Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Unit Operations

Escort of Pediatric Inpatients to Tests and Procedures (Pediatric) (14.32P)

Escort of Pediatric Inpatients to Tests and Procedures (Pediatric) (14.32P) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Unit Operations



Effective Date:
April 30, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 14.32P


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Title: Escort of Pediatric Inpatients Off Unit for
Tests/Procedures/Diagnostics (Pediatric)

To provide a safe and consistent process for pediatric patients to leave their unit for
diagnostic tests and procedures, and to participate in hospital, school, therapies, and
Child Life activities within American Family Children’s Hospital (AFCH) and
A. No child may leave the inpatient units unescorted.
B. Nursing and/or MD staff will accompany all PICU/NICU patients.
C. All general care pediatric patients (ages infant to 18 years old) will be assessed by
an RN as to developmental needs, medical needs, advocacy needs, and parental
comfort and availability to accompany their child to off-unit tests, procedures, and
activities. The RN will provide developmentally appropriate preparation and
support when pediatric patients are escorted from the pediatric units to off-unit
diagnostic tests, procedures, and other activities as needed.


All procedures and therapies that require the patient to leave the unit require the nurse
to complete a Hand Off-Unit note.


A. Once the RN has identified that a patient is scheduled to leave the patient care unit for
a procedure or therapy, the RN will assess the patient's status and ability to travel.
B. General care patients will be accompanied by an RN when the patient has any
significant condition or active treatments that require assessment by an RN, including
but not limited to:
1. Tracheostomy
2. Infusion of opioids, blood products, chemotherapy, or other medication
requiring monitoring
3. Chest tube
4. Oxygen needs above baseline requirement
5. Respiratory support (CPAP, BiPAP)
6. Telemetry or continuous pulse oximetry monitoring
7. Other monitoring needs as determined by RN

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C. The RN will communicate with patient/family the purpose of the travel, estimated
time of departure from unit, and estimated time of return.
D. If the patient’s condition or active treatments do not require an RN to accompany the
patient, the RN will ask parent/guardian if s/he desires to attend procedure with a staff
escort. If parent/guardian is unable or prefers not to accompany child, RN will assign
appropriate personnel (Nursing Assistant, Child Life Specialist, volunteer or another
RN) to accompany in order to promote optimal safety and security of child.
E. The RN (or designee) will schedule the Escort service and prepare the identified level
of staff and escort to accompany child/parent to identified function.
F. The RN completes the Hand Off-Unit Sending RN note if appropriate. The RN and
the care provider assuming care share responsibility for the patient's care through
verbal communication as needed.
G. Verbal report must be given to the RN who is accepting care for all inpatients
traveling to or from the Nursing Diagnostic/Therapy Center.
H. Before leaving the unit, the Escort or health care provider will alert the patient's nurse
that the patient is leaving the unit.
I. A parent/guardian may accompany the patient and Escort without an AFCH
employee if at least 2 of the following have been assessed and determined to be true:
1. Parent/child has been to similar procedures in the past and patient did well
during the procedure.
2. Parent/guardian is able to comfort/support child during procedures.
3. Parent/guardian volunteers and feels comfortable accompanying patient
without an AFCH employee.
J. A Child Life Specialist will be notified as soon as possible regarding a scheduled
procedure to ensure the ability to attend, prepare, and accompany child for procedure.


A. Hospital Administrative Policy 7.33, Guidelines for Participation of Patients’ Primary
Supports and Guidelines for Visitors
B. Hospital Administrative Policy 7.46, Hospital School for the School Age Patient
C. Hospital Administrative Policy 8.10, Transport of ICU Status Patients within UWHC
D. Hospital Administrative Policy 8.88, Hand-Off Communication
E. Hospital Administrative Policy 8.97, Safe Transport of Sedated and/or Intubated
Children in CSC (including AFCH)
F. Nursing and Patient Care Policy and Procedure 1.31, Caring for Adult and Pediatric
Patients Requiring Cardiac Monitoring
G. Nursing and Patient Care Policy and Procedure 13.16, Basic Care Standards-
H. Respiratory Manual Policy 2.05, Transportation of Patients Supported by Mechanical


A. Off-Unit Transport Skill Level for Accompanying Patient (available on U-Connect)


Nurse Manager, Nursing Diagnostic/Therapy Center

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Nurse Manager, PICU, P5, P4
Clinical Nurse Specialist General Care
Clinical Nurse Specialist, Universal Care Unit
Director, AFCH Pediatric Nursing
Nursing Patient Care Policy and Procedure Committee, April 2015


Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing