Responding to a Code Orange
How hospitals prepare for mass casualty incidents
September 21, 2020
By Marguerite Watson, Senior Communications Advisor, Covenant Health
It was a calm summer day and Mackenzie Wardle, an advanced care paramedic with the Banff Mineral Springs Hospital emergency medical services (EMS) team, had just come back from responding to a call when he learned that a tour bus had crashed along the Columbia Icefield in Jasper National Park. Within 30 minutes, he and his supervisor put together five crews of on- and off-duty paramedics and an off-duty physician for four advanced life support ambulances and a rescue helicopter and called for a Code Orange standby at the hospital.
“I let my supervisor know I was going to need as many ambulances as could possibly get signed on, and then I sent out a What’s App text message for last-minute shift coverage,” says Mackenzie.
In a hospital setting, Code Orange is the emergency code for a mass casualty incident such as a tornado, explosion or, as in this case, significant motor vehicle accident. It alerts staff to prepare for the arrival of a large number of patients, potentially overwhelming the hospital’s services. The hospital’s response will vary depending on the support needed and the scale of the incident.
“It’s one of the codes that sites don’t ever want to have to work through, but they need to be prepared,” says Natalie Levers, an emergency disaster management officer with Covenant’s emergency disaster management (EDM) team.
Preparation for a Code Orange incident can vary from hospital to hospital. A rural site, which may be the only hospital in a large area, may have a different response plan in place than an urban site, which has more services available, says Craig Smith, emergency disaster management officer, Covenant EDM.
Key to preparing for a Code Orange response is practice, such as conducting tabletop exercises in which teams run through simulated disasters to understand the flow and steps in the process. “The more you do it, the more comfortable you become with the event. A Code Orange can be very overwhelming for a site,” says Mike Hoffman, a fire safety consultant with Covenant EDM.
As with the Columbia Icefield accident, a site’s plan is often activated when a Code Orange standby is called by an EMS crew heading to a scene. In the standby phase, the hospital notifies the site administrator and managers, calls staff who are off duty and creates space within the facility by discharging patients who can be sent home and asking anyone waiting in the emergency room with a less serious illness to come back later. When the EMS crew reaches the scene, it assesses the situation to determine the support needed. If there are many patients, a Code Orange is declared.
Once on the scene at the Columbia Icefield, Mackenzie and the Banff EMS crews became part of a large rescue and emergency medical operation involving multiple government agencies and service providers — Parks Canada, local fire departments, STARS Air Ambulance, Alberta Air Ambulance, Associated Ambulance, Alberta Health Services, Alpine Helicopters and Peregrine Helicopters — from throughout the region. Limited telecommunications, difficult terrain and lack of road access at the crash site made the situation complex and challenging.
“The patients had rolled down an embankment approximately 30 metres on a road that was not accessible by normal vehicles,” says Mackenzie. “It wasn’t possible to get anywhere close to the scene with an ambulance.”
Lake Louise and Jasper fire department and Parks Canada visitor safety staff extricated the patients — 26 tourists and a driver — from the crash scene and brought them to a primary triage staging area via helicopter long lines.
All EMS crews were then in charge of transporting patients by ambulance from the primary staging area to a secondary area where emergency and flight physicians could re-triage them and perform critical interventions. Mackenzie also served as transport strike team leader, working with transport physicians, Alberta Health Services EMS and Associated Ambulance via cell phone to determine where each patient would be taken by STARS or ground ambulance for further treatment. The accident left three people dead, while another 24 people were transported to hospitals in Banff, Jasper, Calgary, Edmonton, Hinton and Grande Prairie.
Back at Banff Mineral Springs Hospital, getting the Code Orange standby call meant activating procedures. Staff quickly contacted the appropriate EDM teams at Covenant and Alberta Health Services and established communications with Canmore General Hospital and Parks Canada. All team members in all Banff hospital departments were required to stay on-site until cleared to go home.
“We had two physicians — one was at work, and one was on standby — along with our anesthetist. And there happened to be a shift change at 3 p.m., so we had 10 RNs on standby. Everybody’s hands were on deck and ready to go,” says Margie Smith, site administrator for the hospital.
Staff then completed a number of critical tasks, including discharging as many patients as possible; assigning roles, responsibilities and rooms for receiving critical patients; and readying ventilators and critical care equipment. They also placed the operating room, victim services unit and pharmacy on standby for support; provided pre-made disaster packages for patient registration; prepared extra sandwiches and food for the potential additional patients and team members; and briefed team members on how to handle media inquiries. And they put the RMCP on standby to bring more units of blood from Canmore and arranged for backup EMS staff from Alberta Health Services to support the area while the Banff and Canmore EMS teams were at the crash scene.
The hospital was prepared because staff practice Code Orange exercises every year with the Town of Banff, Parks Canada, the Banff Fire Department and other community services, says Margie. “We were working with people we practice with all the time. It’s a very cohesive team.”
In the end, the Alberta Health Services communications centre responsible for dispatching air and ground ambulances decided to transport more patients to hospitals in the northern health zone and sent only one patient to Banff.
“We were ready, and staff have to be congratulated on the work that went into the preparation. When the team comes together, it’s a fine-oiled machine,” says Margie.