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Hospital staff being trained for Code Silver: how to respond to an active attacker

Training is underway across B.C. to prepare hospital staff for a new type of emergency — Code Silver — so they learn to run, hide or even fight in the face of an attacker.
Victoria General Hospital Emergency entrance. The course was launched in Island Health on Monday and 600 people have already taken it. DARREN STONE, TIMES COLONIST

Training is underway across the province to prepare hospital staff for a new type of emergency — Code Silver — so they learn to run, hide or even fight in the face of an attacker.

Mass shootings and other violent attacks around the world prompted the online ­tutorials that kicked off this week in Island Health and Northern Health and will roll out across all health authorities next year.

In-person sessions will follow, starting in Nanaimo Regional General Hospital, Victoria General Hospital and Royal Jubilee ­Hospital in Island Health. The training module is expected to become required learning for new staff.

Gerry Delorme, senior director of ­provincial operations at Health Emergency Management B.C., said there hasn’t been a Code Silver in a B.C. hospital, but it’s ­necessary to prepare for all possible threats.

“It’s deeply disturbing that people go into, whether we’re talking about nursery, whether we’re talking about school, whether we’re talking a workplace or a hospital — which is our workplace — with intent to do harm,” said Delorme. “But our role is to make sure that the health system is prepared.”

“We have to have these conversations — and they’re difficult conversations — but we have to have these conversations to make sure that at the end of the day, our staff and patients are safe.”

An earlier online module was tested to gather feedback on staff questions and concerns, and revised with input from various experts. The course was launched in Island Health on Monday and 600 people have already taken it and given positive feedback, said Delorme. More revisions are expected.

Hospitals have a standard international emergency code list that includes Code Blue for cardiac arrest, red for fire, white for violence or aggression, yellow for a missing patient, black for a bomb threat, green for an evacuation, brown for hazardous spills and orange for a disaster or mass casualties.

Code Silver for an active attacker is very different from Code White, indicating a patient who may become verbally or physically violent, threatening, aggressive or angry, said Delorme.

“Some people in our facilities are having the worst day of their life,” said Delorme. “These individuals are coming into our hospitals with no intent but something happens.” Staff are trained in de-escalation for that kind of scenario, he said.

In the case of a Code Silver, Delorme said, the goal isn’t to de-escalate but to employ mitigating strategies to keep staff and patients safe. “Run, hide or fight,” he said. “That’s the best practice around these things.

“The first strategy is get out, right, but if you are confronted and cornered and can’t egress and the person is moving towards you, the evidence is that ‘the fight’ is utilizing anything that you have and fighting for your life.

“We do know from the evidence that a passive approach will not work and the police say not to be passive.”

Active attacker policies and procedures have become common in health-care facilities in some provinces and in the United States, according to Island Health.

In the face of an active attacker, staff are instructed to use personal alarms or tell the nearest desk to page a Code Silver over the hospital intercom system; 911 is also called.

The message includes the attacker’s last known whereabouts and instructions to exit the facility if safe to do so.

There’s no prescriptive approach because it will be “situational” and require a series of quick decisions based on risk and immediate surroundings, said Delorme.

“We have to talk about judgment and not ‘protocolize’ everything,” said Delorme, who said strict protocols in such situations can lead to more harm. “We rely upon the judgment of our of our health-care teams every day to make very consequential decisions.”

Health Emergency Management B.C. brought in ethicists to help devise the training model because leaving a patient or fighting an attacker can be counter-intuitive for health-care workers.

Delorme likens it to first-aid training where first responders are taught to first identify whether a rescue is safe.

“The thing that we teach first is that we need to protect our staff,” said Delorme. “The second is that we need to protect the patient and we realize how difficult this will be.”

Delorme said the in-person sessions will broach the “moral distress” that some care providers may feel.

Health Emergency Management B.C. has also consulted with police, who eventually will be asked to do walk-throughs in hospitals to evaluate the plan.

“We see what’s happening to the south and we’re doing this in an abundance of caution to really protect our staff and our patients,” said Delorme.

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Cindy E. Harnett

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