Policies,Administrative,UWHC,Department Specific,Respiratory Care Services,Administrative/Organizational

Patient Care Hospital Emergencies and Internal Disasters (1.24)

Patient Care Hospital Emergencies and Internal Disasters (1.24) - Policies, Administrative, UWHC, Department Specific, Respiratory Care Services, Administrative/Organizational


1.24 Patient Care Hospital Emergencies &
Internal Disasters
Category: UWHC Patient Care Policy
Effective Date: November 1, 2016
Version: Revision
Section: Emergency/Safety


To describe Respiratory Care (RC) specific response to all UWHC and AFCH blue carts, rapid
responses, and internal disasters.


A. Comply with cardiopulmonary resuscitation response. See P&P 8.13, Cardiopulmonary
Resuscitation Response Team.
B. Comply with Rapid Response or Pediatric Early Warning Signs (PEWS).
See P&P 7.36, Emergency Response Team.
C. Comply with internal disasters utilizing the Emergency Quick Response Guide. See UW Health
CSC Emergency Quick Response Guide.
D. RC will respond to all Red Alerts and will shut off oxygen valves when instructed.


A. Patient Care Emergencies - "Adult Bluecart” or “Pediatric Bluecart” to room" or "Adult Trauma
Team to the ER" or "Pediatric Trauma Team to the ER" “Level One Trauma” “Level Two
Trauma” (Cardiopulmonary Resuscitation Response Team, Hosp P&P 8.13 and "Do Not Resuscitate/No
CPR Orders”- Hosp P&P 8.23, Hosp P&P 12.18 and RC P&P 1.28, Multi-victim Trauma Response)
1. RC Response:
a. RC staff that discover an arrest victim should begin Basic Life Support and remain at
the site until other RC coverage is arranged by the Charge Therapist. Available RC
staff responds to announced blue carts STAT to assure 2 RCP’s are in attendance and
then are redirected by the Charge RCP at the resuscitation as needed.
b. All non-ICU RCP’s will respond to blue carts in AFCH. AFCH RCP’s will remain in
AFCH for UWHC codes unless the code is for a child. Then the floor AFCH and Peds
Clinic RCP will respond.
c. The Charge Therapist responds to all blue carts STAT.
d. The Emergency Room Therapist responds STAT to the Emergency Department for all
level one and level two traumas.
2. RC will follow Hospital guidelines for resuscitation until the "Blue Cart" team assumes
resuscitation efforts. RC will then assist with airway management.
3. Upon request from Materials Management Reprocessing, Respiratory Equipment Center or the
Charge Therapist will check and re-supply the blue cart.

B. Hospital Emergencies/Internal Disaster; see P&P 12.42, Internal Disaster.
1. Electrical Outage/Equipment Failure.
2. Tornado Alert
a. All routine therapy (i.e. non-life support) will be on "Hold". RC staff will assist with
relocating patients requiring oxygen/aerosol support.
b. Establish alternate continuous oxygen delivery. (Example: The patient's nasal cannula
tubing is extended and brought with them to be plugged into another patient's room along
the inner corridor. A transport oxygen device may also serve as an alternative source,
but its use should be limited to only when necessary.)
3. Bomb Threat
4. Emergency Communication

5. Missing or abducted child (Code Pink)
6. Fire (Code Red) Only RC is permitted to travel through fire doors to shut off oxygen when
7. Medical Gas/Vacuum Outage. RC will respond to exact location of oxygen outage and provide
oxygen for patients who require it.
8. Hazardous Materials Emergency.
9. Active Shooter (Code Yellow).

IV. References
A. UW Health Quick Reference Guide
B. Cardiopulmonary Resuscitation Response Team; Hospital Policy 8.13
C. Do Not Resuscitate/No CPR Orders; Hospital Policy 8.23
D. Fire Response; Hospital Policy 12.27
E. Fire Prevention When O2 is in Use; Hospital Policy 12.21
F. Hazardous Spill Leak; Hospital Policy 12.28
G. Tornado Response Plan; Hospital Policy 12.51
H. Utility Failure; Hospital Policy 12.55
I. Plan for Emergency Loss of Piped Gas Pressure; RC Policy 1.25
J. Internal Disaster; Hospital Policy 12.42
K. Mechanical Ventilation, Adult & Pediatric; RC Policy 2.02
L. Code Yellow, Active Shooter; Hospital Policy 12.61
M. Code Pink, Infant/Child Abduction; Hospital Policy 8.54

Approved by Director of Respiratory Care: Approved by Medical Director of Respiratory Care:

Original copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].