NURSING PATIENT CARE POLICY & PROCEDURE
January 31, 2017
Nursing Manual (Red)
Policy #: 14.41AP
Title: Nurse Call System (Adult & Pediatric)
This policy is intended to provide guidance for unit and individual responsibilities for
use of the nurse call system on inpatient units. This policy also outlines the
procedures to be followed in the event of scheduled/unscheduled nurse call system
downtime or communication device problems.
II. POLICY& PROCEDURE
A. Patient Room Equipment:
1. The hospital bed is connected to the nurse call system using the
Nightingale Wireless Bed Interface. The Nightingale Wireless Bed
Interface eliminates the need for a physical cable to connect the patient
bed to the nurse call system.
2. Jacks on the Auxiliary Panel may be labeled for specific types of
equipment such as ventilators, chair exit alarms and early detection
devices. When the equipment is in use for a specific patient, it should be
plugged into the corresponding labeled jack on the Auxiliary Panel.
B. Patient Call Buttons
1. All patients should have a call light within reach that they are able to
demonstrate the ability to activate
2. Adaptive devices for the call light are available through Central
3. Adaptive devices should be plugged into the Adaptive Device Jack on
the Patient Station Auxiliary Panel.
C. Nursing Unit Console
1. Information about staff assignments and specific patient safety concerns
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such as fall risk, altered mental status, and communication barriers may
be visible from the personal computer (PC) Console module of the
Responder 5 Client Software to assist anyone responding to the call light
2. All call lights ringing at the nurse call console will be answered verbally
within 30 seconds when the console is attended.
a. Certain call priorities initiated in the patient room are transmitted
directly to the communication device of the staff assigned to that
b. Some call priorities immediately page all staff on duty in the nurse
call system for that unit.
c. Other call priorities escalate to additional staff if they are not
answered within a certain timeframe
3. The Health Unit Coordinator (HUC)/Patient Care Technician (PCT) (or
other staff answering a call) will communicate to the appropriate staff
member using "tagged” or “free text” messages, indicating the nature of
the request. In-person contact with the patient is expected to occur
within 5 minutes to address the call or patient request.
4. All units using a communication device for secondary alarm notification
will insure all patients have an RN assigned in Call Stop 2 and the Care
Team Leader assigned in Call Stop 5 in Responder 5 Client Software on
every shift for nurse call and telemetry escalations to work correctly.
D. Individual and Unit Responsibility
1. Pager/Communication Device
a. The pager/communication device assigned to a staff person for
their work shift is their responsibility. Non-functioning devices or
device damage should be reported immediately.
b. Whenever possible, the pager/communication device should be set
to "silent mode" (vibrate) to provide fewer patient disruptions.
c. The pager/communication device must be worn in contact with the
d. Messages are cleared from the pager/communication device as
alerts are addressed. Messages are cleared from
pager/communication device at the end of the assigned shift, prior
to turning the device over to the oncoming shift.
2. Tracer Tags or AeroScout/Service Connections badges are to be worn at
chest height. They should not be placed in a pocket or covered with a
name badge or stethoscope.
3. All direct caregivers will carry a pager/communication device and wear
a Tracer Tag or AeroScout/Service Connections badge on all shifts.
4. If the caregiver cannot respond within 5 minutes, the caregiver must
communicate this to nursing staff by using the call light, and the
HUC/PCT is responsible for verbally communicating the patient request
to another caregiver.
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5. If a caregiver is off the unit for more than 5 minutes including breaks
and meal coverage, the person leaving the unit or going on break is
responsible for one of the following:
a. Turning their pager/communication device over to another
b. Using the Break functionality in the Responder 5 Client Software
to forward their alerts to their assigned buddy.
6. It is recommended that each staff member enter his or her own patient
assignment and log On Duty in the Responder 5 Client Software at the
beginning of the shift and complete the device accounting log (if utilized
on the unit/area.)
a. Patient assignments from the Responder 5 Client Software are
communicated to the physiologic monitoring/telemetry system for
secondary alarm notification so timely entry of assignments is
7. In those instances where the staff member cannot enter his or her own
patient assignment in the Responder 5 Client Software, the HUC or PCT
will enter assignments.
a. Patient assignments will be communicated to the HUC/PCT prior
to starting report.
b. During change of shift report, the HUC/PCT will assign staff to a
pager/communication device and tracer tag, complete the device
accounting log, and enter the assignments into the Responder 5
i. If the unit/area is utilizing AeroScout/Service Connections for
staff presence notification, each staff member is assigned his
or her own personal badge and that specific badge name will
need to be entered in the Responder 5 Client Software as part
of the assignment process.
8. At the end of the shift, each staff member will take him or herself Off Duty
in the Responder 5 Client Software and complete the device accounting log
(if utilized on the unit/area.)
9. In those instances where the staff member cannot take him or herself off
duty, the HUC/PCT will perform that task as well as collect
pagers/communication devices and tracer tags from staff and complete the
device accounting log.
10. In the absence of the HUC/PCT, the Care Team Leader/Senior Team
Member will designate someone to perform the HUC/PCT nurse call
system assignment tasks and complete the device accounting log.
11. Shared pagers, communication devices and tracer tags should not leave the
hospital/work area. If an employee inadvertently removes a device from
the premises, it is expected this is reported to the unit immediately and
returned as soon as feasible (no later than the next scheduled work shift).
12. Do not remove sticker or other identifying marks from a pager or tracer tag.
Moving or replacing the sticker on a pager or tracer does not assign it a new
1. Nightingale Bed Unit Batteries: Bed Unit batteries have a life
expectancy of two years. In the event of the low battery alert from the
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a. At University Hospital and AFCH, notify Clinical Engineering at
263-5208 of the low battery alert. At The American Center (TAC),
notify Clinical Engineering at 234-6656. If after hours or on the
weekend, the batteries will be replaced the next business day.
2. Damaged Nightingale Bed Unit or Wall Unit: Contact the Clinical
Engineering for your site (as listed above) for replacement of damaged Bed
Unit or Wall Unit.
3. Nurse call pager acquisition, replacement, and repair:
a. New nurse call pagers are ordered by the nurse manager or
designee via a Service Now request.
b. Inoperable nurse call pagers should be taken to Clinical
Engineering for your site to be assessed for repair. If the pager
cannot be repaired, the nurse manager will be notified to order a
c. Pagers requiring cleaning/sterilization should be sent to Central
4. Tracer tag acquisition, replacement and repair:
a. New tracer tags are ordered from the distributor using the usual
minor equipment requisition process. The nurse manager should
contact the unit's nursing informatics liaison if current vendor,
pricing or part number information is needed.
b. Tracer batteries can be replaced by unit staff or by Clinical
Engineering. Batteries for tracer tags can be obtained from Central
Services via the CS Online Catalog (#4010580, battery lithium for
c. Inoperable tracer tags should be taken to Clinical Engineering to be
assessed for repair. If the tracer tag cannot be repaired, the nurse
manager will be notified to order a replacement.
5. AeroScout/Service Connection badge acquisition, replacement and
a. New AeroScout/Service Connection badges are ordered from
Information Services by submitting a Service Now Request.
b. AeroScout/Service Connection badge batteries must be replaced by
Clinical Engineering for your site.
c. Inoperable AeroScout/Service Connection badges should be taken
to Clinical Engineering for your site to be assessed for repair. If the
AeroScout/Service Connection badge cannot be repaired, the nurse
manager will be notified to order a replacement.
1. Scheduled Nurse Call System/Paging Network Downtime
a. Clinical Engineering will provide the Nursing Informatics liaison
as much advanced notice as possible with the need for scheduled
downtime of the nurse call system or nursing paging network.
Clinical Engineering will identify the functionality affected by the
downtime and an estimated duration.
b. A planning group including representatives from clinical
engineering and nursing informatics will convene to develop a plan
with a tentative schedule for the downtime. Representatives from
the distributor and the vendor may be included depending on the
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extent of the downtime. The tentative plan will be presented to the
nursing directors for endorsement.
c. The nurse managers will be notified in advance of the scheduled
d. Prior to, during and at the conclusion of the actual downtime, a
variety of methods will be used to communicate downtime status.
This may include paging, telephone calls, scrolling banner alerts
on workstations, and system alerts on UConnect.
e. If warranted, a Post Downtime Review will be conducted by the
downtime planning group.
2. Unscheduled Nurse Call System/Paging Network Downtime
a. Staff noticing problems with the nurse call system should notify
Clinical Engineering for their site (University Hospital, AFCH and
DHC call 263-5208, TAC call 234-6656) if the problem occurs
during business hours.
b. After hours, on weekends and on holidays, use the after hours
contact. (University Hospital, AFCH and DHC contact the Plant
Engineering Control Room at 263-5205, TAC call 234-6666).
c. Problems warranting notification may include, but are not limited
to, interruption of patient calls or voice communication from the
patient room to the nurse call system, failure of patient call
transmission to assigned staff pagers or communication devices,
recurrent error messages, or receiving calls at the nurses’ station
console from patients on another unit.
d. Clinical Engineering will assess the scope of the problem and
address the issue. If it is determined that the problem affects more
that one unit or more than one site, the Clinical Engineer will use a
variety of means to communicate system status to the direct care
staff. See 1.d. above.
A. Rauland Responder 5 vendor materials
B. Responder 5 Resources on UConnect: Clinical Hub>Nursing Hub>Responder
IV. WRITTEN BY
Nursing Informatics Specialist, Nursing Informatics
V. REVIEWED BY
Nursing Informatics Specialist, Nursing Informatics
Nursing Patient Care Policy and Procedure Committee, January 2017
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nurse Executive