# Nurse-call and clinical communication routing readiness evaluation (HospitalRoom.org)

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https://hospitalroom.org/frameworks/nurse-call-routing-readiness

A HospitalRoom.org working checklist, not a published standard. Evaluate the fundamental call path and supplementary routing at shift change and during downtime. Record evidence and an owner for each condition.

## Fundamental path integrity

UL 1069 describes a fundamental nurse-call system — call initiation, audible and visual annunciation at a primary notification station, a call-placed indicator at the station, corridor dome lights, zone lights, and reset/cancellation — and treats phones and other interfaced devices as supplementary operation. Routing to mobile devices sits on top of that path; it does not replace it. NFPA 99 Chapter 7 requires listed nurse-call systems and, for Category 1 systems, redundancy in pathways.

Question: If the routing server, Wi-Fi, or phones fail, does every call type still annunciate at the station and light the corridor?

| Met | Partial | Not met | Evidence | Owner |
| --- | --- | --- | --- | --- |
| ☐ | ☐ | ☐ | | |

## Call-type distinction

Routine patient calls, bath and toilet emergency calls, staff emergency assistance, and code calls are visually and audibly distinguishable, as NFPA 99 Chapter 7 requires, and each maps to a distinct routing priority. Emergency calls initiated in a toilet or bath can only be reset at the station where they were placed. Call stations are present at the locations the FGI Guidelines' table of required nurse-call device locations lists, and in behavioral health areas cords are detachable and no longer than 6 inches (15.24 cm), per the 2022 FGI hospital edition.

Question: Can staff tell a code call from a pillow request by sound and light alone, and does the routing priority match?

| Met | Partial | Not met | Evidence | Owner |
| --- | --- | --- | --- | --- |
| ☐ | ☐ | ☐ | | |

## Assignment-accurate routing

Routing follows the current patient-to-staff assignment and staff-to-device mapping, the two inputs the IHE PCD Alert Communication Management (ACM) profile describes an alert manager using to pick a destination. Location-only calls resolve to a bed and then to a person. Assignments are updated at shift change, breaks, and transfers, and an unassigned room has a defined fallback rather than a silent drop.

Question: At 07:15 after shift change, does a call from every occupied room reach a nurse who is actually assigned to that patient?

| Met | Partial | Not met | Evidence | Owner |
| --- | --- | --- | --- | --- |
| ☐ | ☐ | ☐ | | |

## Confirmed delivery and timed escalation

The routing layer knows whether a call was delivered, read, and accepted — IHE ACM returns dissemination status and operator response from the alert communicator over WCTP and back to the reporting system over HL7 v2 — and an unacknowledged call escalates on a documented timer to a secondary nurse, charge nurse, or unit broadcast. Timers are local configuration; none of the standards cited here set them.

Question: When a nurse declines or ignores a call, how many seconds pass before someone else is notified, and is that written down?

| Met | Partial | Not met | Evidence | Owner |
| --- | --- | --- | --- | --- |
| ☐ | ☐ | ☐ | | |

## Honest measurement and governance

Every call has a time-stamped route and outcome in an audit log. Response time is reported with its definition stated — call placed to cancel, or call placed to staff presence in the room via a presence button, badge, or RTLS — and the two are not mixed. Someone owns the routing tables and assignment rules, changes go through change control, downtime procedures are rehearsed, and the network the routing rides on is inside the organization's IEC 80001-1 risk management.

Question: Who can change a routing rule today, and when was the last downtime drill?

| Met | Partial | Not met | Evidence | Owner |
| --- | --- | --- | --- | --- |
| ☐ | ☐ | ☐ | | |

## Working rule

If the phones went dark tonight, every call type would still reach a human through the fundamental system — and every routed call has an owner, a timer, and a measured end. Fail the first half and the room is not safe; fail the second and the routing is decoration.

## Evidence note

This is a working checklist, not a published standard. It draws on the scope of UL 1069, NFPA 99 Chapter 7, the FGI Guidelines' nurse-call device location table, the IHE PCD ACM profile, and IEC 80001-1. The standards define equipment, signaling, locations, and message flow; they do not set response-time targets or escalation timers, and published evidence comparing routing configurations is limited.