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/clinical/cckm-tools/content/order-sets/hod/cardiac-cath-and-electrophysiology-labs/name-97803-en.cckm

201711317

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Cardiac Cath/EP – Implantable Devices Delegation Protocol – Adult – Preprocedure [5180]

Cardiac Cath/EP – Implantable Devices Delegation Protocol – Adult – Preprocedure [5180] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, HOD, Cardiac Cath and Electrophysiology Labs


Cardiac Cath/EP - Implantable Devices Delegation Protocol - Adult -
Preprocedure [5180]
for Adult Patients OnlyIntended
Delegation Protocol URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/ambulatory-delegation-protocols/name-
97369-en.cckm
Patient Care Orders
Vital Signs [139665]
Vital Signs [NURMON0013] ONCE, Starting today For 1 Occurrences, Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
BP Source:
BP Location:
BP Position:
BP Restrictions:
Upon arrival, Cardiac Cath/EP
Nutrition [139634]
NPO Except Medications [NUT9999] EFFECTIVE NOW, Starting today, Routine
Patient Type: Adult
Diet Type: NPO
NPO: NPO except Medications
Bedside Meal Instructions:
Room Service Class:
Cardiac Cath/EP
Surgical Site Care [139610]
Chlorhexadine Scrub [NURTRT0020] ONCE, Routine, Shave chest if needed., Cardiac
Cath/EP
For Patients With Diabetes [139609]
Glucose, POC [IPGLUCOSE] STAT, Starting today For 1 Occurrences, Routine,
Glucose, POC should always be ordered in
conjunction with orders for hypoglycemia management
and monitoring as indicated in the Hypoglycemia
Management (Adult) panel.
If Conditional, What Condition? Patients with Diabetes
Cardiac Cath/EP
GLUCOSE, WHOLE BLOOD [HCWBGLU] CONDITIONAL For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw if blood glucose
is less than 40 mg/dL or greater than 400 mg/dL.
Draw if blood glucose is less than 40 mg/dL or greater
than 400 mg/dL., Cardiac Cath/EP
Intravenous Therapy
Premedications for Needle Insertion [139592]
Use lidocaine topical dressing kit for stable patient, no lidocaine allergies, have at least 30
minutes time prior to needing to use IV
Sodium chloride (bacteriostatic) 0.9% intradermal: Useful for patients requiring urgent IV
access; onset is within 1 minute. Choice of medication should be based on patient’s previous
experience/preference, history of lidocaine allergy and ease of access.
Page 1 of 6
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:33:02 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

lidocaine (LMX) 4% topical dressing kit [66882] Topical, EVERY 1 HOUR PRN, peripheral line
insertion - see Admin Instructions
Do NOT apply to area greater than 200 square
centimeters (maximum 2.5 g/site; maximum 4 sites
per hour, 6 times per day). Do NOT leave on longer
than 2 hours. Use for stable patient, no allergies to
lidocaine, with at least 30 minutes time prior to IV use
Cardiac Cath/EP
lidocaine (XYLOCAINE) 1% injection [39034] 0.1-0.4 mL, Intradermal, PRN, peripheral line insertion
- see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Cardiac Cath/EP
sodium chloride (bacteriostatic) 0.9 % injection
[50585]
0.05-0.1 mL, Intradermal, PRN, peripheral line
insertion - see Admin Instructions
Use an insulin or TB syringe with a 25-30 gauge
needle to inject solution and create a wheal. Wait 30
seconds to 1 minute then insert IV catheter into center
of wheal. Use if IV is needed within 30 minutes.
Choice of medication should be based on patient’s
previous experience/preference, history of lidocaine
allergy and ease of access
Cardiac Cath/EP
Intravenous Fluids [139628]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Cardiac Cath/EP
sodium chloride 0.9 % infusion [64367] at 20 mL/hr, Intravenous, CONTINUOUS, Cardiac
Cath/EP
Medications
First Line (Single Response) [139598]
cefuroxime (ZINACEF) intraVENOUS - Patients
who are 40 - 120 kg [800030]
1.5 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
cefuroxime (ZINACEF) intraVENOUS - Patients
who are greater than 120 kg [800030]
3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
MRSA/Documented History of MRSA (Single Response) [225322]
For patients 40 - 120 kg [231264]
cefuroxime (ZINACEF) intraVENOUS [800030] 1.5 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
For patients greater than 120 kg [231267]
cefuroxime (ZINACEF) intraVENOUS [800030] 3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Immediate/Severe Reactions to Penicillin or Known Cephalosoporin Allergies [225329]
vancomycin (VANCOCIN) intraVENOUS -
Maximum Dose = 2000 mg [800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
Anti-infective Irrigation [139611]
Page 2 of 6
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:33:02 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

tobramycin irrigation POUR bottle 300 mg/1000
mL [700535]
Irrigation, ONCE For 1 Doses, Cardiac Cath/EP
Laboratory
Laboratory [139627]
ELECTROLYTES [LYTE] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
BUN [BUN] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
CREATININE [CRET] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
CBC WITHOUT DIFFERENTIAL [HEMO] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
MAGNESIUM [MAG] STAT, Starting today For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
Taking Warfarin [139603]
PROTHROMBIN TIME/INR [PT] STAT, Starting today For 1 Occurrences, Routine
If Conditional, What Condition? For patients on
warfarin
Cardiac Cath/EP
Pregnancy Test [121729]
surgery is pelvic, renal, pregnancy test if female between menarche & menopause and any of: (1) Obtain
intercourse, (3) patient missed menses, (4) patient says abdominal, (2) patient had unprotected -or intra
pregnant. she "could" be
Urine, Pregnancy Test [UPREG] ONCE For 1 Occurrences, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
Blood Products
Blood Products [142770]
Page 3 of 6
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:33:02 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Adult) [BLB0006] 1 UNIT, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
Consent Status:
Cardiac Cath/EP
Plasma (Adult) [BLB0003] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Cardiac Cath/EP
Platelets (Adult) [BLB0004] 1 SINGLE, Starting today For 1 Occurrences, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cardiac Cath/EP
Cryoprecipitate (Adult) [BLB0005] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Fibrin Glue, mLs Needed:
Cardiac Cath/EP
Blood Products [186044]
Page 4 of 6
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:33:02 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Red Blood Cells (Pediatric) [BLB0013] 1 UNIT, Starting today For 1 Occurrences, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Uncrossmatched **WARNING** Requesting MD
verifies that the clinical situation is sufficiently urgent
to require release of blood before completion of
compatibility testing and agrees to hold UWHC
harmless for any and all liability for any injuries
resulting from release of blood before such testing:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
Consent Status:
Cardiac Cath/EP
Plasma (Pediatric) [BLB0010] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Cardiac Cath/EP
Platelets (Pediatric) [BLB0011] Starting today, Routine
If ordering < 1 unit specify the Total Volume to be
transfused (mL):
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Irradiated (See Blood Product Guidelines) (May be
pre-selected based on history):
CMV Negative (Heart/Lung Transplant and Neonates
up to 4 Months Only) (May be pre-selected based on
history):
Washed Product (Requires pathology review, call 263-
8367):
HLA Matched (Requires pathology review, call 263-
8367):
Consent Status:
Cardiac Cath/EP
Page 5 of 6
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:33:02 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Cryoprecipitate (Pediatric) [BLB0012] Starting today, Routine
Reason for Order:
Blood Product Need (It will take approximately 30 to
60 minutes from the time nursing notifies the Blood
Bank to prepare the products):
Date Product Needed:
Consent Status:
Cardiac Cath/EP
Tests
Conditional-Lead Extraction Patients [139613]
TYPE AND SCREEN [HCTS] STAT, Starting today For 1 Occurrences, Routine, As
good clinical practice and for patient safety, the
Transfusion Service will automatically crossmatch 2
packed RBCs on all patients with antibodies to ensure
blood would be available in the event it is needed. If
you would like to opt out of this automatic order for this
patient please contact the UWHC Blood Bank at (608)
263-8367 or The American Center Lab at (608) 234-
6600 as appropriate., Cardiac Cath/EP
Diagnostic Tests and Imaging
Diagnostic Tests and Imaging [139667]
ECG - 12 Lead [EKG0008] ONCE For 1 Occurrences, Routine
Reason for exam: PRE-OPERATIVE
Page 6 of 6
Printed by STRAKA, KEVIN F [KFS1] at 10/23/2017 5:33:02 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org