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Safe Transport of Sedated and/or Intubated Children in University Hospital (and AFCH) (2.3.13)

Safe Transport of Sedated and/or Intubated Children in University Hospital (and AFCH) (2.3.13) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures

2.3.13


UW HEALTH CLINICAL POLICY 1
Policy Title: Safe Transport of Sedated and/or Intubated Children in University Hospital
(and AFCH)
Policy Number: 2.3.13
Category: UW Health
Type: Inpatient
Effective Date: October 25, 2016

I. PURPOSE

To ensure consistent monitoring of all clinically unstable pediatric patients with a critical airway during
transport or while in a procedural suite in the University Hospital (600 Highland Avenue) and AFCH. This
includes all children receiving deep sedation, with or without mechanical ventilation, requiring transfer
between areas in the University Hospital and AFCH and, when stated, specific recommendations apply to
those under 2 years of age. For the purpose of this policy, pediatric patients are defined as all patients under
16 years of age and older patients housed at AFCH.

II. POLICY ELEMENTS

Establish unit-and service-based process for monitoring, communication, supervision and care of sedated
and/or intubated infants and children and ensure that the areas in University Hospital and AFCH providing
care for these children are adequately staffed, equipped and prepared for these patients (i.e. MRI, CT, DVI,
Cath Lab, etc.).
This policy does not apply to unsedated, clinically stable patients requiring transport.

III. PROCEDURE

A. Equipment
i. Physiologic monitoring equipment as medically indicated and with the patient at all times:
a. Continuous ECG
b. Continuous waveform pulse oximetry (SpO2);
c. Continuous waveform end-tidal carbon dioxide (ETCO2);
d. Intermittent non-invasive blood pressure (maximum 5-minute interval between
recordings);
e. Internal or external temperature monitoring available (every 5 minutes) and continuously
during MRI;
ii. If clinically indicated, continuous waveform pressure monitoring (e.g. central venous and/or arterial
blood pressure, intracranial pressure, etc.).
iii. No patient should ever be unmonitored. To prevent an unmonitored period, staff need to make sure
the second monitor (the receiving unit’s) is ready to be connected before the transport monitor is
disconnected.
iv. Continuous intravenous medications and pumps will be maintained as needed throughout the
transport. Intermittently-dosed medications should still be administered per routine.
v. Emergency equipment to ventilate the patient (bag-mask ventilation apparatus at a minimum and
oxygen source required).
vi. Suction equipment: Battery-powered required for intubated, or if clinically indicated, for non-
intubated patients.
vii. Patients on mechanical ventilation will have a 15-30 minute trial on the transport ventilator to
assess tolerance. Additional resources as dictated by the patient’s specific condition (e.g. nitric
oxide, CRRT, ECMO, etc.).
B. Personnel
i. Patients under 2 years of age should be accompanied by a minimum of 3 attendees to ensure
sufficient help is available in the event of an emergency:
a. a NICU advance practice provider or one the following physicians:
1. an anesthesia resident or fellow;
2. a PICU or NICU fellow or senior Pediatrics resident with 2 months PICU
experience;
3. an EM resident; or
4. any faculty
b. an RN or anesthetist; and
c. an RT or an anesthesia technician.



UW HEALTH CLINICAL POLICY 2
Policy Title: Safe Transport of Sedated and/or Intubated Children in University Hospital (and AFCH)
Policy Number: 2.3.13

ii. Patients over 2 years of age and based on their clinical status, the following minimum personnel
should accompany the patient:
a. Unstable mechanically ventilated patient (Example: Requiring active respiratory,
hemodynamic, neurologic intervention), 3 personnel:
1. a physician (one of the following):
a. an anesthesia resident or fellow;
b. a PICU fellow or senior Pediatrics resident with 2 months PICU
experience;
c. an EM resident; or
d. any faculty
2. an RN or anesthetist; and
3. an RT or an anesthesia technician.
b. Stable mechanically ventilated patient (Example: No anticipated intervention to maintain
stable vital signs. No critical airway issues), 2 personnel:
1. an anesthesia resident or fellow, or an anesthetist, or RN; and
2. an RT or anesthesia technician.
c. Critical airway (Example: Risk of cardiopulmonary arrest if there is an unplanned
dislodgement of the artificial airway. These patients are difficult to bag-mask ventilate), 3
personnel:
1. a physician (one of the following):
a. an anesthesia resident or fellow;
b. a PICU fellow or senior Pediatrics resident with 2 months PICU
experience;
c. an EM resident; or
d. any faculty)
2. an RN or anesthetist; and
3. an RT or an anesthesia technician.
d. Unintubated patient requiring deep sedation, 2 personnel:
1. a physician, an anesthesia resident or fellow, anesthetist or NP qualified in deep
sedation; and
2. an RN, an RT or anesthesia technician.
e. Unintubated patient, unstable (Example: Patients with a compromised airway, significant
respiratory dysfunction, or active hemodynamic support), 2 personnel:
1. a physician; and
2. a second provider (an anesthesia resident or fellow, RN, anesthetist, anesthesia
or ED technician or RT).
iii. Presence of a faculty physician, approved PICU fellow or senior Anesthesia resident is required for
all patients receiving deep sedation or general anesthesia, regardless of their mode of ventilation.
Unstable patients require direct faculty or fellow level supervision. This physician should be
dedicated to the care of this patient and not have conflicting responsibilities that would impact their
ability to respond and attend to an emergency.
iv. Pediatric cardiac patients may require specialized personnel.
v. Patients requiring mechanical ventilation will be accompanied by a Respiratory Therapist. (unless
being transported by anesthesia team)
vi. All PICU/NICU status patients should be accompanied on transport by a PICU/NICU nurse.
vii. Moderately-sedated patients not requiring mechanical ventilation may be accompanied by
personnel privileged in moderate sedation.
C. Process: communication and coordination
i. A conversation should be held by all relevant personnel prior to every transfer to acknowledge the
elements of this policy, that the necessary equipment and personnel are present and to ensure the
equipment are in working order.
ii. Prior to transfer, the sending patient care area must ensure the receiving area is ready for the
patient. There should be no preventable delays and no patient should have to wait to gain entrance
into the receiving procedural area.
iii. The receiving area must ensure their area is appropriately equipped (as defined in A. Equipment,
including but not limited to lighting, heating sources for infants, monitoring, etc.), staffed and
maintained (i.e. routine maintenance schedules for heavy-use, specialized equipment).
iv. No patient should ever be unmonitored. To prevent an unmonitored period, staff need to make sure



UW HEALTH CLINICAL POLICY 3
Policy Title: Safe Transport of Sedated and/or Intubated Children in University Hospital (and AFCH)
Policy Number: 2.3.13

the second monitor (the receiving unit’s) is ready to be connected before the transport monitor is
disconnected.
v. If at any time the primary team caring for the patient perceives an emergency exists, a Pediatric or
Neonatal Code Blue should be called immediately.

IV. COORDINATION

Author: Vice Chair, Quality Improvement, Department of Pediatrics
Senior Management Sponsor: Vice President, AFCH
Reviewers: Nursing, Radiology, Pediatric Cardiology, Pediatric Anesthesia, Pediatric Critical Care, Pediatric
Cardiothoracic Surgery, Neonatology
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: August 15, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

UWHC policy #8.10, Transport of ICU Status Patients within UWHC
Guideline “Intra-Hospital Transport of PICU Patients”
UWHC Respiratory Care Services Departmental policy #2.05, Transportation of Patients Supported by
Mechanical Ventilator-MV

VII. REVIEW DETAILS

Version: Revision
Next Revision Due: October 2019
Formerly Known as: Hospital Administrative policy #8.97