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Suture and Staple Removal – Adult/Pediatric – Ambulatory [103]

Suture and Staple Removal – Adult/Pediatric – Ambulatory [103] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols




Delegation Protocol Number: 103

Delegation Protocol Title:
Suture and Staple Removal - Adult/Pediatric - Ambulatory

Delegation Protocol Applies To:
UW Health Clinics

Target Patient Population:
Any adult or pediatric patient presenting with the need for suture or staple removal.

Delegation Protocol Champions:
Steven Tyska, MD – Department of Family Medicine - Urgent Care
Michael Sloan, MD – Department of Surgery
Daniel Bennett, MD – Dermatology
Lisa Arkin, MD – Dermatology
Andrew Swanson, MD – Dermatology
Matthew Anderson, MD – Department of Medicine – General Internal Medicine

Delegation Protocol Reviewers:
Teri Kuntzsch, MSN, RN – Nursing Program Specialist
Brian Tisch, RN – Urgent Care, West Towne
Shabvon Johnson, BSN, MBA – UW Health Ambulatory Operations
Stacie Rhinehart – UW Health Ambulatory Operations
Karil Walther, DNP, RN – UW Health Ambulatory Operations
Jodie Cook, RN – Dermatology East Clinic
Lisa Hilker, MA – Dermatology 1 S. Park
Rebecca Hagen, RN, BSN, MA – General Surgery
Donnette Kelly – Ortho/Rehab
Constance Gilke – Specialty Clinics – The American Center
Nathan Wait – Orthopedics – The American Center
Mark Shepherd – Orthopedics – University Hospital
Cheryle Sickels – Sports Medicine – Research Park
Laura Brunner, BSN, RN – Pediatric Specialties – American Family Children’s Hospital
Julie Christofferson, RN, MSN – Clinical Staff Education
Diane Mikelsons, RN – Clinical Staff Education

Responsible Department:
Department of Family Medicine
Department of Surgery
Department of General Internal Medicine
Department of Dermatology
Department of Pediatrics
Department of Orthopedics

Purpose Statement:
To delegate authority from the UW Health Primary Care Provider or UW Health Provider who placed the
suture(s)/staple(s) to Registered Nurses (RNs), Medical Assistants (MAs), Licensed Athletic Trainers (LATs), and
Casting Technicians to initiate suture or staple removal.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs), Medical Assistants (MAs), Licensed Athletic Trainers (LATs), and Casting Technicians
trained in the use of this protocol and who have been trained in suture/staple removal.


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



Guidelines for Implementation:
1. This protocol is initiated when a patient presents for suture or staple removal.
2. If the patient is not medically homed with UW health or the suture(s)/staple(s) were not placed by a UW Health
provider, staff will contact an onsite provider prior to removing sutures/staples.
3. Appendix 1 identifies the locations individual staff may remove sutures/staples from. RNs can remove from any
location and MA can only remove from identified locations in Appendix 1.
4. The RN/MA/LAT/Casting Technician will determine if sufficient time has lapsed to remove sutures or staples. (See
Appendix 1)
5. The RN/MA/LAT/Casting Technician will evaluate the patient using the scripted text contained in the
.npsutureremoval smart phrase (See Appendix 2). The RN/MA/LAT/Casting Technician will use the responses to
determine the appropriate action.
5.1. If any of the following are present the delegation protocol no longer applies to the patient and the
RN/MA/LAT/Casting Technician will consult with the provider for additional direction.
• Erythema
• Exudate
• Any bleeding around the wound
• Fever greater than 100.4 degrees
• Significant discomfort at the wound sites
• Re-operative site
• Dehiscence (wound edge separation)
• Overgrow or excessive scabbing causing inability to visualize the suture/staples
• Radiation Therapy patient
• Chemotherapy patient
• Patients on immunosuppressant(s)
5.2. If the RN/MA/LAT/Casting Technician answers “no” to all questions asked in the evaluation the
RN/MA enters the order for suture or staple removal using the Dressing Change/Suture Removal
Smart Set.
6. After removing the sutures/staples the RN/MA/LAT/Casting Technician will provide patient instructions
using the .pisutureremoval Smart Phrase. (Appendix 3)
7. The RN/MA/LAT/Casting Technician will evaluate the patient after suture or staple removal and will document
appropriately in Health Link.

Order Mode: (RNs, LATS’s) Protocol/Policy, Without Cosign
(MAs/Casting Technicians) Cosign Required, Protocol/Policy

References:
1. Canadian Nurses Association CNA Nurse One.
Nurseone.ca http://www.nurseone.ca/Default.aspx?portlet=StaticHtmlViewerPortlet&pla
ng=1&ptdi=1802
2. Marinelli, M. Incision site care. In Ackley BJ, ed. Evidence-Based Nursing Care Guidelines: Medical-Surgical
Interventions. 1
st
Ed. St. Louis, MO: Mosby:
2008: http://www.nursingconsult.com.ezproxy.library.wisc.edu/nursing/books/978-0-323-04624-4/full-
text?isbn=978-
0-323-04624-4&eid=4-u1.0-B978-0-323-04624-4..50016-
0&fromList=searchListPage&isPageEid=true#hash_4-u1.0-B978-0-323-04624-4..50016-0--subchapter1.
Accessed March 4, 2014.
3. Forsch, MD, MPH, Randall T. Essentials of Skin Laceration Repair. Am. Fam Physician. 2008 Oct
15;78(8):945-951. http://www.aafp.org/afp/2008/1015/p945.html

Collateral Documents/Tools:
Dressing Change/Suture Removal [2378] Smart Set
UW Medical Foundation Policy 102.095. Suture/Staple Removal
Suture Removal Smartphrase - .npsutureremoval
Suture Removal Patient Instructions Smartphrase - .pisutureremoval

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




Approved By:
UW Health Ambulatory Protocol Committee: March 2014; March 2017; August 2017
UW Health Clinical Knowledge Management Council: May 2014; March 2017; August 2017
UWHC Medical Board: June 2014; May 2017; August 2017
UW Health Chief Clinical Officer: June 2017

Effective Date: June 2017

Scheduled for Review: June 2020
Addition of LAT’s and Casting Techs – August 2017
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



Appendix 1 – Suture/Staple Removal Time Table
Location RN MA LATs Casting
Techs
Time
(# of
Days)
Face Yes Yes No No 3-5
Scalp Yes Yes No No 7
Ear Yes No No No 4-5
Eye and within ½ inch around eye Yes No No No 3-5
Chest / Trunk area Yes Yes No No 8-10
Hand Yes Yes Yes Yes 10-14
Feet Yes Yes Yes Yes 10-14
Toes Yes Yes Yes Yes 10-12
Fingers Yes Yes Yes Yes 10-12
Back Yes Yes Yes Yes 10-14
Leg Yes Yes Yes Yes 8-10
Genitalia Yes No No No 8-10
Mucous Membranes (oral
cavity)
Yes No No No 5
Breast Yes No No No 8-10

Type of Suture
Flap Yes No Yes No
Graft Yes No Yes No
General Yes Yes Yes Yes

Appendix 2 – Suture Removal Smart Phrase 1

.npsutureremoval

@NAME@ presents for {SUTURE/STAPLES:23066} removal.

Laceration of {BODY PART:5261} occurred on the date: ***.
Sutures/staples were placed *** days ago at {Clinic locations:23067}.
The number of sutures/staples placed at the time: ***

The number of sutures placed
was not documented at the last visit.

{YES, NO*:21049::"No"}
Any fever greater than 100.4 degrees? {YES, NO*:21049::"No"}

Any redness around the wound?

{YES, NO*:21049::"No"}
Any drainage around the wound?

{YES, NO*:21049::"No"}
Any bleeding around the wound?

{YES, NO*:21049::"No"}
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



Any discomfort at the wound site? {YES, NO*:21049::"No"}
Are the wound edges separating?

{YES, NO*:21049::"No"}
Is the patient currently receiving
chemotherapy or radiation therapy?

{YES, NO*:21049::"No"}
Is the patient currently taking
immunosuppressant medication?

{YES, NO*:21049::"No"}
Is this an re-operative surgical site?
(has the same wound been sutured/repaired
more than once)
{YES, NO*:21049::"No"}

Are any of the answers above "yes"?
{Suture/ Staple Removal:22984}

Yes. Provider was consulted.
No. All sutures were removed without difficulty. The procedure was tolerated well. Continuing wound care discussed
and patient given wound care instructions. Patient will call if any questions arise.

Appendix 3 – Suture Removal Patient Instructions Smart Phrase 1
.pisutureremoval
Suture/Staple Removal: Your Care Instructions

Your wound has healed and the sutures/staples have been taken out. However, the wound may still separate (reopen) if
struck (hit). Keep protecting the wound to avoid further injury.

• Bathing is fine.
• To minimize scarring, keep the wound covered from direct sunlight and/or use sunscreen on regular basis.
• If Steri-Strips were applied, then pat dry when wet. Steri-Strips may be removed in 5-7 days or when ends curl up.

Contact clinic if:
• Drainage, bleeding, or odor from site occurs.
• Redness along site.
• Fever of greater than 100.4 degrees Fahrenheit develops.
• Increase in discomfort.



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