FROM UNIT / PROGRAM SUPERVISOR All Staff:

• Remain indoors

• Close and seal all exterior doors and windows, including attached ambulance bay, where practical

• Close interior fire doors

• Turn off all exhaust fans and equipment that extracts air out of the building or brings air into the building

• Listen for possible “Code Green” - Evacuation

Nutrition and Food Services:

• Turn off cooking fans and exhaust hoods

Pharmacy:

• In consultation with Site Administration / Designate, turn off laminar and biohazard hoods

Laboratory:

• In consultation with Site Administration / Designate, complete procedures in progress. Turn off biohazard and fume hoods

Nursing / Clinical / Physicians:

• Staff working in near negative pressure areas must use infection control airborne precautions and keep doors closed to negative pressure areas

• Do not start new procedures

• Patients using medical air will require alternate therapies

• Monitor patients at high risk for respiratory complications, and assist as required

This template was reviewed and approved by Covenant Health Emegency / Disaster Management June 2015

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Site:

Provincial Template

Document #:

Reference to AHS ERC#7

Approval Level:

Covenant Health E/DM Steering Committee

Initial Effective Date:

June 2015

Cross Reference:

Emergency Response Code Green

Revision Effective Date:

PURPOSE

Code Grey is the designated phrase to alert and notify staff of the need to reduce the movement of

air into and out of the building when there are air quality concerns, potentially from a release of a

toxic or hazardous substance in the environment.

Shelter In Place

has been demonstrated to be the most effective response during the first few

hours of an air quality concern.

The Medical Officer of Health (MOH) may request Code Grey based on an analysis of an

emergency event, such as fire, motor vehicle crash, train derailment, industrial accident or natural

disaster, with a resultant substance release.

APPLICABILITY

Compliance with this Emergency Response Code is required by all Covenant Health and Alberta

Health Services employees, members of the medical and midwifery staffs, students, volunteers, and

other persons acting on behalf of Alberta Health Services (including contracted service providers as

necessary). This Emergency Response Code does not limit any legal rights to which you may

otherwise be entitled.

ACTIVATION

Code Grey can be

initiated

by the Site Administration / Administrator On-Call in consultation with the

Medical Officer of Health, who immediately is notified of an air quality concern.

POST INCIDENT ACTIONS

For a facility impacted by an Emergency Response Code Grey, the Site Administration or

Administrator On-Call is to:

Assess for injuries and facility damage.

Implement subsequent emergency response plans as appropriate.

Complete Incident Documentation:

o

Reportable Incident Form (Seniors’ Health / Continuing Care sites).

o

Urgent Notification of an Emerging Issue (all sites).

o

Other site or Covenant Health specific documentation as appropriate as per policy I-25

Emergency Disaster Management Response.

This template was reviewed and approved by Covenant Health Emegency / Disaster Management June 2015

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Advice on document completion may be sought from Covenant Health Emergency/Disaster

Management staff. Covenant Health Emergency/Disaster Management staff may also be contacted

for assistance in facilitating the post incident debriefing at 780-735-2515 (office), EMO

780-686-0337 or Director 780-863-4360.

REFERENCE

I-25 Emergency Disaster Management Response Policy

This template was reviewed and approved by Covenant Health Emegency / Disaster Management June 2015

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Appendix 1

This template was reviewed and approved by Covenant Health Emegency / Disaster Management June 2015

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