WOMEN & CHILDREN S POLICY AND PROCEDURE MANUAL Page 1 of 9 Title: Infant Protection System Policy No. GEN-1.1 Joint Commission Chapter/Section: Effective Date: May 2015 Source (e.g. document, award, or committee, etc.): N. Davis, MSN, RNC-MNN, IBCLC, Clinical Educator D. Allen, BSN, CCRN, Neonatal Educator Publication Status: New Revised X 6/03, 12/04, 3/06, 12/08, 1/12 Reviewed Cross-Referenced Policy No: Admin Policy - Code Amber SUPERCEDES: GEN-1.2 Infant Abduction Alarms: Placing an Infant/Child in Transport Mode GEN-16.2 Prosec IPS: Care of Sensors/Transponders, for Infant Security System GEN-16.3 Prosec IPS: Tag Battery Function GEN-16.4 Prosec IPS: Down-Time Procedure I. POLICY: 1. It is the policy of Saint Peter s University Hospital to take all reasonable measures to prevent the abduction of an infant/child from the hospital. 2. All infants/children admitted to the mother/baby and/or pediatrics units will have the appropriate tag applied and activated in the Infant Protection System. 3. All families with an infant/child on the IPS system will be provided with standardized education on the system. 4. All users of the IPS will be assigned an individual username and password. 5. An assigned staff member will be responsible for performing a system reconciliation with the unit census to confirm that all admitted infants/children are active in the IPS system at the start and end of each shift. 6. An assigned staff member will be responsible for confirming activation for the IPS tag by performing a visual assessment. 7. Computers for use of the (IPS) will always be plugged into a red electrical outlet. 8. Activation and deactivation of alarm tags will be restricted to the RN on mother/baby and a designated staff member on the pediatric unit. 9. All tags will be cleaned after use with the appropriate cleaning solution. 10. Infant/children being transported off of their unit will placed in check out mode for the appropriate amount of time. 11. Battery life will be checked by using the S-TAD prior to placing a new tag on any newborn/child. 12. Any tag identified as having low battery life will be removed from circulation and sent to security. 13. Tag bands are one-time use only. Bands on infants/children with a long term stay will be replaced every thirty days. 14. Infants being transferred off of the mother/baby units will be accompanied by a RN and will remain with them at all times. 15. All staff will be responsible for monitoring exit points on their unit in the event of the activation of a fire alarm. 16. The transport card will have the capability to transport infants/children on and off locked units, the ability to reset door alarms, and open locked doors on unit during an active alarm. 17. The transport card will be locked at all times. 18. Entry and exit to locked units will require swiping of badge at card access site, even if doors are open. 19. IPS system reports will be generated by the Safety and Security Department.
20. Each unit will be responsible for reporting IPS system issues to the Safety and Security department in a timely fashion. 21. Facility Performance testing will be conducted by the Saint Peter s University Hospital Security department as per manufactures guidelines. Newborn 1. Tag application will occur on L&D for all newborn infants. 2. Tag activation will occur upon arrival to the mother/baby units. Pediatrics 1. All infants/children from the pediatric unit who are on holds by the Division of Child Protection and Permanency (DCPP) that need to be transported will be accompanied by a pediatric staff member. 2. All other infants/children on the pediatric unit may be transported by patient transport services. II. III. PURPOSE: 1. To establish guidelines for the placement of IPS tags on infant/child for purpose of infant/child safety. 2. To ensure that all infant/child IPS tags are functioning properly. 3. To establish guidelines to ensure optimal performance of the infant security system in regard to the care and maintenance of the sensor used on all infants and children. 4. To establish safe guidelines for the infant/child who needs to leave their assigned units for a procedure /test. 5. To ensure there is a defined plan of action when there is an Infant Protection Security System Failure. DEFINITION: S-TAD (Secure Tag Activator/Deactivator): Device used to check the functionality of a tag. Door Alarm: Occurs when a tag enters a monitored zone and the door is opened or is triggered. Loiter Alarm: Occurs when an active tag is lingering in the activation field for longer than a preset allotted amount of time. Supervisor Alarm: Occurs when the performance of the system has been altered due to tampering or inadvertent acts such as cut wires, antenna damage, interference, etc. Door Ajar Alarm: Occurs when a door is open for longer than the preset time Band Removal Alarm: Occurs when a tag/band is removed or tampered with in any way. Transfer Timeout: Occurs when a transferred infant/ child does not reach the destination area within the allotted time. Computer Server Failure: A malfunction of the computer software that enables the user to identify the location of the alarm and the specific tag causing the alarm. A server failure will still produce an alarm at the site of breach and the elevators in that zone will be immobilized. Page 2 of 9
IV. PROCEDURE: A. Application of Tag Infant Tag The L&D/Pediatric RN will: 1. Before applying IPS tag, be sure to clean the application area with a baby wipe. Skin must be free of dirt, oil, blood, vernix and/or lotions to function. 2. Unsnap the cam lock on the bottom of the tag to expose gold contacts. 3. With grey conductive fibers stripes facing the tag and the gold contacts of the tag facing up, slide the pointed end of the band up through the slot on the tag until the folded end is snug against the slot. 4. Slide the pointed end of the band into the cam against the gold contacts so the conductive fibers are touching the gold contacts. 5. Slide loop of band around the child s ankle. Pull the band so that is snug, but not too tight. The Mother/Baby RN will: 1. Activate tag on arrival to unit 2. Trim excess band material to leave the band flush with the tag. 3. When giving newborn bath, be sure to protect band from water by either sliding band up from wash area, or covering band with a glove. Do not submerge in water. Pediatric Cut Band 1. Slide white cut band through opening in tag so that the silver and foam piece is completely covered by tag. 2. Remove perforated clip piece from end of band. 3. Remove bottom portion of pod from backing and apply to bottom of tag, then apply cut band to patient securing with plastic clip piece. 4. Cut excess band from end and securely apply top portion of pod and ensure seal all the way around pod. B. Activation of a Tag Tag is activated with the S-TAD Infant Tag must have skin contact before application to avoid triggering the alarm. The RN will: 1. Press the power button on the S-TAD 2. Enter the code number and press enter. Two LED lights will be lite. 3. Hold the tag against the back of the S-TAD so that the tag is lined up with the tag receptacle on the back of the S-TAD and press enter second time. 4. When tag is activated, the LED light on tag will flash, as well as the LED light in the tag pictured on the face of the S-TAD. 5. If a low battery condition is detected, the low tag battery LED will illuminate red. Return low battery tags to security. C. Assignment of a Tag in the IPS System Newborn The RN will: 1. Select an unused tag from the tag storage area. 2. In the computer, select Tags & Patients from the tool bar 3. Select the tag number in the drop box and click assign 4. Input the appropriate patient identifiers in the dialog box Page 3 of 9
Tags will be assigned to newborns using the following identifiers: LAST NAME box: Mothers Last Name, First Name FIRST NAME box: BB (Baby boy) or BG(baby girl) ROOM: 4DN or actual room number if known MULTIPLES: Include TWIN-A, B, Etc. after the sex Example: Minnie, Mouse BG Twin-A Pediatrics The Assigned Staff Member will: 1. Select an unused tag from the tag storage area. 2. In the computer, select Tags & Patients from the tool bar 3. Select the tag number in the drop box and click assign 4. Input the appropriate patient identifiers in the dialog box Tags will be assigned to patient using the following identifiers: LAST NAME box: Last Name FIRST NAME box: First Name MIDDLE NAME box:: Age, Gender ROOM: Room Number Example: Minnie, Mouse 4y, F D. Reassigning Tags: Reassigning a new tag to an infant/child in the system may be necessary. (e.g. tag malfunction). To Reassign a tag the assigned staff member will: 1. Select tags and patients from the menu bar 2. Select the desired tag number and select Reassign Patient. The Enter tag number window will appear. 3. Enter the new tag number to be reassigned to the patient. 4. Click OK and confirm reassignment by clicking Yes E. Transport of Newborns/Children Off an Alarmed Unit Transporting newborns/children off the unit will require the use of the transport card. Before leaving the unit, place the infant/child into check out mode in the system. The Assigned Staff Member will: 1. Select transfer from the menu bar. 2. Select check out. 3. From the patient drop-down menu, select the patient to be transferred. 4. Enter the estimated transit time. 5. From the destination area drop-down menu, select the destination unit, if available. 6. Select start transfer. Checking in a child The Assigned Staff Member will: 1. Once the infant/child has arrived at the destination select transfers 2. Select Check In 3. Select the patient that was transferred from the drop down menu Page 4 of 9
4. Enter the new patient room number (if applicable) 5. Click check in patient i. Transporting to another mother/baby. The Assigned Staff Member will: 1. Put the infant in check out mode before leaving the unit. The RN/MBT/ will: 1. Swipe the transport card and allow the doors to open fully before exiting the unit. 2. Walk briskly in the middle of the hallway through the doors and off the unit. 3. Swipe the transport card to get into the next unit, again allowing the doors to fully open before walking through. 4. It is the responsible of the primary care RN to accept the patient to the unit by going to check in in the computer system. ii. Transporting the infant using unit elevators on a locked mother/baby unit The use of a buddy is recommended when transporting infants using an elevator on a locked unit. The RN/MBT will: 1. Enter elevator code on the key pad to call elevator. 2. Keep infant bassinet away from open doors to avoid triggering an alarm. 3. Enter the elevator code a second time once the elevator arrives and enter the elevator. 4. Push the infant to the back of the elevator to avoid triggering an alarm. 5. Swipe the transport badge when entering the elevator and select the floor you are traveling to. 6. Once arrived on destination unit, if locked, swipe transport card and allow doors to open fully before entering the unit. 7. Accept the patient to the unit by going to check in in the computer system once on destination unit. iii.transporting a tagged infant to other areas of the hospital The RN/MBT/PCT/NUS will: 1. Place the infant in check out mode in the system and input the destination. 2. Modify the time to accommodate the length of time the infant will be off the unit. The RN/MBT/ will: 1. Swipe the transport badge to get off the unit, allow doors to fully open, and take the infant to destination using transport elevators. 2. Remain with infant until ready to return to unit. 3. Use Check In feature in the security system once infant has returned to home unit. F. Canceling a Transfer 1. From the transfers menu, select pending. 2. Select the patient transfer to be cancelled and select the reason for the cancellation from the drop down menu. 3. Select cancel transfer. 4. Select yes in confirmation window. Page 5 of 9
G. Transfer Timeout The transfer timeout window will open after transfer time has expired on both the originating and destination units. To clear outgoing transfer Timeout window, the time must be extended or the transfer must be cancelled. a. Extend: Enter the amount of time to extend by (1-30min) and click Extend time. b. Cancel: Select reason for cancelling transfer and click cancel transfer. H. Quick Transfer The quick transfer feature is used to transfer unassigned tags to different units in the IPS system. At the time of discharge, the RN will be responsible for transferring the discharge tag back to 4H in the IPS system using the quick transfer feature. I. Discharge from System The RN will complete the following steps when discharging an infant/child: 1. Complete discharge teaching at the bedside 2. Instruct parents/patients to come to the nurses station for band and tag removal once they are ready to exit the unit. 3. Deactivate the tag. 4. Dispose of band in waste receptacle and place used tag in the dirty bin at the nurses station. 5. In the computer system select tags and patients 6. Once the dialog box is open, select the appropriate tag number to be discharged. 7. Select discharge 8. Click Yes to Confirm Discharge 9. Mother/Baby: Use the quick transfer option to return the tag to L&D (4H) census J. Alarm Management The following will discuss required staff response to different alarms within the IPS system: 1. Door Alarm Go to the alarm location to assess the cause of the alarm. Ensure that all infants/children on unit are accounted for. Notify security and initiate a code amber if an infant abduction is suspected. If alarm is determined to be false, reset alarm by swiping transport card at door access site. Clear the alarm by highlighting the alarm event line. Click Clear Document comments for alarm event and include initials. 2. Band Removal Alarm Locate and assure the safety of the infant After locating the infant check the following: a. Infant Tag: Check that the band is snug around the infants extremity and the conductive fiber stripes are in good contact with the infants skin b. If the band has gotten wet or cut replace it c. Ensure that excess band material has been trimmed. d. Clear the alarm by highlighting the alarm event line. e. Click Clear f. Document comments for alarm event and include initials. Page 6 of 9
3. Loiter Alarm Go the alarm location and check the following: a. If an infant/child is loitering in the alarm activation field. b. If there is a stray tag in the zone. After removing the cause, the system will automatically reset 4. Door Ajar Go to the alarm location and check to see if the door is propped open or not completely closed. If open, close the door completely. The IPS system will automatically reset alarm. 5. Supervisor Alarm Go to the alarm location and look for visible damage to the accutech equipment Check for and remove any objects near the zone equipment that may be causing interference Once the issue is corrected the alarm will cease If you are unable to correct the alarm, notify security. K. Viewing Multiple Areas More than one area can be viewed on the computer monitor simultaneously. It is recommended to only view the area that is being monitored to avoid nuisance alarms from other units. If it is necessary to view another unit: To open a unit: 1. Click Open area radio button. 2. Select the desired area and click OK. 3. The new unit will open into the display bar. To close a unit 1. Click Close area radio button. 2. Select the desired area to close and click OK. 3. Enter user name and password and click OK. L. Care/Cleaning of IPS tags and S-TAD Cleaning Procedure- Security Tags The RN/MBT/NUS Will: 1. Use only Clorox Hydrogen Peroxide Wipes for cleansing of tags. 2. Wipe the entire tag until saturated. 3. Allow tag(s) to air dry for 1 minute. 4. Newborn: Clean tags will be collected from each unit and returned to the L&D unit by an assigned staff member. The IPS tags/s-tad are water resistant but not waterproof. To maintain the integrity and function of the security tags: DO NOT: Submerge or soak tags in any liquid (water, cleaning solutions) Autoclave tags Use unapproved cleaning products Cleaning Procedure- S-TAD The RN Will: 1. Wipe the S-TAD clean after every use using Clorox Hydrogen Peroxide Wipes 2. Allow S-TAD to air dry for 1 minute before next use. Page 7 of 9
M. Battery Replacement Security tags with a low battery reading are to be removed from circulation and taken to security. Document the tag serial number on the incident report log. S-STADs uses a 9-Volt battery. Batteries will be replaced as needed and can be found in the office of the unit manager. N. Down Time Procedure Security will respond to all locked units, in the event of a true system downtime. In the event of a down time episode, the RN will be responsible for identifying the type of IPS failure and taking the appropriate action. Computer Server Failure: 1. Continue to apply alarm tags. 2. The ANM/Charge RN will be responsible for maintaining a log of all patients with active tags with the following information a. Patient information b. Admission date & time c. Tag number d. Tag serial number e. Discharge date & time 3. The ANM/Charge RN will input all the data on all current admissions from the log into the computer system once up and running. 4. Completed logs will be turned into the unit manager or ANM. Complete Power Failure: Mother/Baby: In the event of a complete power failure and emergency power is not operational, all infants that are unaccompanied by a parent will be grouped together in one centralized location and will be under the direct observation of a staff member at all times for the duration of the power failure. V. DOCUMENTATION: The RN will be required to document the assigned infant/child security tag number and tag activation status in the electronic medical record. The RN will document the details of alarm events in the event box in the IPS, before clearing the alarm. VI. REFERENCES: Rabuan, J. (2014.) For health professionals: Guidelines on prevention of and response to infant abductions (10 th ). National Center for Missing & Exploited Children. Retrieved from: http://www.missingkids.com/publications/nc05 Accutech (2015). Accutech User Manual. Page 8 of 9
Approved by: CNO/Vice President Patient Care Services 7/20/15 Signature Title Date Interim Director Women & Children s Division 7/20/15 Signature Title Date Origination Date: 6/2/03 Supersedes Date(s): 12/6/04, 3/6/06, 12/3/08, 1/4/12, 7/20/15 Reviewed Date: 8/08 Revised Date: 11/04, 2/06, 11/11, 7/15 GEN-1.1 Page 9 of 9