Code White Response: A Holistic Approach to Emergency Management Training

Marc Aiello
An artistic expression of healthcare professionals gathering to train and ideate.
Graphic created by Vivien Zeng

HIROC is proud to support educational initiatives where our Subscribers and partners collaborate to share knowledge and develop new ideas that improve safety. As the official Education Partner at the recent Emergency Preparedness in Healthcare Conference, hosted by Spark Conferences, many valuable stories were shared over the course of the event. The following story is about a session hosted by the Emergency Management team at London Health Sciences Centre (LHSC). We are sharing this story with the hope that it will inspire new and innovative safety ideas at your organization, ultimately improving our healthcare system for patients, families, and staff.

Creating a safe environment is ultimately the goal of the Emergency Management team at London Health Sciences Centre (LHSC) in Ontario. Safe for patients and clients, but also safe for staff who can experience aggression and violence from patients or their families (a code white event).

It’s crucial for healthcare organizations to have proper support systems, resources, and comprehensive training to prepare staff to effectively manage these traumatic events while still looking out for themselves.

To address this, the LHSC team is taking an innovative approach to facilitate code white training. Their approach focuses on implementing trauma-informed strategies while including the perspectives of both patients and staff.

“When we train our staff, above all else, our goal is to create a safe environment where they can explore different options in their code white response with curiosity, without judgement, and certainly without trauma,” said Rosemary Thuss, Manager of Emergency Management at LHSC.

One of the core goals for Thuss and her team is to empower their frontline staff with regular training that does not re-traumatize or make them fearful the next time they need to respond to a code white. To plan for this, Thuss and her team have created a detailed process that puts compassion and understanding at the forefront.

Planning for Trauma-Informed Training

The first step in planning trauma-informed training is meeting with clinical leaders and educators to understand their unique departments in a code white context. The LHSC Emergency Management team asks things like what services their department provides, the physical layout of the department, whether staff work alone, their level of understanding of a code white, how often code whites get activated, and what staff normally get out of similar training.

According to Thuss, each session has an exercise proposal attached that lays out the purpose, objectives, and goals.

“We know the time staff give us in training is not just a time to train, but to set them up for success,” adds Thuss. “By having the purpose and objectives ready, we’re able to plan ahead of time on what some of the conversations will be and how we can navigate them with support staff.”

This exercise proposal is a roadmap designed to put frontline staff in a position of expertise. It clearly defines each step of the training and encourages trainees to avoid assumptions about themselves, their colleagues, patients and their families.

“Our core values include curiosity, teamwork, and compassion. We ask our staff to embody these values, not just for the patients and families they work with, but for themselves as well,” adds Thuss.

The Impact of Tabletop Exercises

One of the trickiest parts of developing trauma-informed training sessions is choosing a scenario that’s both believable and relatable but does not re-traumatize staff. The Emergency Management team utilizes tabletop exercises to enable meaningful conversations, peer-to-peer learning, and complete training objectives while considering the patient's perspective.

“Having staff consider the patient perspective for a moment does not take a lot of time or resources, but it does make a monumental difference in the way someone may approach an escalating individual,” said Zak Linley, Emergency Management Coordinator at LHSC.

In trainings, Linley recommends frontline staff offer simple choices to patients and their families in the moment to help de-escalate, such as: Would you like to sit up or down? Where would you like to have this conversation?

The team brings three key priorities to all trainings:

  1. Your Safety (safety of staff),
  2. Containing and Controlling the Threat,
  3. Calling for Help.

These priorities assist in helping staff better understand what resources and options they have available in those stressful moments. For example, staff could address patient concerns and preferences, inform patients of their personal boundaries, or call for help, escalate, and activate a code white.

“In the moment, you’re the expert in choosing what resource will fit. I’m not here to tell you when to use them, but the tabletop does give the opportunity to show when it’s appropriate to use which resource,” said Linley.

Considering All Perspectives

After every training session, a summary document is created that includes lessons learned, facilitator notes, areas for improvement, and a recommendation to department leaders on the perspective of what the Emergency Management team has seen in other departments. Being able to provide the summary report makes a huge impact after the training, especially since it can be shared with staff that could not attend.

A key lesson the team learned while facilitating these training sessions was just how vital it is to invite hospital security to them. According to Gary Minder, Emergency Management Coordinator at LHSC, the team found that staff had a few misconceptions about security and their role. By inviting them, they were able to address those and create a better understanding of security’s response.

“I think we take for granted sometimes the number of perspectives that exist within a department,” shared Linley. “We have nurses, PSWs, porters, cleaning staff – and they all come together in a pure learning environment to create a holistic approach to responding and escalating.”

Immediately after a potentially-traumatizing emergency, the team makes sure to approach the debriefing in an emotionally-aware manner. Thuss and her team are on-call for staff support, they provide crisis intervention to staff who responded, and they also make sure to contact all staff who were impacted, including security, to provide emotional support and practical assistance.

During the debrief, the team ensures staff have a psychologically safe environment to reflect in, employing a similar strategy used in their training sessions.

“We need to create an environment where people feel okay to have interpersonal communication, without fear of embarrassment, rejection, or blame assigned,” says Linley. “It’s our job to come in, facilitate the conversation, and create an environment where that conversation can happen in a meaningful way.”

If you have any questions about this article or if you’re interested in sharing a safety story from your organization with HIROC, please connect with us at