Built for Individual LTC Homes and Hospitals
EMERGENCY COLOR CODES
AUDIT READINESS &
EMERGENCY COMPLIANCE
Eliminate Gaps & Ensure 100% Protocol Compliance During Inspections
EMERGENCY COLOR CODES
AUDIT READINESS &
EMERGENCY
COMPLIANCE
Eliminate Gaps & Ensure 100% Protocol Compliance During Inspections
How to Run a Compliant Code Green Evacuation Drill in Long-Term Care
A step-by-step operational guide for healthcare leaders to manage horizontal and vertical evacuations, establish triage staging zones, and ensure regulatory compliance during an emergency evacuation.
1. Regulatory & Compliance Requirements
Under provincial long-term care regulations and fire safety standards, facilities must maintain actionable procedures for both partial (horizontal) and total (vertical/facility-wide) evacuations. Compliance officers evaluate evacuation sequencing, tracking tag accuracy, cross-barrier movement speed, and continuity of care at destination staging areas.
2. Step-by-Step Drill Scenario Execution
Phase 1: Decision & Immediate Command Setup (0–3 Minutes)
When an active hazard (e.g., severe smoke, structural damage, chemical hazard) requires area evacuation:
- Command Declaration: Charge Nurse / Incident Commander evaluates the structural threat and declares a Code Green.
- Overhead Announcement: Page clearly three times:
"Code Green – [Evacuation Area/Unit] to [Destination Staging Zone]". - Emergency Kit Retrieval: Retrieve the Master Evacuation Binder containing resident photos, mobility statuses, emergency contacts, and identification wristbands.
Phase 2: Prioritized Evacuation Sequencing (Minutes 3–15)
Staff clear rooms in a strict priority sequence to maximize survival and speed:
- Priority 1 (Ambulatory): Direct residents who can walk independently or with minimal guidance past smoke barrier doors first.
- Priority 2 (Wheelchair / Semi-Ambulatory): Transport residents requiring wheelchairs or steadying assistance.
- Priority 3 (Bedridden / Total Care): Evacuate bed-bound residents using blanket drags, evacuation sheets, or ski sheets last.
- Room Cleared Signal: Place a designated visual indicator (e.g., door ribbon, flipped card, or magnetic marker) outside each room once fully swept.
Phase 3: Staging Zone Management & Headcounts (Minutes 15–30)
- Cross-Barrier Holding: Move residents beyond automatic fire/smoke doors (Horizontal Evacuation) before attempting stairwell descents (Vertical Evacuation).
- Resident Triage & Tagging: Attach emergency identification bands displaying names, medical alerts, and primary care directives to every evacuated resident.
- Headcount Reconciliation: Staging Lead compares physical resident counts against the master census log and reports missing individuals immediately to Incident Command.
Phase 4: External Transport & All-Clear (Post-Event)
- External Relocation: If internal horizontal zones become unsafe, coordinate transport to designated partner shelter facilities.
- Overhead Announcement: Once the facility or area is cleared and deemed safe by fire officials, page:
"Code Green – All Clear, Code Green – All Clear." - Debrief & Log: Record complete movement timelines, equipment usage, and staff response metrics in the master fire and life safety binder.
3. Common Audit Failures & Corrective Actions
| Audit Area | Common Failure Point | Compliant Action Required |
|---|---|---|
| Evacuation Order | Attempting to evacuate bedridden residents before ambulatory residents, stalling hallway progress. | Strictly enforce Priority 1-2-3 ordering: clear independent walkers first to clear corridors quickly. |
| Room Status Markers | Staff re-enter already cleared rooms, wasting critical response time. | Mandate visual indicators (e.g., evacuation door ribbons) to signal a room is 100% evacuated. |
| Tracking Discrepancies | Residents are moved across units without being logged at the central staging desk. | Assign a dedicated Staging Log Clerk at every cross-barrier staging point to check off resident tags. |