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Ambulatory Procedure Center (APC) and Gastroenterology Procedure Area Preprocedure Orders – Adult – Ambulatory [24]

Ambulatory Procedure Center (APC) and Gastroenterology Procedure Area Preprocedure Orders – Adult – Ambulatory [24] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols



Delegation Protocol Number: 24

Delegation Protocol Title:
Ambulatory Procedure Center (APC) and Gastroenterology Procedure Area Preprocedure Orders - Adult -
Ambulatory

Delegation Protocol Applies To:
UW Health Ambulatory Procedure Center (APC)/Gastroenterology (GI) Procedure Area

Target Patient Population:
Adult outpatients scheduled for GI and endoscopy procedures within APC/GI department.

Delegation Protocol Champion:
Patrick Pfau, MD - Department of Medicine, Division of Gastroenterology

Delegation Protocol Reviewers:
Nancy Gondzur, RN - Nurse Manager, Ambulatory Procedure Center (APC) and Gastroenterology Procedure Area
Hannet Tibagwa Ambord, PharmD, MS, MBA – UW Health Digestive Health Center
Laurie Woodhouse, RN – UW Health Digestive Health Center
Deepak Gopal, MD – Department of Medicine - Gastroenterology
Anne Rikkers, RN – Gastroenterology/Endocrinology Procedures

Responsible Department:
Department of Medicine - Gastroenterology

Purpose Statement:
To delegate authority from the procedure gastroenterology provider to Registered Nurses (RNs) in
the APC/GI procedure area to order pre-procedure medications and labs for outpatients having GI
and endoscopy procedures

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) in APC/GI Procedure Area

Guidelines for Implementation:
1. RN completes nurse assessment. The following are contraindications to the use of this protocol and the RN
will not initiate the protocol if any of the following are determined. Instead, the RN will contact the provider
for further instruction.
1.1. Patient not NPO as instructed
1.2. Incomplete prep
1.3. Anticoagulant medication not discontinued as instructed
1.4. Congestive Heart Failure
1.5. Recent myocardial infarction
2. RN places the following orders via the APC/GI order set: OP–GI – Endoscopy – Adult – Preprocedure.
1.1. Bacteriostatic saline and lidocaine as needed for pain relief prior to peripheral IV insertion
1.2. Insert and maintain peripheral IV
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


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1.3. Sodium chloride 0.9% IV BOLUS (Start at 125 mL/hr, may go up to 500 mL/hr as needed. Maximum of
500 mL total may be infused.)
1.4. Hypoglycemia management orders

Order Mode:
Cosign Required, Protocol/Policy

References:
1. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for
hospitals. Oakbrook Terrace: Joint Commission on Accreditation of Healthcare Organizations.
2. American Society of Anesthesiologists, Task Force on Sedation and Analgesia by Non-anesthesiologists.
Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004-1017.
3. Society of Gastroenterology and American Society of Gastrointestinal Endoscopy (2004). Joint Position
Statement: Role of GI Registered Nurses in the Management of Patients Undergoing Sedated Procedures.
4. American Society of PeriAnesthesia Nurses. Resource 8: The role of the registered nurse in the management
of patients undergoing sedation for short-term therapeutic, diagnostic or surgical procedures. In: Standards
of Perianesthesia Nursing Practice. American Society of PeriAnesthesia Nurses; 2008:80-81.
5. Modifications to the Post anesthesia Score for Use in Ambulatory Surgery by J.Antonio Aldrete, MD, MS,
Journal of PeriAnesthesia Nursing. 1998;13(3):148-155

Collateral Documents/Tools:
OP–GI – Endoscopy – Adult – Preprocedure Smart Set [3427]

Approved By:
UW Health Ambulatory Protocol Committee: November 2012; *July 2015
UW Health Clinical Laboratories Practice Committee: November 2012; *July 2015
UWHC Pharmacy and Therapeutics Committee: December 2012; *July 2015
UWHC Medical Board: January 2013; *July 2015
UW Health Chief Medical Officer: July 2015

Effective Date: July 2015

Scheduled for Review: July 2018
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org