ORIGINATOR: Emergency Preparedness Committee APPROVED BY: Medical Advisory Committee Operations Committee ORIGINAL DATE APPROVED: September, 2002 DATE REVISED: April, 2012 DATE OF IMPLEMENTATION: June 27, 2012 Page 1 of 8 POLICY STATEMENT North York General Hospital is committed to protecting patients, families, staff physicians, volunteers and property from hazardous spills. This policy pertains to all sites and buildings associated with North York General Hospital. Employees using hazardous chemicals are required to be trained in safe handling, storage and disposal by their manager in consultation with the Occupational Health and Safety Department. There are different types of spill response kits. They include Universal, Mercury and Acid. They are available in the areas where hazardous chemicals are being used or can be located by calling Occupational Health and Safety and/or Environmental Services. Healthcare workers responding to a code will take care to assess the environment during the response to protect their own health and safety. DEFINITIONS Code Brown: The term used to alert staff to an unmanageable accidental release of a hazardous or potentially hazardous substance or gas. Code Brown Response Team: The groups of individuals that respond to a Code Brown include: Manager of affected department Occupational Health and Safety Specialist (when available) Clinical Team Manager-on Call/ Administrative Coordinator Director-Building Services
Manager/Supervisor Environmental Services Security Senior Administrator on Call Page 2 of 8 Emergency Medical Service (EMS): External emergency personnel who will provide additional help in a crisis situation. Health Care Worker: (HCW) is defined as employees, physicians, volunteers, students, medical staff, and contract workers. Incident Manager: Upon notification of a Code Brown, the Charge Person of the affected unit/department is designated as the Incident Manager. Upon the arrival of an individual with more expertise, this role may be transferred to him/her. Manageable Spill: The release of material, which can be contained, cleaned up and disposed of using standard housekeeping procedures. Represents little or no risk to staff, patients, visitors, or property. Is within the scope of knowledge and training for the staff performing the clean up and disposal. Material Safety Data Sheets (MSDS): Information provided by the manufacturer indicating the hazards and precautions for a substance. Personal Protective Equipment (PPE): Protective equipment provided for personnel to wear while handling hazardous materials. Radioactive Spills: All spills of radioactive material shall be classified as a Manageable Spill (Minor Spill) unless any of the following conditions are met, in which case it would be defined as an Unmanageable Spill (Major Spill): any personnel contamination; release of a volatile material; and/or more than 100 exemption quantities spilled. Radioactive spills will most likely occur in Nuclear Medicine/Cardiology at either hospital site and each department is equipped with radioactive spill kits.
Page 3 of 8 For all Unmanageable Spills notify the Radiation Safety Officer (RSO) via locating immediately. The RSO will submit a written report to the Canadian Nuclear Safety Commission (CNSC). Spill Response Kit: There are two types of spills kits Chemical kit : For all types of Chemical spills Mercury spill kit: Solely for mercury spills. Unmanageable Spill: The release of material, which, identified by the worker discovering the spill, cannot be immediately identified. This may represent a clear or immediate hazard to patients, visitors, staff, volunteers and property and requires assistance from the Code Brown Response Team using specialized equipment to control, contain and cleanup. Very Hazardous: Any spill that for reasons of its volume, toxicity, reactivity or any combination of the three is beyond the NYGH Code Brown Response Team s ability to control. The declaration of a spill as very hazardous will be decided by the Incident Manager. Workplace Hazardous Materials Information System (WHMIS): A legislative program which is designed to protect the users of materials by providing information through container labels, material data sheets and training.
Page 4 of 8 ROLES AND RESPONSIBILITIES OF STAFF MEMBER DISCOVERING A SPILL OR LEAK OF A HAZARDOUS OR UNIDENTIFIED MATERIAL: RESPONSE: 1. Staff will: S SAFELY EVACUATE EVERYONE FROM THE IMMEDIATE AREA AND SECURE AREA. P PREVENTS THE SPREAD OF FUMES BY CLOSING DOORS. I INITIATE APPROPRIATE SPILL PROCEDURE. L LEAVE ALL ELECTRICAL EQUIPMENT ALONE. DO NOT TURN ON OR OFF. L LOCATE ANY INFORMATION REGARDING THE CHEMICAL, IF POSSIBLE, AND ACTS ACCORDINGLY. If Manageable Spill: Check MSDS sheets and clean up the spill using proper procedures immediately. If Unmanageable Spill: Check MSDS sheets Do not touch the spill At the GENERAL and 4000 Leslie Street site dial 5555: At the BRANSON site dial 2222 to notify Security, then 5555 to page the code At SENIORS call Security at 14-4444 or through locating at 14-5555, call the Fire Department for large spills 1. Request Code Brown be paged overhead 2. Identify yourself by name 3. Identify the location of spill and type of spill, including: Volume or extent of spill If you smell/see fumes 4. Request CTM-On-Call to be paged Move patients and visitors to safety as required.
1. Make sure patient(s) room(s) are safe for their return. Page 5 of 8 ROLES AND RESPONSIBILITIES OF CTM-ON-CALL Response If Unmanageable Spill: 1. In consultation with Occupational Health and Safety Specialist (when available), will assume role of Incident Manager responsible for directing the appropriate response to the chemical spill (in cooperation with the Fire Dept.) 2. Notify Senior Administrator On Call 2. Seek advice from external authorities, as necessary, including the Fire Department (911), Ministry of Environment (1-800-268-6060), Canutec (1-613-996-6666) Coordinate the care of injured patient and staff. 3. Monitor the control and clean-up activities 4. Ensure routine operation of the Hospital is maintained 5. Develop an appropriate contingency plan should the chemical spill be such that key Hospital Areas are affected, e.g. Laboratory. 6. Assume responsibility for coordinating the response to the chemical spill if the Occupational Health and Safety Specialist is unavailable 1. Notify the Corporate Risk Manager via voicemail that a Code Brown has occurred and describe outcome. ROLES AND RESPONSIBILITIES OF TELECOMMUNICATIONS Response 1. Page the Code Brown Response Team 2. Announce overhead, on the paging system, Code Brown and location three times. (3X) 3. Upon direction of Incident manager and/or Occupational Health and Safety Specialist call 911 and relay information. 4. Request Security to meet the EMS personnel and take them to the location of the spill.
Page 6 of 8 1. Upon instructions from Code Brown Response Incident Manager, announce Code Brown, All Clear, repeating three times. (3X) ROLES AND RESPONSIBILITIES OF HOUSEKEEPING Response 1. Proceed to the location of spill. 2. Check MSDS sheets 3. In consultation with the user department, determine the classification of the spill. 4. Obtain Spill Kit - Location of spill kit: General Site: The labs in rooms 4SE-124, in the corridor opposite room 4SE-124, 3SE-173, 3SE-186, 2N Laundry Room, 2N Kitchen and Housekeeping Office Branson: Shared Health Lab (basement) Seniors Health Centre: 2nd floor Medication room 3. Responsible in securing the area of the chemical spill and limiting access to authorized personnel. 1. Dispose of hazardous material appropriately. 2. Return spill kit to storage location. 3. Check and replenish kit after each use. 4. Request cleaning, as required. ROLES AND RESPONSIBILITIES OF OCCUPATIONAL HEALTH AND SAFETY SPECIALIST Response 1. Proceed to location of spill 2. Assess the situation with Manager/Supervisor of Environmental Services to determine risks and how to contain and manage the spill. Provide instructions to other members of the Response Team.
Page 7 of 8 3. If Manageable for Response Team; implement appropriate emergency operations and make sure that Personal Protective Equipment is worn. 4. If Unmanageable for Response Team; make sure that the area is secure and instruct Telecommunications to dial 911 for assistance from the appropriate Emergency Medical Service. Identify the location of spill and type of spill, including: Volume or extent of spill If you smell/see fumes 5. Act as a liaison with Emergency Medical Service. 6. Ensure back-up personnel and stand by equipment is ready. 7. Update Senior Administrator on Call 8. Assess when to end code. 1. Call telecommunications at 5555 to call Code Brown, All Clear, repeating three times. (3X) ROLES AND RESPONSIBILITIES OF SECURITY DEPARTMENT 1. Secure the area. 2. Upon notification from Telecommunications, meet the EMS and take to location of spill. ROLES AND RESPONSIBILITIES OF BUILDING SERVICES 1. Proceed to location of spill. 2. Check MSDS sheets. 3. Isolate pumping/electrical/ventilation equipment/rooms, as required. POST EVENT DEBRIEFING
Page 8 of 8 The team will have an informal debrief amongst themselves within the shift that the Code Brown occurred as organized by the Team Leader/Incident Manager. The Clinical Team Manager of the affected unit/department will discuss with the Corporate Risk Manager the need for a corporate debriefing, and will assemble the appropriate individuals within 10 days of the event to review and assess: The effectiveness of the response Requirement for additional documentation Opportunities for improvement POST EVENT DOCUMENTATION: Person who first identifies a Code Brown will complete a SLIP electronically within 48 hours. If a patient/visitor is injured, a SLIP will be completed within 48 hours. In the event that an employee is injured, the employee will be provided with aide or medical treatment, if needed, either in the Occupational Health and Safety Department or the Emergency Department. The Clinical Team Manager or designate will be informed of the injury immediately and within 24 hours, the employee will complete an electronic Employee Incident Report. If the employee is sent to seek medical care for their injury, the manager or designate is to email the Occupational Health and Safety Department and provide details of the injury/incident. If there is a critical injury or fatality, ensure that the Occupational Health and Safety Department is notified immediately.