/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/ambulatory-delegation-protocols/name-97421-en.cckm

201711331

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Ambulatory Delegation Protocols

Diagnostic Testing and Lab Ordering in General Surgery - Pediatric - Ambulatory [114]

Diagnostic Testing and Lab Ordering in General Surgery - Pediatric - Ambulatory [114] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols




Delegation Protocol Number: 114

Delegation Protocol Title:
Diagnostic Testing and Lab Ordering in General Surgery - Pediatric - Ambulatory

Delegation Protocol Applies To:
UW Health Pediatric General Surgery

Target Patient Population:
Patients treated by the Pediatric Speciality Clinic

Delegation Protocol Champion:
Daniel Ostlie, MD – Department of Surgery

Delegation Protocol Reviewers:
Kayle Herfel, RN – Pediatric General Surgery
Julie Hunter, CNS – American Family Children’s Hospital Specialties Clinic
Angela Vieau, RN – Pediatric General Surgery

Responsible Department:
Department of Surgery – Pediatric General Surgery

Purpose Statement:
To delegate authority from the encounter provider to the Registered Nurses (RNs) to enter orders under
specific conditions clearly indicated in the tables below.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) trained in the use of this protocol and who have successfully completed training
on previsit planning with the pediatric cardiology surgeons and RN triage team.

Float or temporary RNs are not eligible as delegates for this protocol
New RNs who have not completed full competency training may not serve as delegates until their
training has been completed.

Guidelines for Implementation:
1. This delegation protocol is initiated when the patient is scheduled for an appointment in a
pediatric general surgery clinic and meets one of the inclusion criteria outlined in the tables
below.
2. Prior to placing any orders the RN will review patient’s medical record and any provider
documentation to determine if any of the indicated tests have been previously ordered to avoid
duplicates.



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

Table 1
Indication
• Pectus Excavatum Patients scheduled to have Invasive Nuss procedure
Initiation Patient has scheduled appointment in the Pediatric General Surgery Clinic or Chest Wall
Deformity Clinic and the encounter provider has requested to schedule a minimally invasive
Nuss procedure.
Orders 1. Order CT CHEST W/O IV CONTRAST [R71250]
2. Order Nickel Allergy Patch test
2.1. If performed at an outside facility, place order for Outside Order.
2.1.1. Encounter diagnosis: Pectus Excavatum
2.1.2. Enter comments: Perform nickel allergy skin patch test. Patient scheduled for
Nuss procedure on “x” date. Nuss bar is made of Nickel. Please return results
back to Pediatric Surgery facility 4 weeks prior to surgery.
2.2. If performed at a UW Health facility, place order for Consult to Peds Allergy Clinic –
INSIDE UW Health.
2.3. If a negative result: notify patient parent and surgeon of negative result, proceed
with scheduled surgery.
2.4. If a positive result: notify surgeon of positive nickel allergy and obtain from the
surgeon the number of titanium bars needed. Place order through Rapid Response
for a patient matched pre-bent pectus bar. (Forms for this located in Pediatric
surgery RN office).
3. Call Enterprise Imaging (608)265-7118 and ask for the CT images to be sent to Biomet
Microfixation, 1520 Tradeport Dr, Jacksonville FL 32218
4. Fax completed form to Biomet, Attn: James Ricks 904-741-9249
5. Document order has been completed.

Table 2
Indication
• Cloaca, Hirschprung’s Anorectal Malformation (CHARM) patient
• Hirschprung’s Disease
• Constipation patients enrolled in the Bowel Management Program
Initiation Patient has a scheduled appointment for routine care in the Pediatric General Surgery
clinic, CHARM clinic or when patients from these clinics call in to telephone triage describing
symptoms of constipation including soiling, greater than 1 day without a bowel movement
or abdominal pain/distention
Orders 1. New and Established patients with history of Anorectal Malformation Pre/Post Repair
1.1. Order KUB to be performed prior to the patient appointment
2. Established patients with a history of constipation and are being treated in the Bowel
Management Program with enema or laxative therapy
2.1. If telephone triage, RN determines that patient is exhibiting signs/symptoms of
constipation (listed above) and places an order for a KUB to evaluate for stool
burden.

Table 3
Indication
• Diaphragmatic Hernia Repair
• Spontaneous Pneumothorax
• Congenital Pulmonary Airway Malformation (CPAM) detected on either prenatal
ultrasound or imaging done after birth
• Congenital Cystic Adenomatoid Malformation (CCAM) detected on either prenatal
ultrasound or imaging done after birth
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

• Thoracoscopy and Thoracotomy
Initiation Patient has a scheduled appointment for post-operative care in the Pediatric General
Surgery clinic.
Orders 1. CPAM/CCAM
1.1. Order X-RAY CHEST PA & LAT VIEWS [R71020]
1.1.1. Evaluate for atelectasis, pneumothorax and postoperative changes for
CPAM/CCAM.
2. Diaphragmatic Hernia
2.1. Order X-RAY CHEST PA & LAT VIEWS [R71020]
2.1.1. Evaluation for recurrence of diaphragmatic hernia
3. Pneumothorax
3.1. Order X-RAY CHEST PA & LAT VIEWS [R71020]
3.1.1. Evaluate for pneumothorax

4. Thoracoscopy and Thoracotomy
4.1. Order X-RAY CHEST PA & LAT VIEWS [R71020]
4.1.1. Evaluate for atelectasis, pneumothorax and postoperative changes


Table 4
Indication
• Nissen Fundoplication
Initiation Patient has scheduled post-operative follow up appointment in the Pediatric General
Surgery Clinic for either 2 weeks or 1 year post surgery and when patient is exhibiting signs
of Nissen compromise (e.g. retching, vomiting, and gagging).
Orders 1. Order GI UPPER GI W/O KUB [R74240]
1.1. Evaluate intactness of Nissen wrap.
Comments Test will be ordered 1 year post surgery visit and anytime patient is exhibiting signs of
Nissen compromise (described above).

Table 5
Indication
• Dislodged Gastrostomy Tube
Initiation Patient has a scheduled appointment in the Pediatric General Surgery Clinic for a dislodged
Gastrostomy Tube
Orders 1. Order TUBE CHECK, GASTROSTOMY [R76080D]
1.1. Evaluate correct placement of the gastrostomy tube

Table 6
Indication
• Splenectomy
Initiation Patient has a scheduled first post-operative appointment post-splenectomy in the Pediatric
General Surgery clinic
Orders 1. Order CBC WITH DIFFERENTIAL [CBC]

Order Mode: Cosign Required, Protocol/Policy





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

References:
1. Nuchtern JG, Mayer OH. Pectus Carinatum. In: UpToDate, Redding G (Ed), UpToDate, Waltham,
MA. (Accessed on April 17, 2015.)
2. Wesson DE. Congenital Aganglionic Megacolon (Hirschsprung Disease). In: UptoDate, Klish, WJ
(Ed), Singer, JI (Ed), UpToDate, Waltham, MA. (Accessed on April 17, 2015.)
3. Janahi, IA. Spontaneous Pneumothorax In Children. In: UpToDate, Redding G (Ed), UpToDate,
Waltham, MA. (Accessed on April 17, 2015.)
4. Hedrick HL, Adzick, NS. Congenital Diaphragmatic Hernia In the Neonate. In: UpToDate,
Weisman LE (Ed), UpToDate, Waltham, MA. (Accessed on April 17, 2015.)
5. Oermann CM. Congenital Pulmonary Airway (Cystic Adenomatoid) Malformation. In: UpToDate,
Garcia-Prats JA (Ed), Redding, G (Ed), UpToDate, Waltham, MA. (Accessed on April 17, 2015.)
6. Michail, S., (2007). Gastroesophageal Reflux. Pediatrics in Review, Vol. 28 (3), pp. 101-110.
7. Burke, D.T. et al., (2006). Comparison of Gastrostomy Tube Replacement Verification Using Air
Insufflation Versus Gastrograffin. Archives of Physical Medicine and Rehabilitation, Vol. 87 (11),
pp. 1530-1533.

Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: April 2015
UW Health Laboratory Practices Committee: April 2015
Radiology – Gina Greenwood, Director of Radiology Services: June 2015
UW Health Knowledge Management Council: June 2015
UWHC Medical Board: July 2015
UW Health Chief Medical Officer: July 2015

Effective Date: July 2015

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