AL NABHANIYA GENERAL HOSPITAL

DEPARTMENTAL POLICY AND PROCEDURE

INDEX : REPLACES NUMBER:

DEPARTMENT: OPERATING ROOM
NGH-OR-xx NGH-OR-xx

POLICY TITLE/DESCRIPTION: Code Brown policy

EFFECTIVE DATE: NEXT REVIEW DATE: NO.OF PAGES:

December 2023G
December 2020G

APPROVED BY : APPLIES TO: Anesthesia staff, OR Nurses,

Surgeons
HOSPITAL DIRECTOR

1.0 PURPOSE: To ensure safety of patient as well as staff working in OR

2.0 DEFINITON: The evacuation method by which patients as well as staff in OR at the time
of external disasters like chemical spill or major electric shutdown

3.0 RESPONSIBILITIES:

All OR Staff Including Anesthesia staff and OR Nurses and Surgeons

4.0 POLICY:
All staff of OR must be aware of external disastes like chemical spill or electrical shutdown
preventing medical equipment failures.
All staff should know how to move safely taking patients to a safer place out of danger area.

5.0 PROCEDURES :
Check the evacuation route designed by FMS team of our hospital.
Shut down all equipment which run on electricity and shift to manual mode.
Portable oxygen cylinders were brought and used during transport of patients who were
already intubated and needs further oxygen requirements.

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All operations will be suspended till further notice.

Any emergency operations require immediate intervention will be immediately transferred
to nearby hospital.
Aware personnel working within the Operating theatre suite must be made through continuing
education, of specific health hazards within the working environment.

5 Fire Explosion and Safety:

10.5.1 Provided Operating room personnel with adequate orientation and ongoing education
on fire management and evacuation techniques.
10.5.2 Operating Room personnel must be able to state:
a. Location of fire alarms.
b. Location of fire exits.
c. Location of firefighting equipment.
d. Location of the appropriate extinguisher for potential operating room electrical fires,
combustible.
e. Evacuation routes
f. Steps in reporting a fire
g. The initial steps in dealing with a fire.

function effectively in a disaster

situation it is the responsibility of all

health care personnel to be aware

10.5.2 Should a disaster such as a fire

occur, the staff must be ready to

'perform the required duties

expeditiously and efficiently to ensure

safety for the patients and staff

Transport:

5.2.1 During transport ensure that side rails are up and seat belts attached; secure all
lines. Take patient immediately to nearest patient care station or other staffed
area in case of a need for emergency medical attention Call Code BLUE - as
indicated for pulselessness or breathlessness.
5.2.2All critically ill patients should have continuous monitoring of vital signs (NIBP, HR
and rhythm & oxygen saturation), during transfer.
5.2.3 Treatment those are ongoing (e.g. IV infusion or oxygen ) at A & E should be
continuous during transfer and stay in department.
5.2.4Plug in all rechargeable equipment upon returning to unit.
5.2.5 Disinfect equipment used in transport, e.g. stretcher, defibrillator/ monitor.
5.2.6Vital signs may be adjusted as patient condition warrants. Plug monitoring

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equipment into power outlet and position for continuous visibility.

Rescue / Reassure the patient.

Remove the patient immediately from the fire scene. Unconscious patients maybe
supported from the head and down to the floor in a sheet then dragged safely away
from the scene. Re-assure the1 other conscious patients and escort them to the
next room or in accordance with the hospital policy for evacuation of patients

Compressed gas cylinders:

5.2.1.5.1. Shut off oxygen by turning the valve clockwise
5.2.1.5.2. Store the compressed gas cylinders in upright position away from
the fire sources.
5.2.1.5.3. Affix to wall with chain or place a stand to prevent tipping.

LISTEN FOR FURTHER INSTRUCTIONS if other levels of evacuation are necessary.

Level 1 - Patient is moved from the room to another room
Level II - Patient is moved from one end to the opposite end (e.g. MOW to ENT)
Level III -Patient is moved from one floor to another floor
Level IV -Patient is moved out of the building - is a last sort

Doors shall not be obstructed for entrance and exit areas.

1. 6.0 EQUIPMENTS /MATERIALS:

7.0 REFERENCES :

8.0 FORM :

9.0 APPROVAL :

Prepared by: Reviewed by:

Dr Mohammed Musaddiq, Soniya Jintu,

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Anesthesia specialist. OR Head Nurse

Date : Date :

Reviewed by: Reviewed by:

Dr Ahmad Abdullah Ibrahim Dr Kashif Mohammed

Head of surgery FMS Director

Date : Date :

Reviewed by: Reviewed by:

Dr Ahmed Nassar, Dr Hashim Zakaria

Head of Anesthesia Dept. Medical Director

Date :

Date :

Approved by :

MR.AHMAD AL SARANI

Hospital Director

Al Nabhaniya Hospital

Date:

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