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Previsit Planning for New Patient in Cardiology - Pediatric - Ambulatory [119]

Previsit Planning for New Patient in Cardiology - Pediatric - Ambulatory [119] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols




Delegation Protocol Number: 119

Delegation Protocol Title:
Previsit Planning for New Patient in Cardiology - Pediatric - Ambulatory

Delegation Protocol Applies To:
UW Health Pediatric Cardiology Clinics

Target Patient Population:
New patients to Pediatric Cardiology

Delegation Protocol Champion:
J. Carter Ralphe, MD – Department of Pediatrics - Cardiology

Delegation Protocol Reviewers:
John Flammang, RN – Pediatric Cardiology
Julie Hunter, CNS – American Family Children’s Hospital
Teri White, RN – Pediatric Cardiology

Responsible Department:
Department of Pediatrics - Cardiology

Purpose Statement:
To delegate authority from the encounter provider to Registered Nurses (RN’s) to place orders for
diagnostic testing under specific conditions in the Table 1.

Who May Carry Out This Delegation Protocol:
Registered Nurses trained in the use of this protocol and who have successfully completed training on
pre-visit planning in the Pediatric Cardiology Clinic.

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 limited numbers of new staff who must also demonstrate ability before they serve
as delegates.

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 protocol is initiated upon receiving written or verbal request from referring UW Health provider
to schedule patient into Pediatric Cardiology Clinic.
2. The RN will review the patient’s medical record and the referring providers request to determine
the indication.
3. The RN will use Table 1 to determine the specific orders needed. Prior to placing any orders, the RN
will review the patient’s chart 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

2


TABLE 1. ORDERS
Indication Pediatric Transthoracic
Resting Echocardiogram if
not obtained in previous six
months
Pediatric
Electrocardiogram (ECG) if
not obtained in previous
two months
Infant less than 3 months of age
referred to evaluate heart murmur
X
Tachycardia
X
Palpitations
X
Syncope
X
Syncope with exertion
X X
Chest pain
X
Known or suspected:
• Ehlers Danlos Syndrome
• Loeys Dietz
• Marfan Syndrome
• When referred by Geneticist
for expected connective tissue
disorder
X
Family history of cardiomyopathy
(parents, siblings, grandparents)
X X
Family history of bicuspid aortic valve
(parents, siblings, children)
X
Family history of Aortic Aneurysm or
dissection (parents, siblings,
grandparents)
X

Order Mode: Cosign Required, Protocol/Policy

References:
1. Anderson, J. B., Czosek, R. J., Cnota, J., Meganathan, K., Knilans, T. K., & Heaton, P. C. (2012).
Pediatric syncope: National hospital ambulatory medical care survey results. The Journal of
Emergency Medicine, 43(4), 575-583.
2. Black, K. D., Seslar, S. P., & Woodward, G. A. (2011). Cardiogenic causes of pediatric
syncope. Clinical Pediatric Emergency Medicine, 12(4), 266-277.
3. Campbell, R. M., Douglas, P. S., Eidem, B. W., Lai, W. W., Lopez, L., & Sachdeva, R. (2014).
ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 appropriate use criteria for initial
transthoracic echocardiography in outpatient pediatric cardiology. Journal of the American College
of Cardiology, 64(19), 2039-2060.
4. Sharieff, G., & Rao, S. (2006). The pediatric ECG. Emergency Medicine Clinics Of North America,
24(1), 195.
5. Steinberger, J., Moller, J., Berry, J., & Sinaiko, A. (2000). Echocardiographic diagnosis of heart
disease in apparently healthy adolescents. Pediatrics, 105(4 part 1), 815-818.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


6. Warren, A. E., Boyd, M. L., O'Connell, C., & Dodds, L. (2006). Dilatation of the ascending aorta in
paediatric patients with bicuspid aortic valve: Frequency, rate or progression and risk
factors. Heart, 92, 1496-1500.
7. Overview of Cardiac Management in Marfan Syndrome. The Marfan Foundation.
8. Marfan Foundation Updates Cardiac Management Guidance. AAP News July 2015; 36:12.
Collateral Documents/Tools: NA

Approved By:
UW Health Ambulatory Protocol Committee: July 2015
Radiology: July 2015
UW Health Knowledge Management Council: August 2015
UWHC Medical Board: September 2015
UW Health Chief Medical Officer: September 2015

Effective Date: September 2015

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