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Creatinine Orders for Patients Undergoing CT Examinations - Adult/Pediatric - Ambulatory/Emergency Department [35]

Creatinine Orders for Patients Undergoing CT Examinations - Adult/Pediatric - Ambulatory/Emergency Department [35] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols





Delegation Protocol Number: 35

Delegation Protocol Title:
Creatinine Orders for Patients Undergoing CT Examinations ‐ Adult/Pediatric ‐ Ambulatory/Emergency
Department

Delegation Protocol Applies To:
UW Health Ambulatory: patients referred by a UW Health provider
UWHC Emergency Department: All Non‐ trauma patients

Target Patient Population:
Any adult or pediatric ambulatory outpatient or Emergency Department non‐trauma patient referred by a UW
Health referring provider and identified as meeting requirements necessitating a current (i.e. obtained within
one month of examination date) creatinine level prior to undergoing an expected intravenous contrast‐
enhanced CT examination. Requirements necessitating a current creatinine level prior to undergoing a contrast‐
enhanced CT examination include:
• Age > 60 years of age
• Patients whose diabetes is being managed with medication therapy by a provider
• Patients receiving metformin or metformin containing drug combinations
• Receiving chemotherapy or aminoglycoside within the previous one month
• Patients with a history of renal disease including tumor, surgery, solitary kidney, kidney
transplantation, or dialysis
• Patients with hypertension requiring medical therapy

Delegation Protocol Champion:
Lori Mankowski Gettle, MD, MBA – Department of Radiology

Delegation Protocol Reviewers:
Michael Tuite, MD – Department of Radiology
Gina Greenwood, MBA, R.T.(R),(MR) –Radiology
Carol Hassemer – UWMF Clinic Operations
Kari Pulfer – UWMF Radiology
Peter Wasmund – UWHC Radiology

Responsible Department:
Department of Radiology

Purpose Statement:
To ensure that executable creatinine orders exist for patients meeting requirements necessitating a current (i.e.
obtained within one month of examination date) creatinine level prior to undergoing an expected intravenous
contrast‐enhanced CT examination. Any provider referring a patient for a CT examination is delegating to the
personnel designated in this protocol the authority to enter orders for creatinine level tests. The referring
provider is authorizing the tests to be performed before the referring provider co‐signs the order.

Who May Carry Out This Delegation Protocol:
Any Radiology Scheduler (whom also play the role of reception staff) or Radiologic Technologist may initiate
this protocol.

Guidelines for Implementation:
1. At the time a contrast‐enhanced CT examination is ordered, the referring provider is required to assess the
patient’s need for renal function testing, based on the risk factors noted above. If any of these risk factors
are reported, the patient is flagged as requiring a current creatinine level prior to undergoing the
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


examination.
2. Within three days of examination date, a Radiology receptionist will review a Health Link report of
all patients meeting requirements necessitating a current creatinine level for a contrast‐enhanced
CT examination (as determined by the referring provider).
3. The Radiology receptionist will verify that an order for a creatinine has been written for each patient for
whom one is required (using the “Target Patient Population” requirements).
4. If a creatinine order does not exist, the Radiology receptionist will sign an order for creatinine in Health Link
and associate diagnosis code Z01.812 Pre‐procedure lab exam. The order will route for cosignature to the
UW Health provider referring the patient for the CT examination.
5. The Radiology receptionist making the CT appointment reminder call will inform the patient to present to
a UW Health outpatient lab location for the creatinine test.
6. Should a patient happen to arrive for a contrast‐enhanced CT appointment and meet the requirements
necessitating a current creatinine level, but one has not been previously ordered, the receptionist receiving
the patient will immediately sign an order for whole blood creatinine in Health Link, and route the order for
co‐ signature to the UW Health provider referring the patient for the exam.
7. Should a patient happen to arrive outside of normal business hours (Mon‐Fri 7AM‐5PM) for a contrast‐
enhanced CT appointment and meet the requirements necessitating a current creatinine level, but one has
not been previously ordered, the Radiologic Technologist receiving the patient will immediately sign an
order for a whole blood creatinine including a request for stat result.
7.1. Radiology staff must perform collection of specimen if outside hours of operation for UW Health Clinical
Labs Phlebotomy.
7.2. Clinical Labs hours of operation for phlebotomy are available at:
http://www.uwhealth.org/lab/locations‐and‐maps/11308

Order Mode: Cosign Required, Protocol/Policy

References:
ACR Manual on Contrast Media Version 10.2, 2016
1. http://www.acr.org/~/media/ACR/Documents/PDF/QualitySafety/Resources/Contrast%20Manual/2016_Co
ntrast

Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: September 2012; *August 2014; November 2016
UW Health Clinical Knowledge Management Council: September 2012; *August 2014; November 2016
UW Health Clinical Laboratories Committee: September 2012: *August 2014; December 2016
UWHC Medical Board: December 2012; *September 2014; January 2017
UW Health Chief Clinical Officer: *September 2014; *December 2016

Effective Date: January 2017

Scheduled for Review: January 2020
* Expedited Approval Process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org