Children's Hospital Patient Placement Guidelines - MUSC Library

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					               Children’s Hospital Patient Placement Guidelines

In-patient units                                                       August, 2011


 In order to ensure bed availability in the Children’s Hospital, provide an atmosphere that is
 appropriate for children and to match nursing skills and service to the population served, the
 following guidelines have been developed by the Children’s Hospital Leadership group.

Admission Criteria:

   1. Patients over the age of 17 will not be admitted to a CH unless an online exception form
      is done by the physician admitting the patient (possibly link):
      a. Young adults with developmental delays 18 years and older should be admitted to the
      adult hospital
      b. Young adults with oncology diagnosis receiving chemotherapy will be admitted to the
      Children’s Hospital
      c. Pediatric cardiology patients: Adults up to the age 25; ages 25 – 60 with identified
      criteria. Adults 60 years and older will be admitted to the adult hospital.

   2. Exception to the above may be made with the approval of the following through the
      online exception form:
          - Children’s Hospital Administrator or designee
          - MUSC Medical Director or designee

       Each decision will be made on a case-by-case basis taking into consideration patient
       disease status, medical needs, nursing competencies and current census.

   4. The bed assignment will be made based on the child’s needs and diagnosis. Information
      used to determine the most appropriate placement will include diagnosis, isolation status,
      intensity level, staffing requirement, pre-existing conditions, and census (current and
                                            Unit Descriptions

     Unit          Primary Populations                    Size of Unit                    Ages

7E                General Medical/Surgical        25 Operational Beds         5 years - 17years
                  Neurology/Neurosurgery
                  Video EEG                                                   Corrected age must be
                  Burn                                                        > 30 days
                  Established/stable BIPAP
                  Trauma                                                      Crunch (no bed available):
                  CF with diabetes                                            >30 days
                                                                               < 4 years
7A                General Medical/Surgical        18 Operational Beds         4 years old and under
                  Neurology/Neurosurgery          Maximum census = 22         Priority unit for <1yr
                  Trauma
                                                                               Up to age 8 years old
7B                Hematology/Oncology             18 Operational Beds         All Ages
                  Endocrine                       Maximum census = 18         Adult oncology pts
                  Solid Organ Transplant          12 – regular
                  Bone Marrow Transplant          6 – BMT positive pressure

8D                Cardiology                      10 Operational Beds         Newborn – 25 years
                  CT Surgery                      Maximum census = 10         25 yrs – 60 yrs criteria
                  Heart Transplant                                            >60 yrs adult hospital

PICU              Pediatric Intensive Care        11 Operational Beds         Up to age 17 years
                  Intermediate Care                                           Peds Ortho >17 years

Intermediate      Ventilator Dependent            10 Operational Beds         All Ages
Care (7C)         Intermediate Care Patients
                  Have monitored beds

PCICU             Cardiac Intensive Care          10 Operational Beds         Newborn – 25 years
                  Intermediate Cardiac            Maximum census = 12         25 yrs – 60 yrs criteria
                                                                               >60 yrs adult hospital
ED                Patients requiring < 24 hour 12 Operational Beds            Up to age 17 years

Same Day          Pre-op cardiac surgery          6 Operational Beds          All ages
(Open until       Pre heart catheterization
1900)             Post GA/sedation heart cath
                  ECHO Sedation

Procedure         GI procedures                   5 Operational Rooms         Up to age 17 years
Area              Urology procedures              10 Recovery Bays
(Open until       Sedation
                                    Bed Placement Guidelines

Diagnosis                    7E                7B                     8D           7A
Adenovirus                   AL                No                     No           AL
*Droplet/Mask if resp s/s
Aplastic Anemia              HI                US                     HI           HI
Asthma                       US                HI                     HI           US
Burns                        AL                No                     No           No
Cardiology, as approp.       HI                HI                     AL           HI
C-Diff *Contact              AL                Subsp                  CV           AL
Continuous Nebs              AL                AL                     AL           AL
Cystic Fibrosis              AL                No                     No           AL
CT Surgery, as approp.       HI                HI                     AL           HI
Diabetic with CF             AL                No                     No           AL
Diabetic/endocrine           HI                AL                     CV service   HI
*new dx on 7B
EVD/Lumbar drain             AL                No                     No           AL
Fever, R/O Sepsis            AL                Subsp + HI             CV +HI       AL
Flu                          AL                Subsp pts.             CV           AL
*Droplet if over 6yr
*Contact/Droplet under 6yr
GI                           US                HI                     HI           US
ITP                          HI                AL                     HI           HI
Hemophilia                   HI                AL                     HI           HI
Insulin Pumps                No                AL                     No           No
Kawasaki                     AL                HI                     HI           AL
Lupus                        HI                AL                     HI           HI
Meningitis                   US                HI                     HI           US
MRSA                         AL                Subsp + HI             CV +HI       AL
Neurology                    US                HI                     HI           US
Non-infectious Surgical      AL                HI                     HI           AL
Oncology Non Chemo           HI w/ varicella   AL                     No           HI w/ varicella
Oncology receiving Chemo     NO                AL                     No           No
Orthopedic                   AL                HI                     HI           AL
**Parvo         *Droplet     AL                No                     No           AL
Peritoneal Dialysis          No                AL                     No           No
Pertussis *Droplet/Mask      AL                No                     No           AL
Pulmonary                    AL                HI                     HI           AL
Renal                        HI                AL                     HI           HI
Rooming In                   No                No                     HI           AL
RSV        *Contact/Mask     AL                No                     CV Service   AL
Sickle Cell Disease          HI                AL                     HI           HI
TB                           AL                No                     No           AL
Transplant                   HI                AL BMT/kidney/ liver   AL - heart   HI
Wound Vac                    US                HI                     HI           US
Video EEG                    AL                No                     No           HI
Urology                      AL                HI                     HI           AL
Varicella                    AL                No                     No           AL
                                     General Guidelines

Bed Placement Codes:
AL: Always, must go on this unit
US: Usually, priority placement if bed is available
HI: High Intensity No bed immediately available and/or extenuating circumstances on other unit
No: Cannot be placed on this unit

Bed Placement Infusion Database (Intranet/Staff toolbox):
    Guideline to identify which units continuous infusions can be done on (Link site)

General Information:
    Patients on continuous nebs - See guidelines
    BIPAP pts will be discussed on a case by case basis for established pts on bipap
    Ventilator dependent patients are admitted to the ICUs and Intermediate Care Unit
    *Patients being tested for Parvo as part of a general transplant/rejection screening
      evaluation who remain asymptomatic and the MD has a low index of suspicion may
      remain on 7B.
    Patients will not be diverted to units based on number of admissions assigned to unit.
    Patients will remain on 7C if possible until discharge or will be transferred based on unit
      needs as directed by charge nurse and MD.

 Negative Pressure Rooms                  Chickenpox                            TB
  If no rooms available,
 contact infection control
   practitioner on call.
                                 7006 – 7E                        7006 – 7E
                                 7007 – 7E                        7007 – 7E
                                 7011 – 7E                        7011 – 7E
                                 7012 -7E                         7012 – 7E
                                 713 – 7A                         727 – 7A
                                 727 – 7A                         734 – 7A
                                 734 – 7A                         Bed #2 - PICU
                                 Bed #2 – PICU

     Video EEG Rooms                           7E                               7A
    Should go to 7E first.
                                 7013                             706 – 711
                                 7014                             729 - 733

Vapotherm can be done in the non-ICU areas based on this criteria:
          Respiratory will set up equipment
          Infants less than 12 months should be on 2L nasal cannula or less; needs greater
            than this will be evaluated on an individual basis
          Infants over 12 months of age must have oxygen requirements of 4L or < nasal
          If oxygen needs become greater, respiratory and the MD will need to evaluate
            patient for Intermediate care unit or ICU
Crash Bed Guidelines:
       1st Priority – PICU
          PICU is full at 11 beds and PCICU has open beds; PCICU is the crash bed
          PCICU is full at 12 beds, discussion with PACU about using them as crash bed
          PACU may need to be the crash bed or negotiate transferring a patient out of PICIU
           or PACU and then the PICU will become the crash bed. This could be a less acute
           patient or a patient waiting on a non ICU bed. The PICU attending will triage to
           determine if a less critical patient is more appropriate for transfer to the PICU.
          The PICU manager, HSC, and bed management will coordinate this.
          Staffing levels are not factored into the ability to have a crash bed. If staffing is tight
           and a crash bed is needed, the open unit will take the critical patient. After the patient
           is stable the unit needs will be assessed.

Guidelines for Admission of Obstetrical patients:
    Previable <20 weeks - Can go anywhere as no intervention will be possible at this
      gestational age to save pregnancy if miscarriage is threatened

      Periviability, 20-23 weeks gestation - Notify OB service of periviable hospital admissions
       and determine level of service OB should provide. Admission to OB floor is generally
       recommended. There may be instances that care can be optimally provided on another
       floor with OB as primary consultant. This would require formalized information from
       OB nursing for peds to provide appropriate care

      Viable >24 gestation - Admit to OB floor

Direct Admissions
Before getting a direct admission to the floor, you should receive report from the outlying
hospital, MD Office, or other facility. If this does not happen, please let your nurse manager
know this so this can be communicated to bed management.

Cardiology Patients
Should be placed on 8D (May be in with other primary dx but have this also l isted):
Hypoplastic left heart syndrome
Hypoplastic right heart syndrome
Unbalanced AVC
Post Norwood
Post Hybrid
Post Bidirectional Glenn
Post Fontan
Pre-op Tetrology of Fallot due to TET spells

Can be place on other CH Units in the event a bed is not available on 8D:
ASD                                             Repaired Tetrology of Fallot
VSD                                             Truncus Arteriosus
Coarctation of aorta                            Pulmonary stenosis
Interrupted aortic arch
Aortic stenosis
Transposition of the great arteries
Double outlet RV
   1. Admissions to the Children’s Hospital inpatient areas will be coordinated through the
      Admission Transfer Center.

   2. If inpatient beds are not readily available, alternative options will be explored:
           a. Assure discharges occur as early in the day as possible
           b. Case Managers and Clinical Unit Leaders will evaluate potential discharges
           c. Maximally use same day area for patients waiting to be discharged, for
              procedures, and for short-stays, for example after ambulatory surgery.
           d. Discharged patients (non-contagious) waiting for a ride may be discharged and
              allowed to wait in the first floor lobby area accompanied by parent.
           e. Adult discharged patients my wait in discharge lobby in the first floor lobby.
           f. Same Day can be used to begin the admission process when discharges are
           g. A temporary admission to PICU, PCICU, or Intermediate Care Unit coded as non
           h. ED patients will be evaluated on boarding options based on staffing, severity of
              illness and length of wait.

   3. If ICU beds are not available, alternative options will be explored:
          a. ICU MD and Clinical Unit Leader will evaluate who can safely be transferred to
             an inpatient unit
          b. Coordination with NM, bed control and/or house supervisor

                  OVERCAPACITY PLAN

ALL requests for pediatric patient placement will continue to flow through Admission Transfer
Center (ATC) in collaboration with the Nurse Manager, house supervisor and/or MD.

   1.    When the attending and/or charge nurse in the Children’s ED are concerned about the
         ability of the ED to continue to treat patients due to the back-up of patients in the
         rooms and hallway, they will contact the ED NM or house supervisor. The house
         supervisor will contact the Nursing Director of the Children’s Hospital or her designee
         to initiate the Overcapacity Plan.

   2.    The Director will notify the NM during the daytime, Administrator and coordinate bed
         placement activities with the ATC and the House Services Coordinator (after hours).
         The NM or HSC will coordinate these activities with the CUL or charge nurse.

   3.    If CH Overcapacity Plan is instituted, coordination will be done to expedite patients
         from the ED as soon as they can safely be transferred. The unit will need to accept the
         patient and a STAT transfer and report will be done. ATC will be notified.

   4.    The CH Overcapacity Plan will evaluate alternative locations for patients:

          a. Semi-private room usage
             7A has 4 semi-private rooms
             8D has 4 semi-private rooms
Guidelines for patients that must be in a private room.
         Patient with sustained fever of unknown origin. If patient has negative cultures or
          antibiotics have been started, okay to pair.
         Patient with infections requiring respiratory (airborne or droplet) isolation or contact
          precautions, except patients with same organism (e.g., RSV, CMV) Consult Infection
          Control as needed.
         Patient colonized or infected with MRSA, or suspected of having community
          acquired MRSA. Older children with soft tissue infections such as a skin abscess or
          cellulitis that could be potentially be MRSA
         Escalating social issues (this could be overridden if needed)
         Neutropenic patient (ANC less than 1000)
         Solid organ and Bone Marrow Transplant patients.
         Patients on peritoneal dialysis
         Terminally ill patient (this could be overridden if needed)
         Patients with external ventricular devices.
         Sickle Cell patients with crises thought to be caused by infection, such as Parvovirus
          if known. Two febrile sickle cell patients can be put in a semi-private room, but a
          febrile and non-febrile patient should not be put together
         Patient with Cystic Fibrosis
         Phototherapy

   Private room preferred but can safely be placed in semi-private room

          Breastfeeding mother
          Infants < 8 weeks old
          Patients with RSV. Patients may be doubled with another RSV positive patient as
               long as the symptoms are similar
          Patients with an infection of the same causative organism; (except MRSA)
          Patients with a large amount of equipment or anticipated long length of stay.
          Patients < 4 years old with fever, RSV negative bronchiolitis, varicella,

Treatment Room evaluation:
Treatment room bed numbers as follows:
7A E721             8D E821        7C – Will not accommodate crib or bed
7B E762             7E 7017

The unit treatment room will be evaluated for admitting patients based on unit activity:
 The appropriate bed or crib will be obtained (so the patient does not remain on a stretcher
   any longer than necessary)
 A comfortable chair will be obtained for the parent when possible
 A manual bell will be obtained or call bell will be in treatment room
 The treatment door will be wedged open at all times to assure a call for help can be heard
 Curtains will be pulled around the patient for privacy
 If available, an over bed table will be obtained
   The patient’s admission will occur as if the child was in a bed (orders written, therapy
    initiated, assessment documented etc)
   Service Recovery: The patient/parent will receive an apology and explanation for the
    placement, which we hope will be short term. They will be told that individuals will need to
    enter the room for supplies from time to time.
   Service Recovery: The patient/parent will receive a visit by the manager/HS and/or director
    to apologize for the placement and ask for their tolerance.

The Designated CH NM, Nursing Director, HS, and/or MD will attempt to make walking rounds
to identify potential patients for discharge or transfer.

The Nursing Director, HSC, or Administrator will determine when further steps are warranted or
when step-down to normal operations is appropriate

         High Census Adjustment to Admission Guidelines for Children’s Hospital

During periods of high census, the guidelines for Pediatric Critical High Census Events will be
instituted. In addition to the options listed in those guidelines, the following age-specific
admission changes will be instituted.

    1.       Patients age sixteen years (16) and above will be considered for admission to adult
             units provided their admitting diagnosis is not restricted to a pediatric unit.
    2.       The ATC will assist in determining the availability of adult beds and appropriateness
             of this option for pediatric patients ages 16 and above.
    3.       Patients will be placed on any unit, as defined by Bed Placement Guidelines, with bed
             availability and will remain on this unit until discharge.

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