Pages: 10 Originator(s): Telecom Initial Issue Date: December 2004 Owner: Quality and Patient Safety Next Review Date: June 12, 2013

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1 Pages: 10 Originatr(s): Telecm Initial Issue Date: December 2004 Owner: Quality and Patient Safety Next Review Date: June 12, 2013 Key Wrds: E 7.1; Cde Orange; Cde Effective Date: June 12, 2012 Green; External Disaster; Evacuatin; Cmmand Centre; Emergency Shelter; Office f Emergency Management; Emergency Fan Out List Reviewed by: Chief f Nursing and Apprved by: Business Operatins Prfessinal Practice Leadership Team 1.0 Purpse Cde Orange is an emergency cde designated t activate a respnse t an external disaster whereby the influx f patients demands additinal resurces t manage the event. Natural Disasters may include: Mass casualty incidents Chemical(C), Bilgical, Radi-Nuclear, Explsive r envirnmental events due t natural, accidental r intentinal acts Pandemics This plicy prvides the plan fr CAMH t prvide assistance t its cmmunity members in the event f an external disaster. Given that CAMH is a multi-site rganizatin, the Cde Orange als utlines plans t prvide accmmdatin and facilitate nging treatment in the event f a Cde Green - Ttal Evacuatin f ne f the CAMH sites. 2.0 Persns Affected This plicy applies t all staff, physicians, and affiliates f CAMH (hereafter referred t as staff); it als applies t students and vlunteers as apprpriate t the situatin. 3.0 Plicy A Cde Orange will be implemented in the event that: the Senir Manager n Call receives ntificatin by Trnt Plice Services (TPS) f an external disaster which necessitates the prvisin f emergency shelter t medically cleared and stable evacuees; r

2 Page N.: 2 f 10 a Cde Green Ttal Evacuatin has ccurred at ne f the CAMH sites and there is need fr space t prvide accmmdatin and nging treatment. 4.0 Definitins CAMH Emergency Line: An emergency CAMH telephne line that exists fr Trnt Plice Services (TPS) and Emergency Medical Services (EMS) t ntify CAMH f emergent and urgent events in the vicinity f ne r all f the CAMH sites (e.g. release f tear gas, fire at anther hspital). The CAMH Emergency line is managed in Admitting and Lcating Services. Client/Patient Reprting Desk The lcatin where staff receive incming evacuees. The client/patient reprting desk is usually lcated clse t the area where evacuees are allcated. Cde Green Emergency cde designated t initiate an rderly respnse when it is recmmended t evacuate within a certain perimeter until the initial situatin is cntained (OHA, 2008). At CAMH, there are fur types f evacuatins: Cde Red Evacuatin, Hrizntal Extended Evacuatin, Vertical Extended Evacuatin, and Ttal Evacuatin. Cde Orange Emergency cde designated t activate a respnse t an external disaster whereby the influx f patients demands additinal resurces t manage the event (OHA, 2008). Cde Orange Kit Package stred at the Cmmand Centre cntaining infrmatin required in the peratin f the Cde Orange. The kit includes: Cde Orange Plicy; cntact infrmatin f area hspitals; Mdified Health Recrd cntaining all frms relating t Client/Patient Reprting desk requirements (e.g. Admissin Recrd Frm, Medicatin Order Sheets, Dctr s/treatment Order Frms, Cnsent frms, hardcpy Prgress Ntes in case f cmputer dwntime); Cde Orange Tracking Lg Sheets; and statinary supplies. Cmmand Centre Crdinatin pint fr activities taking place during an emergency. The Cmmand Centre is the lcatin where relevant persnnel gather t share infrmatin, make majr decisins, and implement the desired curse f actin in a crdinated way. Each cmmand centre lcatin is equipped with materials (e.g. Cde Orange Kit, Telecm) needed during the Cde. Each site at CAMH has a designated Cmmand Centre: Cllege Street Resident s lunge (Rm G-83) ext Russell St. Bardrm (Rm 2062) ext Stkes Street 6 th flr Rm C6113

3 Page N.: 3 f 10 Emergency Fan Out List Cntact infrmatin fr emplyees within the rganizatin wh need t be cntacted in pririty sequence t return t wrk t participate in an emergency event. Senir Manager On-Call Senir level staff member assigned t prvide leadership as needed in urgent matters and emergencies. Cverage fr the Senir Manager On-Call is prvided 24 hurs a day and is rtated n a weekly basis. In the case f an emergency, the Senir Manager n Call may need t enlist additinal r alternate leadership. 5.0 Respnsibilities 5.1 All Staff Cmplete an annual review f the Cde Orange plicy and the Cde Orange Learning Mdule t learn abut cde range and ptential respnsibilities in the event f a cde range Participate in Cde Orange peratins as designated Prvide supprt t client/patients and evacuees as needed, including the prvisin f accessible infrmatin regarding the Cde Orange (e.g. mdifying centre wide cmmunicatins t meet the needs f individuals with disabilities, arranging fr interpretive services, etc.) Wear CAMH identificatin at all times Wear the required persnal prtective equipment, fllw Rutine Practices precautins, reprt all infectin cntrl and safety cncerns/hazards, unsafe wrking cnditins, near misses, incidents, and injuries. 5.2 Senir Manager n Call Determine need t call Cde Orange in cnsultatin with Executive Team if pssible Initiate need fr cmmand centre and designate cmmand centre leadership team Crdinate and delegate duties t staff Liaise with TPS and EMS, as needed Determine the mst suitable lcatin t accmmdate evacuees Oversee the inpatient transfers, discharges, and disaster patient admissins. Initiate the fan-ut list as required Respnd t the media and all external inquiries in the absence f the Vice President, Cmmunicatins and Cmmunity Engagement Designate lcatin f Client/patient Reprting Desk Designate staff t perate the Client/patient Reprting Desk Ensure all clinical areas are cancelling all in-patient and ut-patient appintments and are rescheduling fr later dates.

4 Page N.: 4 f 10 Direct all visitrs and utpatients t leave the building as apprpriate t the emergency. Assign ntificatin f next f kin f evacuees as needed 5.3 Physician in Chief Assign medical cverage as required t perfrm assessment f arriving client/patients Direct referrals t apprpriate resurces r bed lcatin as needed 5.4 Admitting and Lcating Services Mnitr CAMH Emergency Line and direct Senir Manager n Call and/r Nursing Supervisr t access vic line Direct media calls t the Vice President, Cmmunicatins and Cmmunity Engagement Annunce initiatin and cancellatin f Cde Orange as directed by the Senir Manager/Senir Staff n Duty 5.5 Unit/Department Managers Ensure maintenance f Cde Orange Kit Activate staff fan ut lists as required (as per E 1.4 Emergency Fan Out) Prepare t reprt n bed availability n inpatient units (as relevant) Observe and assist staff wh exhibit signs f stress, fatigue, r inapprpriate behaviur, and ensure that staff receives apprpriate rest perids and nurishment. 5.6 Clinical/Medical Staff Cmplete client/patient dcumentatin fr evacuees t recrd admissin/discharge frm CAMH Arrange fr apprpriate discharge and transprtatin arrangements 5.7 Pharmacy Ensure medicatin is available t any CAMH client/patients being discharged/placed n leave f absence t accmmdate evacuees Ensure medicatin is available fr and dispensed t evacuees as needed and dcumented accrding t usual standards 5.8 Infectin Preventin and Cntrl Lcate required PPE fr staff prtectin as indicated by the disaster, such as gwns, masks (N95 type, surgical), glves, prtective suits, etc. 5.9 Security Maintain traffic flw and crwd cntrl

5 Page N.: 5 f 10 Prvide entrance/exit directin t emergency persnnel t and frm the site 5.10 Vice President Cmmunicatins and Cmmunity Engagement Respnd t all media and external inquiries 5.11 Health Recrds Act as supprt fr fax and phtcpies as needed Prvide guidance in managing the health recrd as needed 5.12 Husekeeping Set up designated accmmdatin Assist in general duties Maintain area f evacuees (i.e. washrms, refuse) 5.13 Fd Services Arrange and prepare snacks and meals as required 5.14 Telecm Ensure Client/patient Reprting Desk has quick access t telephne use Prvide phne lines and access t phnes fr evacuees in designated areas 5.15 IT Prvide cmputing supprt t Cmmand Centres and Client/patient Reprting Desk as needed 5.16 Prcurement Expedite bulk purchases f water, fd, husekeeping supplies, etc. as required 5.17 Materials Manager Crdinate cverage f receiving dck and dispersal f gds 5.18 Plant Operatins and Maintenance r Carillin (80 Wrkman Way, 100 Stkes Street, and 101 Stkes Street) Respnd t Cde Orange and prvide supprt as needed 6.0 Prcedures 6.1 Emergency Shelter CAMH will prvide emergency shelter fr individuals affected by the Cde Orange as fllws:

6 Page N.: 6 f 10 RUSSELL ST. SITE COLLEGE ST. SITE QUEEN STREET ST. SITE Will temprarily hld Cllege Street site evacuees in the Gym until ther arrangements are made. Will determine the number f evacuees it can accmmdate by assess whether patients are stable enugh t be discharged r placed n LOA. Assess whether patients are stable enugh t be discharged r placed n LOA. Will accmmdate a maximum f 150 evacuees (in ne f the the Gymnasiums, Cafeteria r ther suitable vacant lcatin) All areas designated fr use in an emergency have accessible entrances and washrms identified in the CAMH Staff Guide t Ensuring Accessibility fr Peple with Disabilities. 6.2 Management f Cde Orange Fllwing ntificatin frm the TPS r EMS t the CAMH Emergency Line f an external disaster r a CAMH staff f a site evacuatin, the fllwing prcedure shall be implemented: Respnsible Staff Senir Manager n Call (After regular wrk hurs, the Nursing Supervisr is ntified and cntacts the Senir Manager n Call t discuss the nature f the assistance required.) Actin Determine need t call cde range Determine the level f participatin in the Cde such as: need t implement Emergency Fan Out (cmplete r partial); need t attend the site; need t call in ther Senir Managers fr assistance Appint the Senir Manager n Site t manage the Cde Orange (i.e. self, nursing supervisr, ther senir manager) as necessary Establish a Cmmand Centre in designated lcatin: Queen Street Unit 4 Basement, Rm B40 x Stkes Street 6 th flr Rm C6113 Cllege Street Resident s lunge (Rm G-83) x 4744 Russell St. Bardrm (Rm 2062) x 4163 Infrm Admitting and Lcating Services f need t annunce Cde Orange and prvide lcatin f Cmmand Centre

7 Page N.: 7 f 10 Respnsible Staff Admitting and Lcating Services Admitting and Lcating Services Senir Manager n Site All Security, Husekeeping, and Plant Operatins and Maintenance r Carillin (80 Wrkman Way, 100 Stkes Street, and 101 Stkes Street)staff One staff each frm Health Recrds, Admitting and Lcating Services, Dietary, Pharmacy, Clinical prgrams Actin Annunce Cde Orange is nw in affect, the Cmmand Centre is lcated, please refer t yur Emergency Manual and stand by fr further instructins three times. Cmplete immediate ntificatins (including the EVP s and VP, Cmmunicatins and Cmmunity Engagement) and implement the SMG Fan-ut psted at Admitting and Lcating Services Assess available resurces, nature f the disaster, request fr assistance, and need fr additinal resurces cnsidering: Nursing staff (including reassignment and use f agency staff) Medical staff available t cmplete assessments Other clinical supprts (e.g. scial wrk) Physical space Pharmacy supplies and persnnel Infectin Cntrl: required Persnal Prtective Equipment Fd supplies and fd service persnnel Plant peratins and Maintenance r Carillin (80 Wrkman Way, 100 Stkes Street, and 101 Stkes Street) Security Husekeeping staff Admitting and Lcating Services and Health Recrds staff Telecm and IT requirements cmputers, telephnes, bradcasts, vic bradcasts, updates t website Reprt t the Cmmand Centre fr pssible assignments

8 Page N.: 8 f 10 Respnsible Staff Senir Manager n Site (in cnsultatin with Physician in Chief as needed) Husekeeping Clinical/Medical Staff Admitting and Lcating Services Clinical/Medical Staff Vice President Cmmunicatins and Cmmunity Engagement Actin Designate an area(s) f the hspital where evacuees will be accmmdated (see 6.1 Emergency Shelter) Prepare area fr accmmdatin fr evacuees Access Cde Orange Kits as needed Ensure stable inpatients are discharged r placed n LOA, ensuring that they a) receive prescribed medicatin rders/prescriptins prir t leaving site; and b) dcumentatin is cmpleted Set up Client/Patient Reprting Desk in r near the area where evacuees are allcated Admit and discharge client/patients that require care in the usual manner (i.e. identify client/patients,, receive incming health recrd dcuments, start health recrd, nte and address specific accessibility needs f individuals with disabilities) Activate lg sheets and tracking fr evacuees requiring shelter nly Prvide evacuee names and next f kin phne numbers t Senir Manager n Site Liaise with cmmand centre re: dispsitin f all evacuees and client/patients admitted/discharged t/frm site facilities NB: It may be necessary t abbreviate the nrmal prcess in rder t facilitate numbers f evacuees. Cmplete regular activities f assessment, treatment and dcumentatin with evacuees (i.e. health recrd dcumentatin; cmmunicate with family/sdm as apprpriate; establish treatment needs; liaise with pharmacy, dietician, etc.; make discharge arrangements as apprpriate) Facilitate general cmmunicatins t staff, family, client/patients, and cmmunity as required thrugh use f media, annuncements, public bradcasts, Emergency bradcasts, bradcast vic r updates t the CAMH website as required

9 Page N.: 9 f 10 Respnsible Staff Senir Manager n Site Admitting and Lcating Services Senir Manager n Site Key staff frm every prgram/department invlved in the Cde Orange Senir Manager n Site Senir Manager n Site Actin Prvide Admitting and Lcating Services with infrmatinal updates (i.e. lcatin f Client/patient Reprting Desk) and changes t status f Cde Orange as relevant Instruct Admitting and Lcating Services t make intermittent annuncements with further instructins as necessary Maintain cntact with TPS regarding updates and cancellatin f Cde Orange Instruct Admitting and Lcating Services when Cde Orange is ver Annunce CODE ORANGE IS NOW OVER: All departments please resume nrmal activity three times Facilitate Cde Orange Debrief meeting immediately fllwing cancellatin f the Cde Cllect all dcumentatin, with the exceptin f that which is included in the client/patient health recrd, cmpleted during the Cde Orange and prvide t the Senir Manager n Site (e.g. lg sheets, fan ut lists) Attend Cde Orange Debrief meeting t share dcumentatin and experiences regarding issues frm the Cde Orange Cllect all dcumentatin, with the exceptin f that which is included in the client/patient health recrd, cmpleted during the Cde Orange (e.g. lg sheets, fan ut lists) and frward t the Directr f Quality and Patient Safety Delegate the replenishing f Cde Orange Kits Crdinate and lead cde range debriefing, including a balance f management and frnt-line staff Identify and acknwledge what went well. Review and identify prbable rt cause(s) f all patient and vlunteer safety issues Review and identify prbable rt cause(s) f all staff safety issues Identify gaps in cmmunicatin (internal and external), service, patient care, r staff safety. Develp and facilitate any required imprvement plans.

10 Page N.: 10 f References Ontari Hspital Assciatin (OHA). (2008). OHA emergency management tlkit: Develping a sustainable emergency management prgram fr hspitals. OHA: Trnt. 8.0 Links/Related Dcuments 8.1 Plicies and Prcedures AHR Accessibility and Custmer Service fr Peple with Disabilities E 1.2 Cmmand Centres and Cmmunicatin Equipment E 1.4 Emergency Fan Out E 5.1 Cde Green 8.2 Frms Cde Orange Kit Mck Health Recrd Prgress Nte Admissin Ntes Physician Orders Cnsent t Prpsed Treatment Cnsent fr Disclsure f Persnal Health Infrmatin Cde Orange Lg Sheet 8.3 Resurces CAMH Fan Out and Respnse List Template CAMH Staff Guide t Ensuring Accessibility fr Peple with Disabilities Cde Orange e Learning Mdule Prvincial Transfer Authrizatin Centre Reliable Media Surces: 680 NEWS (AM 680); CP24 (ch. 24) Trnt Hspital Cntact Infrmatin 9.0 Review/Revisin Histry Date Revisin N. Revisin Type Reference Sectin(s) December 1.0 New draft N/A 2004 June Mderate Refrmat; incrprated OHA standards and definitins; changes in executive titles July Minr Additin f CAMH Emergency Line May Mderate Streamlined respnsibilities and prcedure June Minr Updated t reflect redevelpment