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Children's Hospital Policies and Guidelines



Chapter 0 : Templates

Clinical Pathway

Education & Implementation Plan

Guideline

Protocol

Protocol Requirements

Standard Work

Chapter 1 : Children's Hospital CLINICAL PRACTICE Guidelines (Interdisciplinary)

Section 1 : Children's Hospital-Wide

1.1.01 : Pediatric Rapid Response System

1.1.01a : Pediatric Code 12 Roles

1.1.02 : Care of Thoracic Surgical Incisions in the Pediatric Population

1.1.03 : Chest Tube Management in the Pediatric Postoperative Cardiovascular Patient

1.1.04 : Progressive Mobility Program

1.1.05 : Critical Care Ventilation Transition to Home/Portable Ventilation While on Transitional Care Unit

1.1.06 : Management of Autonomic Instability “Storming” following Brain Injury

1.1.07 : Management of Broken Tunneled Central Venous Line

1.1.08 : Vascular Access in Pediatric Cardiovascular Surgery Patients

1.1.09 : Pediatric Heart Sternal Site Infection Prevention Bundle

1.1.11 : Daily Chlorhexidine Baths for Pediatric Patients prior to Cardiac Surgery

1.1.12 : Pediatric Inpatient Acute Hyperkalemia Treatment Sequence Guideline

1.1.13 : Managing an Acute Exacerbation of Asthma in the Pediatric Patient

1.1.16 : Pediatric Convulsive Status Epilepticus

1.1.17 : Low Response in Pediatric Brain Injury

1.1.18 : Ethanol Locking of Central Venous Catheters in Pediatric Patients for CA-BSI Prevention

1.1.20 : Response to Patient Events on the Pediatric Epilepsy Monitoring Service.

1.1.22 : Ketogenic Diet for Children with Epilepsy

1.1.23 : Management of Pediatric Diabetes and Diabetic Ketoacidosis (DKA)

1.1.24 : Specialized Formula Preparation for Infants and Children: Guideline for Formula Room

1.1.26 : Use of Near Infrared Spectroscopy within the Children’s Hospital

1.1.27 : Pediatric Anaphylaxis and Hypersensitivity Reaction Management Guideline

1.1.28 : THE Management of Community Acquired Pneumonia in the Pediatric Patient

1.1.29 : Determination and Evaluation of ECMO Candidacy for Patients in the Children’s Hospital

1.1.30 : Monitoring and Treatment of Neonates at Risk for Neonatal Abstinence

1.1.31 : Pediatric Iatrogenic Withdrawal

1.1.31 : UVA Children’s Hospital Non-accidental Trauma (NAT) Screening and Management

1.1.01b : Neonatal Emergency Response Protocol NERT

Anticoagulant Dosing and Reversal in Infants and Children under 45 kg

Declaration of Death by Neurologic Criteria (Brain Death)

Malignant Hyperthermia Initial Management (Non-OR setting)

Medical Nutrition Therapy by Registered Dietitians/Nutritionists

Sedation for Diagnostic and Therapeutic Purposes - Pediatric

Standard Work | Admitting Oncology Patient from Outpatient to Inpatient with Active Infusion

Standard Work | Admitting Oncology Patient from Outpatient to Inpatient with Controlled Substance Infusion

Standard Work | Emergent Pediatric Cardiac ECMO (eCPR)

Standard Work | Non-Emergent ECMO Activation

Standard Work | Subcutaneous Treprostinil (Remodulin) Infusion

VTE Prophylaxis Guideline - Pediatric

Section 2 : Acute Care

1.2.01 : Pulse Oximetry In Acute Care Setting

1.2.02 : Telemetry for Acute Care Pediatrics

Section 3 : NICU

1.3.01 : Avastin Treatment of Retinopathy of Prematurity

1.3.02 : Oxygen and Flow Titration in the Neonatal Intensive Care Unit for Patients on Nasal Cannula

1.3.03 : Non-Nutritive Suck and Cue-Based Feeding in the NICU

1.3.04 : Neonatal Ventilator-Associated Pneumonia (VAP) and Neonatal Ventilator Injury Prevention Guideline

1.3.05 : Surgical Treatment of Retinopathy of Prematurity

1.3.06 : NICU Hand Hygiene and Gloving

1.3.07 : RETIRED - Nursing and Respiratory Care Guideline for Newborns on Nasal CPAP in the NICU

1.3.08 : NICU Guideline for Use of the Klockner Family Suites

1.3.09 : General Movement Assessment (GMA)

1.3.10 : Best Practice Guidelines Regarding Cardiovascular Surveillance of Premature Infants in the Neonatal

1.3.11 : Placental Lab Draw

Section 4 : PICU

1.4.01 : Sedation guideline for Mechanically Ventilated Patients in the Pediatric Intensive Care Unit

1.4.02 : Neonatal & Pediatric Critical Care Pain, Agitation, and Delirium Management

Emergent Pediatric Cardiac ECMO (eCPR)

Lung Protective Ventilation Guideline for Pediatric Acute Respiratory Distress Syndrome (PARDS)

Standard Work | Placement of Pediatric Non-Weighted Post-pyloric Tube

Section 5 : ECMO

1.5.01 : Pediatric Cardiac ECMO Team

1.5.02 : ECMO Safety Check

1.5.03 : Hemofiltration via the ECMO Circuit

1.5.04 : Blood Priming, Initiating and Decannulating Neonatal and Pediatric ECMO

1.5.05 : Transporting a Patient on ECMO: Internal

1.5.06 : Transporting a Patient on ECMO Inter-Hospital

1.5.07 : Set Up and Clear Priming the ECMO Circuit

1.5.08 : Weaning and Trialing from ECMO

1.5.09 : Bivalirudin for Anticoagulation in Neonatal and Pediatric ECMO

1.5.10 : Heparin Management in Neonatal and Pediatric ECMO

1.5.11 : Autotransfusion for ECMO Patients

1.5.12 : CRRT Guideline and Procedure with Prismaflex for Pediatric/Neonatal ECMO Patients

1.5.13 : RotaVAD Device Setup

1.5.14 : Antithrombin (Thrombate) Use during Neonatal and Pediatric ECMO and Pediatric VAD

1.5.15 : Set-up and Priming the CARDIOHELP-i System HLS Set Advanced

Determination and Evaluation of ECMO Candidacy for Patients in the Children's Hospital

Standard Work: Emergent Pediatric Cardiac ECMO (eCPR)

Standard Work: Non-Emergent ECMO Activation

Section 6 : Ambulatory Clinics

Diphtheria, Tetanus, and Acellular Pertussis (DTaP) Vaccine, Administration

Haemophilus influenza Type B Vaccine (HIB), Administration

Hepatitis A Vaccine, Administration

Hepatitis B, Administration

Human Papillomavirus Vaccine (HPV), Administration

Streptococcus Infection Diagnosis by Throat Culture

Tetanus, Diphtheria, and Acellular Pertussis (Tdap/Td) Vaccine, Administration

Chapter 2 : Children's Hospital NURSING Care Guidelines

Section 1 : Children's Hospital-wide

2.1.01 : Discharge Of The Newborn

2.1.02 : Care And Support Of Breastfeeding Patients

2.1.03 : Patient Triage

2.1.04 : Tunneled Central Venous Line Breakage - Nursing Care of

2.1.05 : Apnea, Bradycardia, And Cyanotic Events

2.1.06 : 24% Oral Sucrose Solution for Analgesia in Infants [see 3.1.25]

2.1.07 : RETIRED - Feeding Intolerance Guideline and Algorithm

2.1.08 : Daily Chlorhexidine Baths for Pediatric Patients with Central Lines and Indwelling Urinary Catheters

2.1.09 : Neonatal and Pediatric Pain and Sedation Guideline, Using N-PASS Scale

2.1.10 : Pediatric Bladder Scanning Algorithm

2.1.11 : Neonatal and Pediatric Sedation and Withdrawal Guideline using the Withdrawal Assessment Tool (WAT-1) and State Behavioral Scale (SBS).

2.1.12 : Transcutaneous CO2 Monitoring in the Children’s Hospital

2.1.13 : Breastmilk Storage, Handling and Administration

Standard Work: Freezing Breastmilk

Standard Work: Obtaining a DME Breast Pump with a Voucher Payment

Standard Work: Procurement of a Breast Pump through ABC Healthcare

Standard Work: Zebra Band Printing

Section 2 : Acute Care

2.2.01 : [RETIRED] Asthma Patient

2.2.04 : Chemotherapy

2.2.05 : Enema Solutions for Infants and Children

Section 3 : NICU

2.3.02 : Nursing Care In The Newborn Intensive Care Unit

2.3.05 : Extremely Low Birth Weight Infant

2.3.06 : Establishing Breastfeeding In The Preterm Or Sick Infant

2.3.07 : ECMO Patient: Admission, Stabilization, and Cannulation

2.3.08 : ECMO Patient: Routine Bedside Nursing

2.3.09 : ECMO : Decannulation And Post-cannulation Care in NICU

2.3.10 : Pulse Oximetry (NICU)

2.3.11 : RETIRED - Management of NICU Patient on a High Frequency Ventilator

2.3.12 : Kangaroo Care / Skin to Skin Holding Guideline in the NICU

2.3.13 : Critical Congenital Heart Disease (CCHD) Pulse Oximetry Screening Protocol in the NICU

2.3.14 : Thermoregulation - From Delivery to NICU Admission (& Flow Diagram)

2.3.15 : Cycling of Total Parenteral Nutrition

2.3.16 : Intravitreal Avastin Guideline for the Neonatal Intensive Care Unit

2.3.17 : Guideline for Safe Sleep in the Neonatal Intensive Care Unit

2.3.18 : Prevention and Care of Multi-Drug Resistant Organisms (MDRO) in Neonatal Intensive Care Unit (NICU)

2.3.19 : Clinical Guideline for Bubble CPAP in the Neonatal Intensive Care Unit

2.3.20 : Drawing Neonatal Blood from the Placenta after Delivery

2.3.21 : Gastric Residual Check

2.3.22 : Intraventricular Hemorrhage Prevention Bundle for Infants less than 32 weeks Gestational Age

2.3.23 : Bathing in the Neonatal Intensive Care Unit (NICU)

Guideline for Delayed Cord Clamping and Cord Milking for Preterm and Term Infants

Section 4 : PICU

2.4.01 : Care Guidelines For The Care Of An Intubated Patient With A Critical Airway

2.4.02 : [Retired] | Obtaining Arterial Blood Gases After Cardiac Surgery

2.4.03 : Obtaining Arterial Blood Gases In The PICU

2.4.05 : Guideline - Nursing Care of Right Atrium (RA) Line

2.4.06 : Care of a Patient with a Temporary Epicardial Pacemaker

Standard Work | Double Pumping Vasoactive Infusions

Chapter 3 : Children's Hospital MEDICATION Guidelines

Section 1 : Children's Hospital-wide

3.1.01 : Amphotericin Administration

3.1.02 : Dihydroergotamine (DHE) Administration in Children and Adolescents

3.1.03 : Double Check Medications

3.1.04 : Intravenous Epoprostenol Therapy Initiated in the Pediatric Intensive Care Unit

3.1.06 : Administration Guideline for Infliximab (Remicade) in Children and Adolescents

3.1.07 : Intravenous Immunoglobulin (IVIG)

3.1.09 : Intravenous Electrolyte Administration

3.1.10 : Treprostinil (Remodulin) Therapy in Infants and Children

3.1.11 : Rituximab (Rituxan) Administration

3.1.12 : Antithimocyte Globulin (Rabbit) Injection Administration

3.1.13 : Hyaluronidase Administration following IV Medication Extravasation

3.1.14 : Alprostadil (Prostaglandin E1, PGE1) Administration

3.1.15 : Neonatal IV Medication Administration Guidelines

3.1.16 : Pediatric IV Medication Administration Guideline

3.1.17 : Pediatric Factor VIIa

3.1.18 : Pediatric Parenteral Nutrition

3.1.19 : Epoprostenol (Flolan) Therapy for the Neonate with Persistent Pulmonary Hypertension of the Newborn (PPHN)

3.1.20 : Low Dose Continuous Lidocaine Infusion for Pain Control in the Pediatric Patient

3.1.21 : Influenza Vaccination - Nurse Driven Protocol, Pediatric Inpatient and Ambulatory

3.1.22 : Use of Intravenous Hypertonic Saline in Severe Pediatric Cerebral Edema

3.1.23 : Pediatric Antimicrobial Preauthorization Restrictions

3.1.24 : Use of Systemic Alteplase for Thrombolysis in Pediatrics

3.1.25 : 24% Oral Sucrose Solution for Analgesia in Infants

Anticoagulant Dosing and Reversal in Infants and Children under 45 kg

Standard Work: Continuous Infusion Transfer for the Interfacility Admission

Section 2 : Acute Care

3.2.01 : Intravenous Milrinone Administration

Section 3 : NICU

3.3.01 : Insulin Infusion for Continuous IV Infusion

3.3.02 : Surfactant Administration for the Neonate

Intravenous Immunoglobulin (IVIG)

Section 4 : PICU

Chapter 4 : Children's Hospital POLICIES

Section 1 : Children's Hospital-wide

4.1.01 : Infant Positioning and Safe Sleep Practices for Infants Less Than 1 Year of Age

Section 2 : Pediatric Acute

Section 3 : Pediatric Intensive Care

Section 4 : Neonatal

CH and TWP Policy: Hepatitis B Vaccine for Newborn Infants

Section 5 : Children's Hospital Ambulatory

5.1.01 : Patient Notification of Women’s and Children’s Hospital (WCH) Ambulatory Service Schedule Changes Related to an Emergency Event

Section 6 : Ambulatory - Patient Friendly Access (Women's and Children's)

Standard Work for Patient Notification of Women’s and Children’s Hospital (WCH) Ambulatory Service Schedule Changes Related to an Emergency Event

Section 7 : Child Development and Rehabilitation Center

Section 8 : Children's Hospital Administrative Policies

4.08.01 : Attendance Policy Addendum

4.08.02 : Special Visitors

4.08.03 : Tdap Immunization for Volunteers in the Children’s Hospital

4.08.04 : In Kind Donations

Chapter 5 : Model Cell

Section 1 : Model Cell Expectations

MCE.1 : Department Leaders

MCE.2 : Service Line Leadership

MCE.3 : Unit/Clinic Leadership

MCE.4 : Frontline Team Member

MCE.5 : Advanced Nursing

MCE.6 : Service Line Be Safe Coach

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