Code black in the emergency room: what does it mean in different countries of the world?

To understand the concept of ‘code black’, it is first necessary to understand the concept of ‘triage’. Triage is a system used in Emergency Departments and DEAs (Emergency and Acceptance Departments) to select those involved in accidents according to increasing classes of urgency/emergency, based on the severity of the injuries sustained and their clinical picture

The code black in triage:

Hospital triage uses a colour code to make the urgency of treatment universally identifiable for each individual subject; in order of severity the patient will then be considered:

  • code red or ’emergency’: life-threatening patient who has immediate access to medical intervention;
  • code yellow or ‘urgency’: urgent patient with access to treatment within 10-15 minutes;
  • code green or ‘deferable urgency’ or ‘minor urgency’: patient with no signs of imminent life-threatening conditions, with access within 120 minutes (2 hours);
  • code white or ‘non-urgent’: patient who can refer to his or her General Practitioner.

Code black in Italy does not identify a state of seriousness, like the other colour codes, but rather indicates that the patient has died and can no longer be resuscitated.

Italy, code black is associated with certain death of the patient

In some cases, as happened during the pandemic caused by Covid-19, reference is made to code black when the doctors in a given health facility can no longer cope with the excessive number of patients arriving, or when there are no beds available for new admissions.

In the most serious cases, reference could be made to code black when the available beds in the intensive care unit are full, so it is necessary for the doctor to decide – in effect – who survives and who does not.

Let us suppose, for example, that three life-threatening patients arrive who would be destined for intensive care, but that only one place is available in this ward (and in the intensive care wards of neighbouring hospitals): in this case, it will be up to the doctor to decide which of the three patients can access that one place and thus have the best chance of survival.

Other colours used in triage are

  • code orange: indicates that the patient is contaminated;
  • code blue or “differential urgency”: is a patient with an intermediate severity between code yellow and code green, with access within 60 minutes (1 hour);
  • code blue: indicates that the patient has compromised vital functions in an out-of-hospital environment, generally activated in the absence of a doctor.

Code black abroad and in Grey’s Anatomy

In episode 16 of the second season of the TV serial Grey’s Anatomy, originally called ‘It’s The End Of The World’ and in Italian ‘Apocalypse (Code Black)’, a patient is brought to Seattle Grace with an explosive device inside his body.

The heart surgeon Burke announces the ‘code black’ (in the original language ‘code black’) that blocks all activities in the surgical wing: in this case ‘code black’ is used to indicate the presence of a bomb in the building, i.e. a potentially catastrophic extraordinary event.

Code black, in fact, takes on different meanings in various states

For example, in Canada it is used to indicate the presence of a bomb (or a suspicious package) in the building.

In England – as in Italy – it is used to indicate the absence of available beds for new admissions.

In Australia, these colour codes are used instead

  • code black: personal threat of various kinds;
  • code black alpha: missing or abducted infant or child;
  • code black beta: presence of individual using firearms in the building;
  • code black j: patient engaging in acts of self-harm.

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