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Code Purple: Time to call in the emergency reinforcements

In hospitals throughout the country, a "Code Blue" alert indicates a patient in need of immediate resuscitation, most often as a result of cardiac arrest. Depending upon the country or state, "Code White" might indicate a pediatric emergency, a violent patient, or severe weather.

In U.S. military hospitals and in some civilian hospitals, "Code Black" usually indicates mass casualty. "Code Green" or "Code Orange" or "Code Silver" can mean a combative person, a call to evacuate, or an "all clear." "Code Red" usually refers to fire, and "Code Pink" or "Code Amber" signals an infant or child abduction.

To this rainbow of alerts, Community Hospital and a growing number of hospitals in the United States and Canada have added "Code Purple," a signal that the Emergency department (ED) is "impacted," or suddenly overwhelmed by the number of patients awaiting emergency medical attention.

Emergency department overcrowding is a nationwide problem. It is a source of patient frustration and can impede the delivery of care. The goal of a Code Purple is to launch a response that will reduce the length of patient waits and improve patient safety and satisfaction during times of high demand.

At Community Hospital, a "Code Purple" is announced through a paging system when all the beds in the Emergency department are full and there are five or more people in the waiting room, or when any patient has been waiting for more than two hours.

"Everyone in the hospital knows the ED is busy, but some people might have no idea that it is that busy," says Catherine Powers, director of nursing administration.

From a hospitalwide standpoint, the code alerts staff that the department needs help expediting patients. The hospital recognizes that patient flow through the department is influenced by many factors besides the most obvious: the number of patients seeking care, and the severity of the problem that brought them to the ED. Registration, laboratory, radiology, and housekeeping services, as well as patient transport within the hospital, ambulance traffic, and the number of patients in other departments and floors, are among the many elements that affect how quickly the next Emergency bed can open up so a new patient can be admitted.

"In the past, ED overcrowding and the resulting long waits were considered solely an Emergency department problem," says Dr. John Hage, Emergency department physician. "The impetus behind Code Purple is the recognition that solving emergency room overcrowding is a hospitalwide challenge. The faster a patient can be registered and examined, have diagnostic tests performed and disposition determined, and be physically moved out of the ED to an inpatient bed or home, the more quickly the next emergency patient can be cared for."

Before calling a Code Purple, the Emergency department evaluates its staffing and calls in additional staff as needed. Once a Code Purple is activated, a chain of events is put into play. Attending physicians are required to evaluate possible inpatient admissions within 30 minutes. Lab testing and radiologists’ readings of studies are expedited, and medications needed from Pharmacy are filled within 15 minutes. All available transporters report to the Emergency department when done with their current assignments. Beds must be assigned within 5 minutes of request, and the nursing floors must take patients as soon as rooms open.

"The reason it still seems like such a long time from the patient’s perspective," says Jodi Schaffer, director of the Emergency department, "is because when they come into the ED, we not only go through process and intake, but our position when we do any testing is that we have to have the test results back before we make a disposition. We need to make sure we are sending patients to the right place once they leave the ED. We need to make sure we’re not missing anything. It’s part of the full level of service you get when you come into the ED."

On an average day, the department is usually able to stay on top of patient volume until noon or 1 p.m., when traffic reaches its peak. The department typically receives another surge around 3 p.m. and again at 6 p.m. If the department gets backed up, it’s time to call in reinforcements.

"We implemented this for our community because we recognized that the most common concern is wait time," Schaffer says. "We wanted to minimize that to the best of our ability without compromising care. It’s a team effort, and the ED staff appreciates the rest of the hospital staff who help us with our patients."

Code Purple is still a relatively new endeavor, and there is no data yet regarding its impact on patient care. But so far, every time a Code Purple has been called, staff has been able to attend to patients and clear the waiting room within two-and-a-half hours during high-volume periods, rather than the four-to-eight hours it took before. The expectation, Schaffer says, is that this system will continue to expedite emergency care, enhancing outcomes and improving patient satisfaction.