PH DOH – HEMS Guidelines on Early Warning and Alert Systems (For DOH Hospitals)

PH DOH – HEMS Guidelines on Early Warning and Alert Systems (For DOH Hospitals)

From Guidelines for Health Emergency Management – Hospitals, Philippines, 2nd edition, 2008, DOH, HEMS

ROJoson’s Notes: These guidelines may be adapted to city government hospitals and private hospitals.  The target is all hospitals to use the same early warning and alert systems as much as possible so that there will be alignment, avoidance of confusion, and effective networking.

The Code Alert System of the Department of Health is a mechanism for the provision of health services during emergencies and disasters which describes the conditions that govern the expected levels of preparation and the most suitable responses by all concerned, particularly during mass casualty situations.


The first code alert system provided by A.O. 182 s. 2001 was directed to the Department

of Health hospitals given that “most emergencies and disasters are unpredictable

but are not totally unexpected.” The tri-color system has been revised to expand beyond the hospital, paving the way for the harmonization of the code alert of the hospitals, regional offi ces, key central offi ces and the HEMS Central offi ce. The code starts its lowest level of alert at Code White, then Code Blue and Code Red.


The Integrated Code Alert System of 2008 (Administrative Order No. 2008 – 0024)

describes the conditions for adopting the alert status, the human resource requirements

and other requirements (e.g., logistics) with the procedure in implementing the Code Alert.



Alert Signals


It is a known fact that the occurrence of all hazards cannot be predicted.


• Earthquakes may occur without warning.

• Some hazards can be predicted as to

❍ Occurrence

❍ Impact on the community

❍ Outcome whether emergency or disaster

❍ Consequences or risks

• Hazards such as typhoons, volcanic eruptions, or threats of civil disorders, can be anticipated several hours before they occur, giving at least ample time to get ready to respond before emergencies or disasters are foreseen and/or declared.



Guidelines for Effective Early Warning and Alert Systems


Basic considerations in understanding a warning and alert system are described below

(Carter, 1991; SDP, 2000).


Timely warning of an imminent or probable hazard with a potential to cause an emergency or a disaster will possibly prevent the occurrence or lessen the severity of its

consequences. The extent of such reduction depends upon the interaction of three elements, namely:

• Accuracy of warning

• Length of time between the warning being raised/declared and the expected onset of the event

• State of Emergency/Disaster Preparedness



Requirements for Effective Warning include the capability to:


Receive international warning

Example: cyclone warnings from Tropical Cyclone Warning Centers in various locations;

meteorological indications from weather satellites of possibly developing threats

Initiate in-country warnings necessary in cases such as floods, landslides, volcanic

eruptions, earthquake

Transmit warning from national level and other key government levels; mostly done by radio links or broadcast systems

Transmit warning at local community level; may be done by local radio stations, sirens, loud hailers, bells, messengers

Receive warning and act upon it. This requires:

❍ possession of or access to a radio receiver or similar facility

❍ being in hearing/seeing distance of signals

❍ knowing what various warnings mean


Alerting consists of a number of response phases, namely:


Alert – The period when it is believed that resources may be required to enable an increased level of preparedness


Standby – The period normally following an alert when the controlling organization believes that deployment of resources is imminent – personnel are placed on standby to respond immediately


Call-out – The command to deploy resources


Stand-down – The period when the controlling organization has declared

that the emergency is controlled and that resources may be recalled


To implement these phases, there needs to be:


• A protocol of which organizations to alert for which emergencies and what tasks;

• A contact list for all organizations;

• Duty officer rosters in all organizations to ensure that the organization can be

contacted during off hours; and

• A description of the type of information that should be supplied in the various

phases of alerting.


Warnings should be transmitted using as many media as available. These may originate


• The scene or the potential scene of the emergency and passed upwards; or

• The national government and passed down to the scene of the impending emergency


A community warning should cause appropriate public responses to minimize harm.


Warning messages should:

• Provide timely information about an impending emergency.

• State the action that should be taken to reduce loss of life, injury and property


• State the consequences of not heeding the warning.

• Provide feedback to response managers on the extent of community compliance.

• Be short, simple and precise.

• Have a personal context.

• Contain active verbs.

• Repeat information regularly.


Code Alert Levels (White, Blue, and Red)


Code White


1. Conditions for adopting Code White:

• Strong possibility of a military operation within the area/region, e.g., coup attempt

• Any planned mass action or demonstration within the catchment area

• Forecast typhoons (Signal No. 2 up) the path of which will affect the area

• National or local elections and other political exercises

• National events, holidays, or celebrations in the area with potential for MCI

• Any emergency with potentially 10-50 casualties (deaths, injuries)

• Any other hazard that may result in emergency

• Unconfi rmed report of reemerging diseases, e.g., bird fl u, SARS


2. Human Resource requirements for responding to the Code:

• First response team ready for dispatch to include the following:

✔ 2 doctors preferably Surgeon, Internist, anesthesiologist, etc.

✔ 2 nurses

✔ First Aider/EMT

✔ Driver


• Second response team should be on call


• The following should be available for immediate treatment of incoming patients:

✔ General Surgeons

✔ Orthopedic Surgeons

✔ Anesthesiologists

✔ Internists

✔ O.R. Nurses

✔ Ophthalmologists

✔ Otorhinolaryngologists

✔ Infectious Specialists


• Emergency service personnel, nursing personnel and administrative personnel residing at the hospital dormitory shall be placed on call status for immediate mobilization.


3. Other requirements:

• The Hospital Operations Center should be activated. It should continuously report and coordinate with the Regional and DOH Central Operations Center.


Medicines and Supplies

• Ensure that emergency medicines (especially for trauma needs) be made available at the emergency room.

• Medicines and supplies in the operating rooms should likewise be reviewed and in

creased to meet sudden requirements.

• Other needs such as X-ray plates, laboratory requirements, etc. should be made available and not required to be purchased by victims.

• Personnel department to prepare for mobilization of additional staff.

• Finance department to ensure availability of funds in cases of emergency purchases and the like.

• Logistics department to coordinate with possible suppliers for additional requirements.

• Dietary department to open and meet the need of the victims as well as the health personnel on duty.

• Security force to institute measures and stricter rules in the hospital.

• Activate Bird Flu Plan/ SARS Plan, etc.

• Enforce and monitor use of personal protective equipment (PPE) for all health personnel.

• Triage system should be activated.




Code Blue


1. Conditions for Adopting Code Blue:

Any of the following conditions:

• When 20-50 casualties (red tags) are suddenly brought to the hospital.

• Any internal emergency/ disaster in the hospital which brings down their operating capacity (i.e., vital areas) to 50% or which would require evacuation of patients and setting up of a Field Hospital.

• For conditions other than MCI, the influx of patients is beyond the capacity of the hospital to handle.

• Confirmed/documented report of reemerging diseases (SARS, human to human avian flu) within the catchment area.



2. Human Resource requirements for responding to the Code:

• HEMS Coordinator to be physically present at the hospital.

• On-scene Response Team

• Medical Offi cer in charge of the Emergency Room

• All residents of the Department of Orthopedics

• Medical Offi cer in charge of the Operating Room

• Surgical Team on duty for the day

• Surgical Team on duty the previous day

• Mental health professionals

• All anesthesiology residents

• Toxicologist, chemical experts for poisoning and/or chemical cases (if available)

• All third and fourth year residents

• Administrative Officer or designate

• Nursing supervisor on duty

• All OR nurses

• Social workers

• Dietary personnel

• Offi cer in charge of supplies at the CSR

• The entire security force

• Institutional workers on Duty


3. Other requirements:

All those mentioned in Code White plus:

• Activate Hospital Emergency Incident Command System (HEICS).

• Other needs of victims apart from medicines and supplies depending on the disaster should as much as possible be made available.

• The Chief of Hospital/ Medical Center or his designate should make proper coordination with other hospitals for networking and/or possible transfer of patients.

• Incident Commander should assign a Safety Officer, Liaison offi cer to coordinate with other agencies, and Public Information Officer to serve as the spokesperson of the hospital.

• Social Service section should prepare assistance to victims in coordination with mental

health professionals of the hospital, if available, and the Department of Social Welfare;

in addition they should lead in providing information to relatives of victims.

• Mortuary section should anticipate dead victims brought to the hospital for proper care and identification.

• The security team, in anticipation of possible influx or patients, relatives, responders,

police, press, etc. should ensure smooth flow of traffic inside the compound especially for the ambulances.

• Should report regularly to HEMS OpCen and as much as possible have regular press

releases or briefings.




Code Red


1.Conditions for Adopting Code Red:

Any of the following is present:

• When more than 50 (red tag) casualties are suddenly brought to the hospital.

• An emergency wherein the services of the hospital is paralyzed since 50% of the manpower are themselves victims of the disaster.

• Hospital is structurally damaged requiring evacuation and/or transfer of patients.

• Conditions requiring mandatory quarantine of hospital and its personnel (e.g.,

SARS, avian fl u); uncontrolled human to human transmission of SARS/avian flu

within the catchment area.


2. Human Resource requirements for responding to the Code:

All personnel enumerated under Code Blue

All medical interns and clinical clerks

All nurses

• All nursing attendants

All institutional workers

All administrative Staff


3. Other requirements:

All those mentioned in Code Blue plus:

• The Chief of Hospital/Medical Center Chiefs can cancel all types of leaves and can order all personnel to report to the hospital.

• The Chiefs of Hospital/Medical Center Chiefs can temporarily stop all elective admissions and surgeries and network with other hospitals.

• The Chief of Hospital/Medical Center Chiefs should anticipate requests for additional

manpower and specialists not available in his hospital.

He is further authorized to accept medical volunteers and other professionals to augment the hospital’s manpower resources rather than transferring patients based on

some agreements.

• Networking with other hospitals for augmentation of resources and transfer of patients

in special cases.

• Answer all queries of the media pertaining to patients in the hospital.

• Anticipate evacuation and/or use of field hospital; closure and/ or quarantine of the


• The Chief of Hospital/Medical Center Chief to specifically be concerned with safety and security, not only of the patients but of the personnel as well.



Guidelines in implementing the Code Alert

• The Hospital Code Alert shall be declared by the Secretary of Health or by the Director of HEMS for external emergencies; by the Medical Center Chiefs; Chiefs of Hospital; HHEMS Coordinator; or Head of the Disaster Committee of the Hospital emergencies within their catch ment area.

• Chiefs of hospital/medical center to automatically declare Code White during national events and activities especially with the potential of an MCI.

• Each hospital shall prepare its own procedures in declaring and lifting the Code.

✔ The alert level is raised, lowered or suspended by the Secretary of Health, Director of HEMS for external emergencies and national events; the respective Medical Center

Chiefs/Chiefs of Hospital or their designates for emergencies within their catchment


✔ Conditions to raise or suspend the alert level depends on the threat – whether it is increased or is no longer present.

✔ Arrival of patients in the hospitals warrants the raising of the alert level; likewise alert can be suspended when no significant incident is monitored and the hazard or condition (typhoon, election, bombing, etc.) is finished and/or contained.





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