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Children's Hospital Medical Center
II-121 Monitoring and Alarm Notification Nurse Call System and Stat
Original Date: 2/26/2004 Last Review Date:
To provide guidelines for the use and maintenance of the Hill-Rom Composer Nurse Call System, and to provide staff accountability for
timely communication between personnel and patient/families, and staff response to monitor and emergency calls.
Policies and Procedures
1. System Setup
a. Equipment Placement
- Master stations located at each communication desk on inpatient units
- Room stations located in every patient room, in each patient hallway, unit conference room, and any area deemed necessary for
patient communication and safety
b. Page and Locator Zones
- Patient rooms are identified by room number.
- Hallways on inpatient units are indicated as HL with a rounded room number designation
c. Operation Mode:
1. Master station will be kept in unattended mode at all times
2. System will automatically operate on low volume from 10:00 p.m. to 6:00 a.m.
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3. Reminder feature will be activated with every patient or monitor call that requires follow up
4. Nurse/patient assignment will be put into Composer and/or the Statview alarm pagers by a designated staff person at the
beginning of every shift and anytime there are changes of patient assignment, ie. admissions, discharges, staffing changes.
5. Nurse/patient assignments are to include a second nurse as a back up. The nurse call system will locate the assigned nurse and
the back up nurse simultaneously. Therefore, the recommendation would be to assign the nurse working in the same hallway,
pod/vicinity, or the PCF as a last resort. There must be ongoing communication between the assigned and backup nurses
concerning their activities for the day which may take them out of the area or if they will be involved in a lengthy
procedure which would delay their response.
6. The nursing staff will respond to patient calls from room stations either in patient rooms, hallways, conference rooms or by going
to the patient's room.
7. If the unit is staffed with a HUC, they will respond to patient calls and locate the assigned nurse(s) to respond to the patient.
8. Monitor alarms require nursing staff to respond as soon as possible to the patient's room, assess the patient, and determine the
need for further intervention. (Attached Flow Chart) Monitor alarms must be reactivated when they have been silenced,
paused, or disabled. In the event that a loud alarm, such as a fire alarm, obscures the audibility of either the nurse call system or
the monitor alarms, the alarms malfunction, or the nurse call system malfunctions and is unable to locate staff, the following
process will be followed:
a. The PCF will assess the status of the patients on the unit
b. He/she will devise a plan with tthe staff to ensure the close observation of all the patients.
c. He/she will assign a staff menber to continuously observe the nurse call monitor screen and CIC screen, if available, for any
monitor alarms or patient calls and alert the assigned staff.
9. Response to calls, either patient or monitor, is everyone's responsibility. All staff should be aware of dome lights over the
patients' room doors and respond appropriately whether an alarm is heard or not.
2. Personnel Locator Badges
a. Badge assignment
Badges will be issued to all inpatient unit staff.
1. The Clinical Director is responsible for establishing a system for issue of badges, and battery replacement, and
maintaining a log of users.
2. The employee and personnel locator badge ID number will be entered into the master station upon hire, or transfer
and deleted upon termination.
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3. Each member of the nursing staff must wear a personnel locator badge whenever on duty.
4. Badges must be worn on the lapel, name badge, or pocket, that the L.E.D. (Locator Emission Display) is not covered
3. Staff Information
a. The first initial and last name of all unit staff will be entered at time of hire. Float staff information will be entered at the
beginning of the shift by the HUC along with their patient assignment. Their name will be deleted at the end of their shift.
b. The designated staff person will confirm that all patients have a staff member assigned to them.
4. Patient Information
1. When a patient is admitted or transferred to the unit, the designated staff person will create a patient information card in the
Patient's first name and last name
2. The staff-patient assignment will be updated to include the new patient.
3. When a patient is admitted or transferred to the unit, the designated staff person will add/delete their patient information card.
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