Group photo of training staff
Toronto Western Hospital Emergency Department nurses and Code Orange Committee members after a recent training session. (L to R, back): Dalena Dang, Catriona White, Gillian Labrie, René Samuda; (front) Nicole Harada and Laurie Metcalf (missing Michelle Gallant). (Photo: UHN)

It's a sign of the times.

As horrifying events that once only happened a world away – vehicle attacks on pedestrians, mass shootings, rampages in urban centres – have come to Toronto, hospital staff members have had to focus attention on how they would deal with a Code Orange, which is a mass casualty event.

"In our line of work, you have to have forward thinking and always update your disaster planning," says Kathy Bates, Nurse Manager of the Toronto Western Hospital Emergency Department (ED).

In preparation for the Pan Am Games in 2015, Kathy tapped into her team and recruited ED nurse Nicole Harada to help develop the unit procedures. Nicole, in collaboration with UHN's Emergency Preparedness team, developed the resource binder in case of a mass casualty event.

The resource binder was to provide guidance to staff who – after first responders – would be the front line of the healthcare system activated to handle a mass casualty event.

Although Kathy has great faith in her staff to handle whatever comes their way, the complexity and changes to regular operating procedures in a Code Orange require more support, regular training and practice.

Even before the awful events in Toronto of the Yonge St. van attack and the Danforth shooting, several departments across UHN, as well as other hospitals in Toronto and the GTA, had started to ask "what if it happened here." At UHN, they turned to Emergency Preparedness for guidance.

"We started getting more inquiries from various departments about what they could do to better prepare in case of a Code Orange," says Paul Beverley, Manager of the UHN Emergency Preparedness Program. "Updating Code Orange processes was always part of our project plan but it became an urgent priority after the van attack in the spring."

To that end, the Code Orange Steering Committee, which features representatives from all UHN sites, started meeting last month to develop a workshop that will improve departmental Code Orange protocols, tools, awareness, and competency, and enable each department to provide care and treatment to multiple patients from a sudden surge that occurs in a mass casualty incident.

Best way to empower is through education

At TW, in an attempt to ease anxiety on part of staff in dealing with a Code Orange, a team of seven staff from the ED came together to develop a training session for their peers.

"We really didn't want staff to have any anxiety or feel unprepared at the thought of a Code Orange," Nicole says. "The best way to empower them was through education, and so we looked at how to bring the binder to life so we could teach everyone exactly what to do."

The team, including Nicole, Dalena Dang, Michelle Gallant, Gillian Labrie, Laurie Metcalf, René Samuda, and Catriona White, went about walking through each Code Orange process to figure out how best to teach it to their colleagues.

The team consulted Emergency Preparedness to work through some of the larger system questions to include an overview of what happens in the wider hospital in a Code Orange situation.

"We really got into the details," explains Nicole. "In a Code Orange, regular activity at the hospital and how we approach situations changes – for example, all UHN clinics are closed and some get taken over for use by the ED to treat patients.

"At TW, the Fracture Clinic becomes 'The Green Treatment Area' for patients who can walk but are also wounded," she continues. "We went into that clinic to understand its set up and flow, and discussed how we would use the space in an actual Code Orange so we could include this in our training."

Ambulance on the road

As unsettling events around the world were visited upon Toronto, healthcare staff across the city prioritized updating procedures and re-training staff  for response to a Code Orange, mass casualty event. (Photo: Google Images)


In the end, the team developed  a four-hour class, with roughly two-thirds of the time devoted to drills.  

But this was around the time real-life intervened – the late April van attack on Yonge Street, which underlined the need for Toronto to be prepared for anything.

The session was ready to go by late summer, and the need for it was highlighted again by another tragedy close to home – the shooting attack on the Danforth.

TW ED staff began signing up for training in early August and, by mid-September, more than 80 per cent  had completed the class. The experience has been both empowering and, despite the serious context, fun.

"The fact that the training was delivered by my own colleagues, by people I know and work with, made it better," says Cherie Aggabao, a fellow nurse in the ED, and one of the first to attend the session.

"The nurses on the committee are in touch with the ED's concerns, they know the layout of our work space, and can relate to our department so we could ask them any question and get answers that were real to our environment instead of a hypothetical."

"I feel much more ready to handle a Code Orange situation now," she adds. "And I know we'll have opportunity to keep practicing and build the muscle memory for this process."

Video being developed to be e-learning module

The Code Orange Committee at TW has already planned ways to keep the training fresh and build staff's familiarity with the code response.

After all staff have completed training, Nicole and her team will start spontaneous Code Orange scenario drills. A staff member will be handed a card with a scenario and asked to walk through the necessary steps to respond.

For example, one scenario asks staff to take account of the current status of patients in the ED and decant – or move them to other areas in the hospital as necessary – to make room for patients on their way to the TW ED as result of a Code Orange. The drill encourages staff to think on their feet using real-time information.

The committee also worked with UHN Emergency Preparedness to develop a video that will eventually become an e-learning module.

It's sometimes difficult to consider and plan for worst-case scenarios. But for now, the Code Orange Committee, and wider TW ED team, are embracing the opportunity and looking for the positive as they train to be as ready as possible.

"We love our team so much," says Nicole. "We work in a very supportive culture, and any time we can focus on strengthening our team in a low stakes environment, is nice.

"The sessions have done a lot for team morale."​

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