St Mary s Hospital - Camrose EMERGENCY RESPONSE CODE PURPLE Hostage EMERGENCY RESPONSE CODE PURPLE ALGORITHM Staff Member taken hostage If able: Call for HELP Activate panic button Appendix I Staff Member Discovering the incident Notify Switchboard / Designate / Protective Services to activate. Call 86 Code / Location response 911 to be called requesting Police assistance and provide as much detail as possible: - exact location of captor and hostages - number and description of captors - number of hostages and any injuries known - number and type of weapons - any demands made - call back # Prevent others from entering the area Move patients, visitors and staff in the immediate vicinity to a safer area away from the incident If moving is not advisable, shelter in place behind secured doors (locked / barricaded) Switchboard / Designate Upon receiving notification, advise all staff: Code / Location (three times) Call 911 Site specific variations to overhead announcements and internal activations Hold all calls to the hostage area Notify: Protective Services if onsite 780-678-4200 or Covenant Health Security Managerat 1-780-446-9497 Site Administration 780 781 0895 / Administrator On-Call 780-679-7688, unless already done When directed by Site Admin / Admin On-Call, announce: Code, All Clear (three times) Site specific variations to overhead announcements and internal activations) Reviewed and Approved By Covenant Health Emergency/Disaster Management May 2016 Page 1 of 5
Protective Services or Supervisor (if PS not on-site) Respond to incident and provide assistance as required If requested by the manager or person in charge/ Designate, Protective Services is prepared to assume the on-scene Incident Commander role Secure the area and control access Assist uninvolved areas to lockdown their areas Meet and assist Police on their arrival, providing a copy of facility s layout, information on how facility doors open or close, utility access, video feeds (CCTV), keys and access cards Prevent unnecessary / unauthorized traffic into the area to preserve evidence until Police arrive Supervisor / Designate of Affected Area Assist and direct staff to move those in vicinity of incident to a safe area Gather information from staff discovering the incident Confirm Code has been activated Confirm Site Administration / Administrator On-Call has been notified Notify physician and obtain health record if captor is a patient Assist Police as required Consult with Police, Site Administration / Administrator On-Call / Protective Services (if on-site) for possible escalation or when to announce All Clear as appropriate Arrange for staff support as needed (EFAP etc) Ensure incident documentation is completed by staff All Staff Members If a Code is called for your work area while you are away, do not return there Report to an unaffected area to assist staff in securing their access OR If Code is called for a different work area while you are away, return to your own work area if it is not affected, and it is safe to do so Close and secure doors if possible Ask visitors to remain in your work area until the All Clear is announced Reviewed and Approved By Covenant Health Emergency/Disaster Management May 2016 Page 2 of 5
Site Administration / Administrator On-Call Consult with manager or person in charge of affected area / Protective Services / Police to determine actions, based on risk Escalation of response Determine need to establish Site Command Post to coordinate actions and communications to staff Ensure notification to Zone Leadership, Communications, RAAPID via Incident Notification Algorithm Ensure Urgent Notification of an Emerging Issue form has been completed In consultation with engaged parties determine when incident has resolved: Advise Switchboard / Designate to announce All Clear (three times) Ensure all other incident documentation has been completed Site: St Mary s Hospital, Camrose Approval Level: Covenant Health E/DM Cross Reference: Lockdown Emergency Response Procedure Document #: ERC 4 Initial Effective Date: May 2016 Revision Effective Date: May 2016 PURPOSE is the designated phrase to alert personnel to an incident where a patient / client, visitor, a member of staff or a physician is being held against their will by another individual or where someone is threatening violence with a weapon. APPLICABILITY applies to all personnel. ACTIVATION can be initiated by any member of staff or physician who witnesses or recognizes a potential or actual situation of someone being held against their will that requires an immediate response by following the preceding algorithm. Reviewed and Approved By Covenant Health Emergency/Disaster Management May 2016 Page 3 of 5
The Police may respond to a Code. Once on site, the Police should be briefed by Protective Services (if on-site) or the Supervisor of the impacted area. If possible, relevant floor plans and a copy of this should be made available. The Police would assume command and control and would follow their own scene safety and management procedures. POST INCIDENT ACTIONS For a facility impacted by an, Site Administration is to: Assess for injuries and facility damage. Implement subsequent emergency response plans as appropriate. Complete incident documentation as follows: o Reportable Incident Form (Senior s Health / Continuing Care sites). o Urgent Notification of an Emerging Issue (all other sites). o Other site or zone-specific documentation as appropriate. Advice on document completion may be sought from Covenant Health Emergency / Disaster Management staff or from the Local Administrator On-Call (during evenings and weekends). Emergency/Disaster Management staff may also be contacted for assistance in facilitating the post incident debriefing. A patient s health record would not normally be annotated with details of the incident. However, all pertinent health information and collaborating information relevant to the care of the patient should be documented in the patient s health record. Pertinent health information is defined as anything having a potential effect on the patient including anything relative to the stay, or anything having direct medical, physical or mental consequences. REFERENCE Corporate Policy I-25 Emergency/Disaster Management Response Reviewed and Approved By Covenant Health Emergency/Disaster Management May 2016 Page 4 of 5
Appendix 1 STAFF MEMBER TAKEN HOSTAGE The first 15 45 minutes of a hostage-taking have the greatest threat of violence and aggression. Do s: Remain calm, if spoken to, speak in a calm voice Be patient and be an empathetic listener Consider escape opportunities carefully. If there is an accessible escape route and it is safe to do so and you are sure you will be successful, attempt to evacuate; regardless of whether other hostages agree or are able to follow. Try to build rapport by reminding captors of your human needs and by asking for items that increase your comfort (going to the bathroom, eating, drinking) Follow the instructions of your captors especially if that means turning in your cell phone as you do not want to get caught being deceptive by keeping your cell phone Try to stay a safe distance away from captors Avoid appearing to study your captors Identify yourself initially by first name only, but do not be deceptive about your identify Maintain a low key profile, remain alert and stay facing your captors Avoid phony camaraderie Adapt to the vocabulary level of your captors Stay away from doors and windows to avoid injury in the event of a Police intervention Ask for clarification of captor s instructions only if it will not escalate the situation, and be tolerant of other hostages Do not s; Do not attempt to handle dangerous situations alone. Do not be aggressive or use threatening body language Do not speak unless spoken to and do not volunteer information Do not be deceptive about your identity as you do not want to get caught in a lie. Do not negotiate by making promises in exchange for release. Do not make suggestions to your captors, never beg, plead, cry, demand or complain, do not debate the captor s cause. During or immediately after the Police intervention: Do not run Drop to the floor, remain still and keep in plain view Follow the instructions of Police and keep your hands visible to them You may be placed in handcuffs or subdued until captors have been taken into custody Reviewed and Approved By Covenant Health Emergency/Disaster Management May 2016 Page 5 of 5