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Preoperative Testing for Foregut Surgery - Adult - Ambulatory [142]

Preoperative Testing for Foregut Surgery - Adult - Ambulatory [142] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols



Delegation Protocol Number: 142

Delegation Protocol Title:
Preoperative Testing for Foregut Surgery - Adult - Ambulatory

Delegation Protocol Applies To:
UW Health General Surgery Clinics

Target Patient Population:
Adult patients scheduled to undergo foregut surgery

Delegation Protocol Champions:
Anne Lidor, MD – Department of Surgery - General Surgery
Jacob Greenberg, MD – Department of Surgery - General Surgery
Michael Garren, MD – Department of Surgery - General Surgery
Luke Funk, MD – Department of Surgery - General Surgery
Michael Sloan, MD – Department of Surgery - General Surgery
Amber Shada, MD – Department of Surgery - General Surgery

Delegation Protocol Reviewers:
Sarah Smith, NP – General Surgery
Rebecca Hagen – Clinic Manager - General Surgery (University Hospital)
Connie Gilke – Special Clinics Manager (The American Center)

Responsible Department:
Department of Surgery - General Surgery

Purpose Statement:
This protocol delegates authority from the patient’s Surgeon to Registered Nurses (RNs) to place orders
for testing under specific conditions in Table 1.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) trained in the use of this protocol.

Training will be led by senior staff with considerable experience and demonstrated ability to carry out
the delegated acts (as confirmed by the delegating providers). Training will consist mostly of one-on-
one instruction with new staff who must also demonstrate ability before they serve as delegates.

Guidelines for Implementation:
1. This delegation protocol is initiated when a patient scheduled for surgery has not had the required
testing in the past year.
2. The RN will use Table 1 to determine the specific orders needed. Prior to placing any orders, the RN
will review the patient’s medical record to identify previously ordered tests to avoid duplication.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


3. If the testing was performed outside UW Health the RN will obtain the additional information
indicated if available from the outside facility
Table 1. Orders
Indication Esophageal
Manometry
Upper GI without
KUB
Impedance
pH
EGD
Achalasia X X
Esophageal Reflux X X X X
Barrett’s Esophagus X X X
Hiatal Hernia,
Paraesophageal Hernia,
Gastric Volvulus
X X
Dysphagia/Difficulty
Swallowing
X X X
Gastrointestinal Stromal
Tumor (GIST)
X
Additional Information to
Obtain for Outside Tests
Imaging and
Reports or Cine
Reports and
Imaging
Biopsy, Pathology,
Imaging
* Gastrointestinal (GI), Kidney, Ureter Bladder (KUB), Esophagogastroduodenoscopy (EGD)

Order Mode: Cosign Required, Protocol/Policy

References:
1. Zinner, M.J. & Ashley, S.W. (2013). Maingot’s Adominal Operations. (12 ed.) New York, NY: McGraw
Hill http://accesssurgery.mhmedical.com/content.aspx?bookid=531§ionid=41808776
Collateral Documents/Tools: N/A

Approved By:
UW Health Ambulatory Protocol Committee: May 2016
UW Health Center for Clinical Knowledge Management Council: May 2016
UWHC Medical Board: June 2016
UW Health Chief Clinical Officer: June 2016

Effective Date: June 2016

Scheduled for Review: June 2019

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org