Code Orange: How SickKids plans for the unimaginable

Picture this: It’s 8 p.m. and less than zero degrees outside on a snowy December evening in Toronto. In the city's largest stadium, a 50,000-person pop concert reverberates into the blizzard. Its echoes can almost be heard across town, straight through a bustling University Avenue to where some of its concertgoers, many of them youth, will end up by the end of the night – The Hospital for Sick Children (SickKids).

It’s respiratory virus season and the hospital is at 90 per cent capacity, with Emergency Department (ED) wait times at about eight to nine hours long. Patients and their families sit in the waiting area after hours as staff diligently admit and care for them.

Suddenly, alarms go off overhead. An announcer begins calling a Code Orange – known to staff as an external disaster or a mass casualty event.

Pagers begin to come to life across the ED, their shrill sound a call for all-hands-on-deck. Apparently, the pyrotechnics at a nearby concert malfunctioned and the resulting fire, equipment collapse, and crowd surge caused life-threatening injuries to several young people. Toronto Paramedic Services has called to say they are on the way with patients, but it’s unclear just how many will need life-saving care.  

“Six minutes until EMS arrives!” someone calls out to the flurry of nurses and physicians now organizing in the trauma room.  

Care teams are built within the first few minutes. A nurse and a physician are stationed in the ambulance bay. They have no idea what to expect but prepare for the worst.  

What happens next in a disaster is elusive to most. But it’s the exact scenario that over 160 staff at SickKids aimed to solidify and practice in a hospital-wide simulation this September.     

The code can be called in response to a variety of incidents, like multiple vehicle or bus collisions, acts of public violence, large fires, major weather events, or infrastructure collapses, to name a few.

Andrea Boysen, who has worked at SickKids for 31 years – 25 of those years as a frontline nurse and more recently as quality lead for the ED – has seen first-hand how crucial such simulations can be.  

“I remember 9/11, I was working, and we thought they might transfer patients to us from the States. Several years later, we held our breath when an Air France plane skidded on the runway at Pearson Airport. More recently, there was the Danforth shooting,” says Boysen.  

Those incidents didn’t result in a Code Orange activation for SickKids.  But Boysen remembers two real activations during her time here.  

“We were prepared for those real Code Oranges, and thankfully, the incidents didn’t seriously impact hospital operations. So it feels like a lot of close calls. But each is a reminder that it’s not a matter of if it happens. We need to prepare for when it happens,” she says.

The hospital has traditionally run small-scale multidisciplinary trauma simulations once per month. In 2019, co-medical director of the Trauma Program Dr. Suzanne Beno, along with Drs. Natasha Collia, Jonathan Pirie and others, evolved these simulation exercises into large-scale, hospital-wide mass casualty trauma and burn simulations. The aim was to push the system’s limits even further and combine the Code Orange preparation that was already happening within the organization.    

“We see that external disasters are happening increasingly across the globe, and Toronto is not immune to that. We want patients and families to know we’re practicing constantly to work out the kinks, be precise and ready to provide the best possible care,” says Beno.  

As the hospital maintains normal operations during the exercise, it was their priority to plan it in a way that would not impact patient care. Staff already engaged in pre-arranged education days were chosen for the simulation, and any others who wanted to participate were provided ample coverage in their units. Patients and families in the waiting room and other affected areas were also notified in advance. 

Charge nurse Leah McFeeters, centre, speaks to another staff member in front of the ambulance bay before the simulation begins. 

The “patients” start to arrive 

Once the Code Orange is called for the exercise, the first button in the trauma room of the ED goes off and everyone rushes to where they need to be. The simulation begins.  

The ED is impacted first, but the waves of a Code Orange spread far beyond it. In fact, this is the largest simulation the team has organized to date, with the priority to simulate how every department in the hospital becomes a key player in the real-life scenario. 

Left: A “patient” is brought into the trauma room from the emergency bay as part of the hospital’s simulation. Right: A physician examines an ultrasound for a simulated patient in the trauma room.

A hospital Command Centre is activated, which includes a roundtable of key SickKids leaders who mobilize quickly to plan hospital operations and troubleshoot during any major colour code.  It's composed of representatives from several teams – from Protection Services, who liaise with external organizations like police, to Child Health Services, who monitor and address resource gaps across the hospital. 

“We coordinate the hospital-wide response, including mass internal redeployment of staff, opening alternate care spaces and reallocating resources to keep patients and staff safe,” says Yvonne Howard, who is the Improvement Specialist – Emergency Preparedness and led the planning of the Command Centre component of the simulation.  

The Command Centre also supports the Social Work team to open a Family Information Support Centre (FISC) which helps locate and reunite families with patients in this type of crisis situation.  For the simulation, live actors pose as parents looking for their children.  

Andrea Boysen, right, and other staff work to register simulated patients as they arrive. 

On other levels of the hospital, beds and operating rooms need to be vacated, and quickly.   

The Diagnostic and Interventional Radiology, Surgery and Critical Care teams begin anticipating patient transfers while ED teams downstairs assess the interventions or procedures their patients need.   

Because the Operating Room and Critical Care may be impacted for days or weeks after a mass casualty event, the exercise is crucial for practicing patient transfers, cancelling surgeries, and ‘fanning out’ to obtain more staff. From there, they can create highly specialized care teams, including those ready to deploy to the ED at a moment’s notice.  

Outside of these areas, the blood bank prepares to service a higher volume of patients, and surgical subspecialties like Neurosurgery, Orthopaedic Surgery, and Burns and Plastic Surgery are standing by, ready to spring into action at any time.  

Back in the ED, patients continue arriving in the ambulance bay and are assessed, triaged, and assigned to a team that includes a trauma team leader (TTL), two nurses, and an anesthesiologist. A medical lead (paediatric emergency physician) and a surgical lead (general surgeon) will provide oversight and leadership to these care teams. 

Four simulated patients are already being cared for in the trauma room. Their teams crowd around them as other patients arrive with severe injuries.  

“There is a sensory overload. You feel a sense of urgency, you feel nervous but alert. It’s loud, there are a lot of sounds, movements and distractions because of the sheer volume of people and the high clinical severity of the patients,” says Dr. Joshua Ramjist, medical co-director of the Trauma program.  

A care team member stabilizes a patient in the trauma room.  

In the front of the room, one patient, in this case a life-like manikin, is lying on a bed as her team quickly tends to her injuries and communicates with one another.  

“I’ve got pressure on the wound.”  

“Do we have blood from the blood bank yet?” 

“I’m anticipating an intubation.” 

The team works quickly to inspect the child. A facilitator for the exercise shares that the patient was hit by a metal bar from an overhead light from the concert stage. It had penetrated her lower abdomen.  

“She’s screaming in pain,” the facilitator shares. 

“Can we let the MD lead know that we need a surgeon in the room?” A member of the care team shouts. 

They decide to give their patient pain medication and continue. 

Meanwhile, a team across the room begins transporting their patient, who was trampled during the crowd surge at the concert, for a CT scan on the second floor. Each person wears a focused resolve, a stark contrast to the organized chaos around them. 

“We make a big deal about eliciting a lot of overwhelming feelings in the sim. We want you to feel like your plastic manikin is the most important thing in the world. Because if you’ve felt those feelings before, when it happens in real life, you'll have been there,” says Ramjist. 

Once on the second floor, the team uses a practiced, swift movement to place their patient onto the CT scanner platform from the stretcher. The Diagnostic Imaging specialists take over.   

In succession, they all look down at their phones as they receive word that the simulation has ended. 

Dr. Joshua Ramjist reviews notes made by staff regarding areas for discussion during the Code Orange simulation debrief session. 

The simulation evolves 

Afterwards, all participants converge in the hospital’s Daniels Hollywood Theatre for a debrief. The debrief is a key component to the simulation, because it informs any processes identified throughout the sim that need to be improved upon.  

“All of our processes are constantly evolving, being tested, reviewed and revised through simulation,” says Leah McFeeters,  a charge nurse in the ED overseeing emergency preparedness and one of the nursing leads for the exercise. 

“It’s the reason we decided to implement a physician and secondary triage process to help with difficult decision making. Our blood bank process has also evolved, so we can get blood to patients even quicker than before,” says McFeeters.  

Left/Top to right/bottom: Andrea Boysen speaks to other SickKids staff at the Code Orange debrief. A breakout group discusses areas for improvement for the next scheduled simulation. Dr. Suzanne Beno, co-medical director of the Trauma Program, organizes feedback as part of a debrief exercise.

Interprofessional Education Specialist and nurse Seona Dunbar addresses a crowd of participants and facilitators at the Code Orange simulation debrief, located in SickKids’ Daniels Hollywood Theatre. 

Seona Dunbar, interprofessional education specialist and nurse, stands at the front of the room and facilitates conversations about what worked, and what didn’t. She is also one of the nursing leads for the exercise.

“Nurses are one of the largest workforces, we’re the glue that keeps everything together – the same is true in a Code Orange. There’s a wealth of learning to be gained from their roles alone,” says Dunbar.

Given her decades as a nurse at SickKids, Dunbar calls on Boysen, asking for her thoughts about the evolution of the simulation over time. 

She takes a pause to respond.  

“I’ve seen real disasters and simulated ones over the years. Each year I watch as we put so much care into fine-tuning and improving with each iteration, and that’s what will save lives. That’s why we do this, and we should be very proud,” she responds.