RMC Policy Number: EC-337
POLICY TITLE: Code Grey
Policy owner (TITLE ONLY): Emergency Management Coordinator
Manual: Environment of Care
New or revise date: 04/2017
Review Cycle: Annually
Officer with oversight: COO
All RMC affiliated employees, physicians, vendors, on-site subcontractors, all HCA affiliated employees for any division working in or visiting RMC, affiliated physician practices, members of the medical staff or credentialed allied health professionals.
It is the intent of this plan to implement an effective response to severe weather conditions, such as a tornado and ensure safety to patients, staff and visitors.
There is no guaranteed safe place during a tornado; however, some locations are better than others. It is very important for staff to provide for the safety of patients and visitors, to keep them calm and reassured. Move patients and visitors away from glass and windows.
A tornado watch issued by the National Weather Service means that weather conditions are right for the possible formation of tornados in the area under the watch.
A tornado warning issued by the National Weather Service means a tornado has been detected in the area and immediate protective action should be taken.
- In the event a Tornado Watch has been issued by the National Weather Service for our area, Security, PBX and Nursing Operations will monitor weather reports until the Tornado Watch is lifted. All 3 areas have National Weather Alert units to monitor these conditions.
- The PBX operator is the primary location for monitoring National Weather Alert Modules. Plant operation will do monthly checks of this unit to verify it is in working order.
- The PBX operator will notify administration or the house supervisor during non-business hours of the tornado watch in Jackson County Missouri.
- Announcement of “Jackson County Missouri is under a Tornado watch till xx:xx will be made.
- Administration or the Nursing Supervisor will instruct each nursing unit to run a census report with patient information that will be kept by the Charge Nurse.
- If the National Weather Service issues a Tornado Warning, the Severe Weather Plan shall be activated.
Initiation of Severe Weather Plan
Activation of this plan is for the following counties in Kansas: Johnson, Wyandotte, and in Missouri: Cass, Clay, or Jackson
- The PBX operators will alpha page “Tornado Warning insert county” to the disaster pager group and notify administration or House Supervisor after hours.
- Administration or the House Supervisor will monitor local media and security observation reports and will activate a house wide CODE GREY if there is a threat to either campus. This is done by contacting the PBX operator,
- At this time the PBX operator will announce CODE GREY using the overhead page system. Immediately following announcement the PBX will alpha page CODE GREY to the disaster group to alert all units and the Brookside Campus staff.
- When the CODE GREY announcement is made, all units should activate their patient sheltering plans. All patients should be sheltered in place using the most central interior hallway.
- Visitors will be allowed to move to the interior hall as well. We encourage all visitors to remain in the hospital till all clear is given. Visitors may leave the facility but they are assuming their own risk.
- Non-essential personnel should report to the B level Horn of Plenty to shelter and prepare for assignment by the Incident Commander. Incident command will utilize this staff to assist with pt sheltering assignments.
- The Incident Commander should continue to monitor media outlets for reports of destruction. If destruction to populated areas in the Kansas City Metropolitan Area then the Incident Command should activate via PBX operator CODE YELLOW: FULL ACTIVATION.
- ED will monitor and notify incident commander of influx of disaster patients or if they receive notification of activation of MCI plan.
Specific Instructions for Departments
- ED patients and visitors will be moved away from the front ED waiting room glass atrium during severe weather that could be of threat to the glass tower. ED charge nurse will notify house supervisor or administration if area is evacuated.
- Charge nurse will monitor and notify the house supervisor if EMSystem, HEAR, or phone messages that activate the mass causality plans.
- ED charge nurse is also responsible for updating the EMSystem with bed availability when requested to do so.
- Monitor local weather broadcasts (along with Nursing Operations and PBX) until the situation is clear.
- Maintain visual surveillance of Medical Center area and surrounding landscape.
- Advise people outside facility to go inside.
- Assist with monitoring of exterior conditions and notify ED charge nurse if conditions warrant need to evacuate glass tower in ED.
- Assist Security as a weather observer.
- Fire Exits will be closed and checked.
Nursing Units/Patient Floors
- Clear patient hallways of equipment, carts, etc.
- The Charge Nurse will keep census report with patient information until threat is over.
- Staff will assist patients to hallways, providing blankets for protection. Keep away from windows/glass during code grey activations.
- Isolation patients shall be gowned and masked as appropriate and then moved to the hallway.
- All patient room doors will be closed.
- Staff and Nursing will remain with patients at all times.
- Move all visitors to the hallways as far away from windows as possible.
- Monitor local weather broadcasts via TV and/or NOAH weather radio.
- Make rounds to evaluate the situation and determine if additional assistance is needed.
- Assign additional personnel where needed.
Environmental Services and Food Services
- Be prepared, at a moment’s notice, to assist visitors in waiting areas and dining room to the nearest interior hallway.
- Keep away from windows/glass.
- Shut down gas appliances if necessary.
- Remain with patients.
- Do not transport patients back to their units.
- Have a list of in patients available for Command Center staff.
- Assist nursing units with ambulation/transportation of patients to safe areas.
- Hold all non-emergency procedures
- Verify notification of all department staff, including staff in medical building and exterior buildings. (Verify and patient and staff in non-permanent structures such as trailers have been evacuated into the hospital structure.
- Keep away from windows/glass.
- Elective procedures will be delayed until notification by Administration or Chief of Surgery.
- For emergency procedures and operations in progress, surgeons and surgery personnel will be kept informed of the situation.
- Keep away from windows/glass.
All Other Departments
- Report to your department for instructions.
- Be prepared to assist nursing units with moving patients.
- Clear hallways and keep away from windows/glass.
Research Brookside Campus
- Communication will be done via Disaster Communication Policy.
- Once the severe weather has passed, an ‘all clear’ will be issued by the House Supervisor/Administrator on call, via PBX announcement.
- See Earthquake/Explosion Plan for scene assessment instructions.
- Account for all staff, patients and visitors, render any needed first aid.
- If area is free from damage, return patients to their rooms and resume normal operations.
- If building has structural damage or loss of utilities activate code yellow via PBX operator.
III. Equipment Required (if applicable)
- Weather alert radio
- PBX paging system
(insert links if applicable)
(Alerts, HCA corporate policies, state specific or regulatory or accrediting agency)
- U.S. Department of Health and Human Services “Emergency Preparedness for Every Emergency”
- The Joint Commission Resources “Emergency Management in Health Care, an All Hazards Approach.
Approval level one (1)
- Phil Keary - Emergency Preparedness Coordinator
- William Ludwig - Directory, Safety and Security
- Tammy Lightner - VP of Quality
- Jerry Baker - Directory, Plant Operations
Approval level two (2)
- Emergency Management Committee
- Environment of Care Committee
Approval level three (3)
- Officer with Oversight: John Myers - COO
Original Policy #: 02/2012
Revision Dates: 04/2014, 04/2017