EMERGENCY RESPONSE CODE GREY Shelter in Place / Air Exclusion St. Joseph s Auxiliary Hospital EMERGENCY RESPONSE CODE GREY ALGORITHM Supervisor / receiving notice Notice received from Emergency Personnel of hazardous air quality and advised to Shelter In Place Notify Site Administration / Administrator On-Call (780-735-9000) Site Administration / Administrator On-Call Upon receipt of notification of incident: Consult with Medical Officer of Health, Facilities Maintenance and Engineering 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 / to activate site Code Grey response Determine need to establish Site Command Post to coordinate actions and communications to staff Ensure notification to Senior Leadership, Communications, RAAPID via Incident Notification Plan In consultation with engaged parties determine when event has concluded. Notify Switchboard / to announce Code Grey, All Clear three (3) times. Switchboard / Upon receiving notification of Code Grey, advise all staff: Switchboard / overhead page by pressing the Emergency Page button on any facility telephone, dial 99999 and announce Code Grey and location three (3) times. Notify: Covenant Health Security Manager and Emergency/Disaster Mgmt When directed by Site Admin / Admin On-Call, announce: Switchboard / to overhead page by pressing the Emergency Page button on any facility telephone, dial 99999 and announce Code Grey, All Clear three (3) times. Facilities Maintenance and Engineering In consultation with Site Administration / Administrator On-Call 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 Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 1 of 5
EMERGENCY RESPONSE CODE GREY ALGORITHM Protective Services (if onsite) / Site Administration / In consultation with Site Administration / Administrator On-Call 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 clients / patients / residents to remain indoors until All Clear is announced Remain engaged with Site Administration / Administrator On-Call, requesting additional resources / personnel, if needed. Unit / Program Supervisors within Affected Site In consultation with Site Administration / Administrator On- Call determine actions to support clients / patients / residents 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 / Administrator On-Call to convey recovery plan for Unit / Program UNDER THE EXPLICIT DIRECTION FROM UNIT PROGRAM MANAGER / SUPERVISOR Staff Actions when Notified of Code Grey All Staff: Remain indoors Close and seal all exterior doors and windows, including attached bays, 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 / Administrator On-Call, turn off laminar and biohazard hoods Nursing / Clinical / Physicians: 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 Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 2 of 5
Site: St. Joseph s Auxiliary Hospital Approval Level: Cov Health Emergency/Disaster Mgmt Cross Reference: Emergency Response Code Green Document #: ERC 7 Initial Effective Date: June 2017 Revision Effective Date: June 2018 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 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 other sites). o Other site or zone-specific documentation as appropriate. Advice on document completion may be sought from Emergency/Disaster Management staff on-call (780-735-9000) or from the Local Administrator on-call (during evenings and weekends). Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 3 of 5
Emergency/Disaster Management on-call staff may also be contacted for assistance in facilitating the post incident debriefing. REFERENCE Corporate Policy I-25 Emergency Disaster Management Response Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 4 of 5
Reviewed and Approved By Covenant Health Emergency/Disaster Management Page 5 of 5 Appendix 1