Diversity of Emergency Codes in Hospitals

Background: Hospitals must be prepared to deal efficiently and effectively with different emergencies. To accomplish this, several countries have standardized their hospital emergency codes to improve their response capability. This is particularly important in Puerto Rico given that many health professionals, particularly physicians and nurses, provide services in more than one hospital. This study examined the emergency codes and alerts utilized in Puerto Rican hospitals. Objective: To assess hospitals’ level of emergency preparedness and response capability related to the variability of emergency codes and alerts utilized to respond to a situation in Puerto Rico. Method: A survey was conducted to characterize hospital emergency department level of preparedness and response to a mass fatality incident. A total of 39 out of a sample of 44 hospitals participated in the study. Semi-structured questionnaires were administered by the research team to members of each hospital’s administrative staff to explore the following: general hospital characteristics, emergency plans, emergency department capacity, collaborative agreements, personnel training, emergency communications, laboratory facilities, treatment protocols, security, epidemiologic surveillance, equipment and infrastructure. Results: Some hospitals in Puerto Rico use color coded emergency alerts, while others use key words or codes. Single color emergency codes can have different meanings in different hospitals. Conclusions: The findings clearly show that there is a lack of uniformity and clarity in the emergency codes utilized by hospitals in Puerto Rico. Single color codes have diverse meanings in different hospitals. This could adversely affect hospitals’ efficient and effective emergency response.


Introduction
An emergency is defined as any incident, caused by humans or a natural event, that requires an effective, responsive action to protect life or property [1].Therefore, the response to an emergency must be quickly, coordinated and well-planned [2].Initial efforts for the standardization of emergency codes in hospitals started with an incident where three persons were killed in southern California in a shooting at a medical center after the wrong code was called [3].This particular incident led the Hospital Association of Southern California to develop a comprehensive campaign to achieve standardizetion of hospital emergency codes [1].
Assuring emergency preparedness and response re-quires a systematic and structured methodology that enables an objective assessment [4].As part of this effort, a number of jurisdictions have moved towards standardization of hospital emergency codes.The need for code uniformity is underscored due to the mobility of the health care workforce.Staff who are reassigned to a new medical facility, or who must practice in more than one facility, need to be immediately familiarized with a code identifying the nature of a given crisis and their expected response [5].
The purpose of the study was to assess hospitals' level of emergency preparedness and response capability related to the variability of emergency codes and alerts utilized to respond to a situation of emergency in hospitals in Puerto Rico.

Methods
A survey was conducted to characterize hospital emergency department level of preparedness and response to a mass fatality incident.A total of 39 out of a sample of 44 hospitals participated in the study.Semi-structured questionnaires were administered by trained research assistants to hospital directors to explore the following: general hospital characteristics, emergency plans, emergency department capacity, collaborative agreements, personnel training, emergency communications, laboratory facilities, treatment protocols, security, epidemiologic surveillance, equipment and infrastructure.The selection of the hospital emergency departments that participated in the study was conducted by the Puerto Rico Department of Health (PRDOH) Office of Public Health Preparedness and Response (OPHPR).The OPHPR provided the research team with a list of 44 healthcare facilities grouped into six (6) coalitions: North, South, East, West, Metro A and Metro B. The list consisted of forty-one (41) hospitals and three (3) community health centers, which included a Diagnostic and Treatment Center, a primary health center and a family health center.All these healthcare facilities were located in 23 municipalities throughout Puerto Rico.Figure 1 shows the location of the participating emergency departments.At the end of the study, 39 hospital facilities agreed to participate in the study, yielding a response rate of 88.6%.
To gather the data, seven (7) electronic instruments were constructed considering ten (10) dimensions identi-fied through the literature.These dimensions were: 1) general characteristics of the hospital; 2) emergency plans; 3) collaborative agreements between agencies; 4) infrastructure and equipment; 5) epidemiologic surveillance; 6) protocols for medical treatment; 7) laboratory; 8) training among personnel; 9) communications during an emergency; and 10) hospital physical security.Confidentiality and voluntary participation issues were discussed with all subjects and all study activities were reviewed and approved by the Human Subjects Institutional Review Board.IRB: RCM IRB, protocol #A66640211, January 31, 2011.

Results
Results from this study showed that some hospitals use color coded emergency alerts, while others use key words or codes.Moreover, a single color emergency code can have diverse meanings in different hospital installations.Among the key colors that showed the highest diversity were code blue with seven different meanings, code yellow and code white with six different meanings, and code green with five.The findings of the study showed the following color codes as the most used: red for fire with 79.5% (n = 31); gray for safety/security situation with 74.4% (n = 29); and, green for cardio-respiratory arrest with 71.8% (n = 28).

Discussion
The findings clearly show that there is a lack of uniformity and clarity in the emergency codes and alerts utilized in hospitals in Puerto Rico.A single code could have diverse meanings in different hospitals.This could adversely affect an efficient and effective emergency mobilization of patients, visitors and hospital personnel during an emergency.The lack of standardization increases the potential for confusion or misinformation during critical times [1].In Puerto Rico, on August 10, 2011 Law 170-2011, which allows the Department of Health to implement the standardization of protocol codes for emergency care facilities in the private and public health sector was approved [6].This law represents an additional preparedness effort; however, it is not completely implemented yet.An emergency can happen at any time.Clear communication is a key element to ensure a quick response to protect patients, visitors and staff.The fact is that code alert and standardization among all hospitals may not be immediate and there will need to be a planned transition to the recommended code set.Several implications of the diversity or inconsistent codes for the differences in terminology have to be considered for planning, communication, and operations during an actual event [7].According to the Hospital Incident Command System guidance, it is important to point out the need to use clear language in case of a disaster event, especially when dealing with external resources [8].The goal is for hospitals to phase in the implementation of the recommended codes so that the required materials and training can be developed and offered at a time best suited for hospital personnel.Clearly, considerable training and financial resources will be required for this transition to be conducted efficiently and effectively [9].