International Journal of Clinical Medicine, 2013, 4, 499-503
Published Online November 2013 (http://www.scirp.org/journal/ijcm)
http://dx.doi.org/10.4236/ijcm.2013.411088
Open Access IJCM
499
Diversity of Emergency Codes in Hospitals
Nilsa Padilla-Elías1, Marisol Peña-Orellana1,3, Ralph Rivera-Gutiérrez1,3, Juan A. Gónzalez-Sánchez2,
Heriberto A. Marín Centeno1,3, Héctor Alonso-Serra1, Liza Millán-Pérez1, Patricia Monserrrate-Vázquez 1
1(Center for Public Health Preparedness) Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico,
San Juan, Puerto Rico; 2(School of Medicine) Department of Emergency Medicine, Medical Sciences Campus, University of Puerto
Rico, San Juan, Puerto Rico; 3Department of Health Services Administration, Graduate School of Public Health, Medical Sciences
Campus, University of Puerto Rico, San Juan, Puerto Rico.
Received September 13th, 2013; revised October 14th, 2013; accepted November 2nd, 2013
Copyright © 2013 Nilsa Padilla-Elías et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Hospitals must be prepared to deal efficiently and effectively with different emergencies. To accomplish
this, several countries have standardized their hospital emergency codes to improve their response capability. This is
particularly important in Puerto Rico given that many health professionals, particularly physicians and nurses, provide
services in more than one hospital. This study examined th e emergency codes and alerts utilized in Puerto Rican hospi-
tals. Objective: To assess hospitals’ level of emergency prep aredness and response capability related to the variability
of emergency codes and alerts utilized to respond to a situation in Puerto Rico. Method: A survey was conducted to
characterize hospital emergency department level of preparedness and response to a mass fatality in cident. A total of 39
out of a sample of 44 hospitals participated in the study. Semi-structured questionnaires were administered by the re-
search team to members of each hospital’s administrative staff to explore the follo wing: general hosp ital characteristics,
emergency plans, emergency department capacity, collaborative agreements, personnel training, emergency communi-
cations, laboratory facilities, treatment protocols, security, epidemiologic surveillance, equipment and infrastructure.
Results: Some hospitals in Puerto Rico use color coded emergency alerts, while others use key words or codes. Single
color emergency codes can have different meanings in different hospitals. Conclusions: The findings clearly show that
there is a lack of uniformity and clarity in the emergency codes utilized by hospitals in Puerto Rico . Single color codes
have diverse meanings in different hospitals. This could adversely affect hospitals’ efficient and effective emergency
response.
Keywords: Communications; Hospitals Health; Health Communications; Emergency Preparedness; Preparedness;
Emergency Codes
1. Introduction
An emergency is defined as any incident, caused by hu-
mans or a natural event, that requires an effective, re-
sponsive action to protect life or property [1]. Therefore,
the response to an emergency must be quickly, coordi-
nated and well-planned [2]. Initial efforts for the stan-
dardization of emergency codes in hospitals started with
an incident where three persons were killed in southern
California in a shooting at a medical center after the
wrong code was called [3]. This particular incident led
the Hospital Association of Southern California to de-
velop a comprehensive campaign to achieve standardize-
tion of hospital emergency codes [1].
Assuring emergency preparedness and response re-
quires a systematic and structured methodology that en-
ables an objective assessment [4]. As part of this effort, a
number of jurisdictions have moved towards standardiza-
tion of hospital emergency codes. The need for code
uniformity is underscored due to the mobility of the
health care workforce. Staff who are reassigned to a new
medical facility, or who must practice in more than one
facility, need to be immediately familiarized with a code
identifying the nature of a giv en crisis and their expected
response [5].
The purpose of the study was to assess hospitals’ level
of emergency preparedness and response capability re-
lated to the variability of emergency codes and alerts
utilized to respond to a situation of emergency in hospi-
tals in Puerto Rico.

Diversity of Emergency Codes in Hospitals 500
2. Methods
A survey was conducted to characterize hospital emer-
gency department level of preparedn es s and re s pon se to a
mass fatality incident. A total of 39 out of a sample of 44
hospitals participated in the study. Semi-structured ques-
tionnaires were administered by trained research assis-
tants to hospital directors to explore the following: gen-
eral hospital characteristics, emergency plans, emergency
department capacity, collaborative agreements, personnel
training, emergency communications, laboratory facili-
ties, treatment protocols, security, epidemiologic surveil-
lance, equipment and infrastructure. The selection of the
hospital emergency departments that participated in the
study was conducted by the Puerto Rico Department of
Health (PRDOH) Office of Public Health Preparedness
and Response (OPHPR). The OPHPR provided the re-
search team with a list of 44 healthcare facilities g rouped
into six (6) co alitions: North, Sou th, East, West, Metro A
and Metro B. The list consisted of forty-one (41) hospi-
tals and three (3) community health centers, which in-
cluded a Diagnostic and Treatment Center, a primary
health center and a family health center. All these health-
care facilities were located in 23 municipalities through-
out Puerto Rico. Figure 1 shows the location of the par-
ticipating emergency departments. At the end of the
study, 39 hospital facilities agreed to participate in the
study, yielding a response rate of 88.6%.
To gather the data, seven (7) electronic instruments
were constructed considering ten (10) dimensions identi-
fied through the literature. These dimensions were: 1) gen-
eral characteristics of the hospital; 2) emergency plans; 3)
collaborative agreements between agencies; 4) infras-
tructure and equip ment; 5) ep idemiologic surv eillance; 6 )
protocols for medical treatment; 7) laboratory; 8) training
among personnel; 9) communications during an emer-
gency; and 10) hospital physical security. Confiden-
tiality and voluntary participation issues were discussed
with all subjects and all study activities were reviewed
and approved by the Human Subjects Institutional Re-
view Board. IRB: RCM IRB, protocol #A66640211,
January 31 , 2011.
3. Results
Results from this study showed that some hospitals use
color coded emergency alerts, while others use key
words or codes. Moreover, a single color emergency
code can have diverse meanings in different hospital in-
stallations. Among the key colors th at showed the highest
diversity were code blue with seven different meanings,
code yellow and code white with six different meanings,
and code green with five. The findings of the study
showed the following color codes as the most used: red
for fire with 79.5% (n = 31); gray for safety/security
situation with 74.4% (n = 29); and, green for cardio-res-
piratory arrest with 71.8% (n = 28). Figure 2 shows the
different emergency codes used in hospitals in
Puerto Rico based on the response of 39 healthcare
facilities.
MOCA
MAYAGUEZ
SAN GERMAN
AGUADILLA
ARECIBO MANATI
OROCOVIS
VEGA BAJA
PONCE
YAUCO
LARES
GUAYAMAARROYO
CAYEY
CAGUAS
HUMACAO
AIBONITO VIEQUES
CAROLINA
FAJARDO CULEBRA
SAN JUAN
B AYAMON
Source: Office of Public Health Pre
p
aredness and Res
p
onse
,
Puerto Rico De
p
artment of Health
Figure 1. Location of Participating Emergency Departments.
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Diversity of Emergency Codes in Hospitals 501
Figure 2. Diversity in Puerto Rico hospital’s use of emergency codes N = 39.
Emergency Code Meaning of the code n %
Cardio-respiratory arrest 28 71.8
Death or health hazard 1 2.6
Agitated patient 1 2.6
Internal disaster 1 2.6
Green
Rapid Response Team 1 2.6
Assisting patient w ith primary need 8 20.5
Bomb (explosives or threat) 1 2.6 Black
Dead or dying patient 1 2.6
Rapid Response Team 8 20.5
Orange Critically ill patient 2 5.1
Brown Evacuation 10 25.6
External disaster 11 28.2
External/Internal disaster 5 12.8
Cardio-respiratory arrest 5 12.8
Disaster 4 10.3
Flood 2 5.1
Earthquake 2 5.1
Blue
Internal disaster 1 2.6
Fire 31 79.5
Arrival of first victim 1 2.6 Red
Major emergency 1 2.6
Flood 9 23.1
End of the emergency 2 5.1
Kidnapping/robbery/theft of child/infant or child lost 1 2.6
Puncture with syringe 1 2.6
Emergency with psychiatricpatient 1 2.6
White
Bomb (explosives or threat) 1 2.6
Spill of hazardous material/substance 14 35.9
Safety/security situation 2 5.1
Kidnapping/robbery/theft of child/infant or child lost 2 5.1
External disaster 2 5.1
Emergency with pediatric patient 1 2.6
Yellow
Internal disaster 1 2.6
Kidnapping/robbery/theft of child/infant or child lost 9 23.1
Fire 1 2.6 Pink
Emergency with pediatric patient 1 2.6
Network shut down 1 2.6
Water 1 2.6
Hospital at maximum capacity 1 2.6
Violet
Kidnapping 1 2.6
Safety/security situation 29 74.4
External disaster 2 5.1
Guns or fire arms 1 2.6
Grey
Escaped Alzheimer patient 1 2.6
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Diversity of Emergency Codes in Hospitals
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502
Continued
Emergency Codes Meaning of the code n %
10 14 Suspiciou s pe rson 1 2.6
Alpha Kidnapping/robbery/theft of child/infant or chil d lost 1 2.6
Amber Kidnapping/robbery/theft of child/infant or child lost 11 28.2
Coca Cola Real patient during dr i l l 1 2.6
D1 External disaster 1 2.6
Delta External disaster 1 2.6
Delta Internal disaster 1 2.6
H2O Flood 20 51.3
H2O Spilled liquids 1 2.6
Don’t know Don’t k now the emergency codes 3 7.7
“Rápida” Rapid Re sponse Team 1 2.6
S Attempted kidnapping 2 5.1
TD Evacuation 1 2.6
4. Discussion
The findings clearly show that there is a lack of unifor-
mity and clarity in the emergency codes and alerts util-
ized in hospitals in Puerto Rico . A single code could have
diverse meanings in different hospitals. This could ad-
versely affect an efficient and effective emergency mobi-
lization of patients, visitors and hospital perso nnel during
an emergency. The lack of standardization increases the
potential for confusion or misinformation during critical
times [1]. In Puerto Rico, on August 10, 2011 Law 170-
2011, which allows the Department of Health to imple-
ment the standardization of protocol codes for emergency
care facilities in the private and public health sector was
approved [6]. This law represents an additional pr eparedness
effort; however, it is not completely implemented yet.
An emergency can happen at any time. Clear commu-
nication is a key element to ensure a quick response to
protect patients, visitors and staff. The fact is that code
alert and standardization among all hospitals may not be
immediate and there will need to be a planned transition
to the recommended code set. Several implications of the
diversity or inconsistent codes for the differences in ter-
minology have to be considered for planning, communi-
cation, and operations during an actual event [7]. Ac-
cording to the Hospital Incident Command System guid-
ance, it is important to po int out th e need to us e clear lan-
guage in case of a disaster event, especially when dealing
with external resources [8]. The goal is for hospitals to
phase in the implementation of the recommended codes
so that the required materials and training can be devel-
oped and offered at a time best suited for hospital per-
sonnel. Clearly, considerable training and financial re-
sources will be required for this transition to be con-
ducted efficiently and effectively [9].
5. Acknowledgements
Data for this study came from the Assessment of the
Emergency and Disaster Preparedness and Response Ca-
pabilities of Hospital Emergency Departments in Puerto
Rico, conducted during 2011. Funding source by ASPR-
USDHHS, administered by the Puerto Rico Department
of Health, Office of Public Health Preparedness and Re-
sponse, under contract 2010-DS0609. We acknowledge
the support we received from the hospitals that partici-
pated in the study and the Hospital Association of Puerto
Rico for their willingness to take into account data de-
rived from our studies in formulating health policy. We
would also like to thank Wined Ramírez López, for help-
ing in the edition of this manuscript and Julieanne
Miranda Bermúdez, for the preparation of the map.
REFERENCES
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Diversity of Emergency Codes in Hospitals 503
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