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Featured Article:

Modern nurse call systems are capable of providing much more than nurse call

Jeff Carpenter, PE, RCDD

Modern nurse call systems can play a role so important to the delivery of care that the phrase ‘nurse call’ hampers big-picture thinking about the advanced capabilities and uses of such systems today. (Photo by KJWW)

Modern nurse call systems can play a role so important to the delivery of care that the phrase ‘nurse call’ hampers big-picture thinking about the advanced capabilities and uses of such systems today. (Photo by KJWW)

On the surface, a nurse call system seems like a straight-forward, almost universally understood concept. Indeed, when they hear the phrase “nurse call,” most people who have worked in healthcare will visualize the same things: dome lights, tones emanating through corridors, and patients using their pillow speakers to change television channels from their beds. They also will picture the chaos of a nurse station while someone speaks to a patient on a nurse call telephone handset.

While these images all are aspects of nurse call, the modern needs, capabilities and uses of such systems today are often less understood.

For many years, the technical capabilities of a nurse call system didn’t stray very far beyond what the relevant codes and best practices required. As a result, nurse call systems logically became associated with the hardware and software used to meet those requirements. Today, however, such systems go so far beyond the codes – and can play a role so important to the delivery of care – that the phrase “nurse call” hampers big-picture thinking about the advanced capabilities. Perhaps “caregiver communication and workflow system” more accurately describes where the technology is today.

The traditional role of nurse call remains relevant, of course, and the basic devices remain fundamental to the healthcare environment. Codes and best practices still require the use of specific devices in specific rooms in specific occupancies. Evolutionary product improvements occur, but the underlying role of a nurse call system remains fundamentally unchanged: for a patient to alert and engage in communication with their caregiver. This aspect of the system is addressed by UL 1069 “Hospital Signaling and Nurse Call Equipment.” (UL 2560 covers similar equipment in senior living facilities.) UL 1069 covers the placement, notification and resetting of staff-initiated and patient-initiated signals intended to alert others to a need, and requires:

  • Audible and visual annunciation of calls at nurse stations
  • Call annunciation at the room’s dome light
  • Visual “call placed” indicator on the patient station
  • Dome light zone visual annunciation
  • Call reset / cancellation

Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Hospitals and Outpatient Facilities also addresses nurse call and includes specific device requirements based on room type. (While this article uses the word “required,” FGI is a best practices guideline or a code requirement depending on a particular state’s adoption or lack thereof.)

Components of Traditional Nurse Call

Master stations provide audible and visual annunciation of calls at the nurse station. A variety of equipment accommodates this:

  •  A telephone handset device. Various sizes of LCD screens provide information about calls; some include touch screens
  •  A PC-based console with telephony capabilities. This includes OS-embedded appliance configurations and traditional PCs with large monitors to display high volumes of information.

Patient stations are located at an inpatient bed and initiate communication to caregivers. The patient usually originates the communication by pressing a button on the pillow speaker, which also can provide television control, lighting control and control of window treatments and room temperature. Caregiver-initiated communications at the patient station include code blue and a request for nurse assistance. (FGI determines what types of communication are required for each room type.)

The patient station also serves as the wiring hub for several other stations near the patient bed including:

  • Bed connector (wired and wireless options) between the patient bed and nurse call to monitor bed rail position and alert the master station to changes
  • Medical equipment connectors to monitor alarm conditions of bed-side medical equipment at the nurse call master station

Other stations: Per FGI guidelines, other room types not containing an inpatient bed still require nurse call devices. These stations include:

  •  Toilet stations. A pull cord attached to the station summons assistance in getting on or off the toilet and can be activated from a lying position on the floor should a patient fall.
  •  Shower stations. These serve a similar purpose as the toilet station but are listed for the wet environment of the shower.
  •  Caregiver-initiated stations. These are required by FGI in a range of room types and are used to initiate a request for assistance (i.e., nurse assist call) or to summon a response team (i.e., code blue call).

Dome lights are placed outside any room that contains an initiating station. The dome light quickly alerts staff to the specific location of the call to expedite the response. Dome lights use multi-colored LEDs and can communicate a variety of information in different ways, including:

  •  A unique color to distinguish the nature of the need
  •  Various flashing patterns to provide additional information •
  •  Used in conjunction with staff-locator technology to indicate the type of caregiver in the room

Dome lights are intended to be mounted so they are visible from the nurse station. When a room is not visible from the nurse station, zone dome lights are used to lead the caregiver in the direction of the call until the room’s light is visible.

Duty / staff stations allow caregivers therein to be aware of a master station call when they are not at the master station. These are typically rooms where caregivers perform various duties and include nourishment stations, linen rooms, break rooms and similar spaces.

Duty and staff stations serve similar purposes but there are differences. A duty station provides audible (but not voice) and visual indication that there has been a call initiated on the system. Typically there are three levels of call severity: normal, emergency and staff emergency. A staff station includes the functionality of the duty station and adds two-way voice communication.

Some manufacturers have stopped producing separate duty and staff stations. Instead they produce a station with two-way voice functionality (traditionally known as a staff station) but market it as a duty/staff station to imply it meets both application needs. This is accurate, but it adds confusion to the difference between a staff and duty station.

Infrastructure: Traditional nurse call historically has been viewed more like other specialty systems such as fire alarm, paging or security (prior to IP cameras) with its own specialty wiring requirements unrelated to the category cabling world, rather than as a network-based system.

As part of the evolutionary improvements made in nurse call, even basic nurse call systems with feature sets no deeper than UL 1069 and FGI requirements now have system architectures that have more in common with category cabling than in the past.

The typical nurse call system today consists of a controller or control panel that is directly on a TCP/IP network, connected using category cabling. The controllers are dispersed through the hospital and their quantity and location are determined based mostly on system capacity considerations. It is not unusual, given that these controller panels are native TCP/IP devices, for them to reside in the telecommunication rooms if the hospital adopts a convergence philosophy.

A nurse call infrastructure usually uses category cabling downstream of the controller. In most cases the nurse call system dome light is the “wiring hub” for the collection of nurse call stations that are in the room to which the dome light belongs. After bringing category cabling to the first dome light, many brands continue to daisy chain additional dome lights on the same category cabling run. In most cases, it is not a star topology. Despite category cabling being used, this is usually not TCP/IP communications. Rather, it is simply the use of category cabling as the transport mechanism. Most dome lights have an input and output for the category cabling. It is more like a communication trunk line or bus than a conventional structured cabling architecture. The dome lights continue to be daisy chained until the manufacturer’s maximum number of devices or maximum bus length has been achieved. Some manufacturers have their own unique differentiators for the cabling infrastructure, so it is important to understand the intricacies of the product.

Some manufacturers’ devices do have Ethernet communication over the category cabling. This typically occurs with master stations that use VoIP technology. It is very important to understand how the manufacturer uses Ethernet technology in their solution. Of primary concern is whether the particular Ethernet device is inside or outside of the UL 1069-rated umbrella; this has implications on the acceptability of various termination options of the category cabling in the telecommunications closet.

The lesson here is that it is important to understand the details of a particular manufacturer’s system topology. Despite category cabling being used in many nurse call system applications, the likelihood is that most of it is not Ethernet communications. How the cabling is ultimately routed, terminated and bundled are project-level design decisions.

Beyond UL 1069 and FGI

Recent significant advancements have been made in nurse call, most of which go beyond UL 1069 and FGI requirements. This is where the revolutionary change is occurring, and why “nurse call” may not be a suitable name going forward.

Driving much of this change is the Affordable Care Act, a game changer for providers in many ways, with nurse call playing a significant role as the healthcare system shifts from a “fee for service” to a “fee for outcomes” structure. Nurse call helps healthcare providers meet the challenges of this new reimbursement model in two primary ways: HCAHPS and operational efficiency.

HCAHPS and patient satisfaction:In simple terms, HCAHPS – Hospital Consumer Assessment of Healthcare Providers and Systems – is a patient satisfaction survey. A portion of healthcare reimbursements are tied to HCAHPS scores. This means that healthcare, like other industries, is now being rated in terms of “customer service.” Healthcare customers – i.e., patients – may rate their service by answering such questions as:

  • • How well did the hospital take care of my needs?
  • • How fast did caregivers respond to me?
  • • Did they help me when I needed help?
  • • Did they bring me a drink when I wanted one?

Countless examples could be provided. The bottom line is that nurse call systems serve as the primary communication tool between caregiver and patient – and can have a positive or negative influence on a patient’s level of satisfaction. Therefore, the choice of nurse call system, how it is used, and the system architecture serve a significant role in HCAHPS scores.

A great deal of effort should be spent looking at how to use nurse call technology to decrease the time it takes for a patient to talk to a caregiver and for that patient to see the caregiver in their room. Specific nurse call systems today are engineered to be best suited for specific caregiver models and are no longer a commodity in which every vendor manufacturers the same box on the wall. Some of the most common caregiver models are:

  •  Decentralized nursing communication: This is the conventional approach consisting of a unit-based master station at a conventional unit-based nurse station. Patient calls are routed to the unit-based master station and then triaged out to the assigned caregiver.
  •  Centralized nursing communication: In ICT terms, think of this as a central phone system operator. One (or more) staff members are dedicated to answering patient calls in a centralized location with the calls coming in from multiple units, multiple floors, an entire building and even an entire campus. Patient calls are triaged out to the assigned caregiver’s mobile telephony devices from this centralized operator. Some convincing evidence from healthcare systems using this approach show meaningful increases in responsiveness to patients through a decrease in most types of response times.
  •  Direct-to-caregiver: In this model, the master station takes a backseat and becomes the “fallback plan.” Patient calls are routed directly to the mobile telephony device of the assigned caregiver. The master station (still required by UL 1069 and FGI) is used should the caregiver not respond to the call within the required time. The challenge with this model is that responsiveness to one patient can become an interruption to another patient. In addition, some calls require an RN (i.e., pain medications) and some do not (i.e., “I need a drink.”). Ultimately, however, one caregiver must be chosen to receive the initial call – assuring that in a significant percentage of the cases, the initial caregiver answering the call will be the wrong caregiver for the need.

Operational efficiency: Nurse call plays a significant role in automating, monitoring, reporting and simplifying processes in the hospital. Indeed, most nurse call manufacturers now talk about “workflow” in their marketing materials and sales presentations.

Many current nurse call products that deal with workflow processing are hardware-focused solutions requiring a caregiver to go to a fixed location to initiate a workflow process. Some manufacturers take a different approach based on the highly mobile environment of healthcare. They believe workflow processing should be done while mobile, so they focus more on a software approach using the caregiver’s mobile devices in lieu of a fixed hardware location.

Whether hardware- or software-driven, today’s nurse call can serve as the system that handles clinical workflows in a variety of ways:

  •  Automating notification to housekeeping (when a patient room needs to be cleaned) and to the admission,    discharge and transfer (ADT) system (when a room is ready for admission) to improve room churn
  •  Automating notification when a patient is ready to be seen by a particular specialist, when a particular lab result is available, or when a patient is in need of transport staff, etc.
  •  Automating the check-in process for rounding, requesting chaplain services, requesting a family member consultation, etc. • Powering the intelligence behind “bed boards,” the large monitors displaying dashboard information about the status of the room and the staff and patients within it

Making the right (nurse) call

The recent advances in modern nurse call systems mean that there are proper applications and misapplications of any specific nurse call solution depending on the unique project requirements.

A well-informed selection process needs to exist in order to properly recognize and vet these nuances between systems.

The end goal is for the selected nurse call system’s unique characteristics to meet the needs of a particular healthcare facility’s workflow and care delivery model. This will improve patient satisfaction, HCAHPS scores, operational efficiency, and ultimately the facility’s bottom line.

Jeff Carpenter, PE, RCDD, is a principal and National Director of Technology for KJWW Engineering Consultants.

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