/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-97418-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

Previsit Planning for New Patient in Vascular Surgery - Adult - Ambulatory [111]

Previsit Planning for New Patient in Vascular Surgery - Adult - Ambulatory [111] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols


Protocol Number: 111

Delegation Protocol Title:
Previsit Planning for New Patient in Vascular Surgery – Adult – Ambulatory

Delegation Protocol Applies To:
UW Health Vascular Surgery Clinics

Target Patient Population:
Adult patients referred to Vascular Surgery Clinics

Delegation Protocol Champion:
Jon Matsumura, MD - Department of Surgery – Vascular

Delegation Protocol Workgroup:
Jenna White, MBA, PHR – Department of Surgery - Vascular Surgery
Lisa Kaikuaana, RN – Department of Surgery - Vascular Surgery
Pam Laufenberg, RN – Department of Surgery – Vascular Surgery
Joann Linder, RN – Department of Surgery – Vascular Surgery
Donnette Kelly, RN – Department of Orthopedics/Rehabilitation – Orthopedics General
Brianne Stapelmann, RN – Department of Surgery - Vascular Surgery

Responsible Department:
Department of Surgery – Vascular Surgery

Purpose Statement:
To delegate authority from the providers in the Vascular Surgery Clinics to Registered Nurses (RNs) to order
appropriate diagnostic and laboratory orders as previsit planning for select indications. The intent of this
delegation protocol is to streamline care for patients referred to this clinic to ensure a patient-centered
satisfactory experience.

Who May Carry Out This Delegation Protocol:
Registered Nurses (RNs) trained in the use of this delegation protocol and who have successfully completed
training on Pre-Visit Planning with the Vascular Surgeons and RN triage team as outlined below:

1. Overview: Training will be tailored to the trainee’s practice area, prior vascular experience, and previous
knowledge of the electronic medical record. Training will concentrate on the practice site and patient
population(s). Training will be done primarily by one-on-one instruction. The training hours and/or a
probationary period may be extended, as needed, at the discretion the Vascular Surgery Clinic Manager or
Vascular Surgery Division Chair.
2. Supervision: During the training period, the trainee will be directly observed by a current member of RN
triage team. All orders and notes entered by the trainer will be reviewed and cosigned by the vascular
surgeons during this training period.
3. Training completion: The adequacy of training is assessed after six months by demonstrated competency to
Vascular Surgery Division Chair. Areas of assessment include clinical judgment, communication with
patients, families, and referring providers, and proficient use of computer technology.
4. Training phases:
4.1. Phase I Training Period:
• Phase I training consists of one-on-one instruction, discussion and case examples.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

• 150 hours of training with a member of the RN Triage Team who has 5 or more years of experience
in Previsit Management.
• After Phase I training is complete, the trainee moves on to Phase II.
4.2. Phase II Training Period:
• Review of New Patient Pre-Visit Management: Each order will be reviewed by an experienced
member of RN Triage Team prior to signing by the trainee. The trainer will document an assessment
of each patient’s pre-visit management orders by the trainee.
• A minimum of 25 total new patients and corresponding orders must be reviewed and cosigned by
the faculty vascular surgeon during the training period.
• Areas of deficiency will be noted, discussed with the trainee, and forwarded to the Vascular Surgery
Clinic Manager. If, based on these assessments, the trainee routinely shows deficiencies and/or
lacks the knowledge of key clinical concepts, the phase II training period will be extended and re-
evaluated after the completion of an additional ten patients and corresponding orders.
5. Due to the extensive training requirements float RNs will not be included in this protocol.

Guidelines for Implementation:
1. This delegation protocol is initiated when a patient is referred to a Vascular Surgery clinic.
2. The RN reviews the referral and if the reason for referral is unclear the RN contacts the referring provider for
clarification.
3. The RN references the appropriate section in Appendix 1(Vascular Surgery Clinic Previsit Testing) to
determine patient criteria and appropriate testing.
4. The RN reviews the patient’s medical record and obtains any external records and results relevant to the
referral. For patients with a Health Link record, the RN reviews Imaging, Media, Outside Documents, Care
Everywhere, Encounters and Notes. For external records, the RN requests the referring provider provide
both the final results and actual images.
5. The RN contacts the patient and discusses the referral and obtains any additional patient history, including
relevant symptoms and additional testing performed outside of UW Health.
6. The RN will use the provider referral, presentation of symptoms, results of previous testing, and provider
notes in combination with the tables in this protocol to determine the appropriate orders. Prior to entering
any orders the RN reviews the patient’s medical record for any previously ordered and scheduled testing to
prevent duplication.
7. The RN will consult with the Vascular Surgeon prior to placing any orders if:
7.1. The patient does not meet the criteria
7.2. The referral is unclear
7.3. The results do not support the reason for referral
7.4. Any other discrepancy or concern by the nurse
8. The RN will consult with the Vascular Surgeon when after assessment recommendation from Appendix 1 is
not in agreement with the referring provider’s testing request. The Vascular Surgeon will assess and discuss
with the referring provider.
9. The RN or MA or scheduler will provide patient with appropriate instructions regarding the tests to be
performed and the recommendations for the clinic visit.
10. The RN or MA will route the encounter back to scheduler to arrange for appointments. Radiology exams or
PFTs done at UW Health should be scheduled to be performed immediately before (adjacent to) the first
clinic visit. The scheduler will enter all tests scheduled or to be done in clinic before appointment in the
appointment “notes” field in the Health Link schedule.
11. If the test is performed prior to the day of the visit with Vascular Surgery and the patient does not arrive for
the visit, the MD or RN will notify the vascular surgeon of the results and will inform the referring or primary
care provider of the results (abnormal or normal) for his/her follow up.

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:
General:
1. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular
Evaluation and Management of Patients Undergoing Noncardiac Surgery: A Report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2014;64(22):e77-e137. doi:10.1016/j.jacc.2014.07.944.
2. Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MW. Diagnostic Performance of Computed Tomography
Angiography in Peripheral Arterial Disease: A Systematic Review and Meta-analysis. JAMA. 2009;301(4):415-
424. doi:10.1001/jama.301.4.415.

Carotids
3. Grant et al (2003). Carotid Artery Stenosis: Gray-Scale and Doppler US Diagnosis – Society of Radiologists in
Ultrasound Consensus Conference. Society of Radiologists in Ultrasound Consensus Conference, 229, 340-
346
4. Turnipseed WD, Kennell TW,et al., MRA and Duplex Imaging: Noninvasive Tests for Selecting Symptomatic
Carotid Endarterectomy Candidates. Surgery 1993; 114:643-649
5. Hunik MGM, PolakJF et al., Detection and Quantification of Carotid Artery Stenosis: Efficacy of Various
Doppler Velocity Parameters. AJR 1993; 160:619-625
6. MonetaGL, Edwards JM, et al., Correlation of North American Symptomatic Carotid Endarterectomy Trial(
NASCET) Angiographic Definition of 70 % to 90 % Internal Carotid Artery Stenosis with Duplex Imaging.
Journal of Vascular Surgery 1993; 152-159.
7. Reynolds, T. (2007). The Echocardiographer’s Pocket Reference (3rd ed.). Phoenix: Arizona Heart Institute
8. Rumwell, C. & McPharlin, M. (2006) Vascular Technology: An Illustrated Review (3rd ed) California: Davies
Publishing, Inc.
9. Wardlaw JM, Chappell FM, Best JJK, Wartolowska K, Berry E, on behalf of the NHS Research and
Development Health Technology Assessment Carotid Stenosis Imaging Group, Non-invasive imaging
compared with intra-arterial angiography in the diagnosis of symptomatic carotid stenosis: a meta-analysis,
The Lancet, Volume 367, Issue 9521, 6–12 May 2006, Pages 1503-1512, ISSN 0140-6736,
http://dx.doi.org/10.1016/S0140-6736(06)68650-9.
(http://www.sciencedirect.com/science/article/pii/S0140673606686509)
10. Ricotta JJ, AbuRahma A, Ascher E, Eskandari M, Faries P, Lal BK, Society for Vascular Surgery. Updated
Society for Vascular Surgery guidelines for management of extracranial carotid disease. J Vasc Surg. 2011
Sep;54(3):e1-31.

Lower Extremity Arterial Disease
11. Daigle, R. (2008) Techniques in Noninvasive Vascular Diagnosis (3rd ed). (pp. 159-201). Colorado: Summer
Publishing, LLC.
12. Hagen-Ansert, S. (2001). Textbook of Diagnostic Sonography (5th ed.). (pp. 521-527). St. Louis: Mosby, Inc.
13. Reynolds, T. (2007). The Echocardiographer’s Pocket Reference (3rd ed.). (pp. 411-416, 430-435). Phoenix:
Arizona Heart Institute.
14. Rumwell, C. & McPharlin, M. (2006) Vascular Technology: An Illustrated Review (3rd ed). (pp. 50-61,90-96).
California: Davies Publishing, Inc.
15. Strandness, D. &Zierler, R.E. (2000). Nonimaging Physiologic Tests for Assessment of Lower Extremity
Arterial Occlusive Disease. In Zwiebel, WJ. Introduction to Vascular Ultrasonography (4th ed). (pp. 229-248).
Pennsylvania: W.B. Saunders Company.
16. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW,
Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM Jr, White CJ, White J, White RA. ACC/AHA 2005
guidelines for the management of patients with peripheral arterial disease (lower extremity, renal,
mesenteric, and abdominal aortic): a collaborative report [trunc]. Bethesda (MD): American College of
Cardiology Foundation; 2005. 192 p.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

17. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff
MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE, Society for Cardiovascular Angiography
and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular
Surgery. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral
artery disease (updating the 2005 guideline): a report of the American College of Cardiology
Foundation/American Heart Association Task Force [trunc]. J Am Coll Cardiol. 2011 Nov 1;58(19):2020-45.

Upper Extremity Arterial Disease
18. Daigle, R. (2008) Techniques in Noninvasive Vascular Diagnosis (3rd ed). (pp. 219-232). Colorado: Summer
Publishing, LLC.
19. Edwards, J. & Zierler, R. (2000). Assessment of Upper Extremity Arteries. In Zwiebel, WJ. Introduction to
Vascular Ultrasonography (4th ed). (pp. 249-262). Pennsylvania: W.B. Saunders Company.
20. Hagen-Ansert, S. (2001). Textbook of Diagnostic Sonography (5th ed.). (pp. 521-527). St. Louis: Mosby, Inc.
21. Rumwell, C. & McPharlin, M. (2006) Vascular Technology: An Illustrated Review (3rd ed). (pp. 61-65, 85-90).
California: Davies Publishing, Inc.

SMA/Celiac Arterial Disease
22. Daigle, Robert J. “Techniques in Noninvasive Vascular Diagnosis”. 3rd Ed. Littleton, Summer Publishing. 287-
89. 2008.
23. Rumwell, Claudia. McPhalin, Michalene. “Vascular Technology”. 3rd Ed. Pasadena. Davies Publishing. 103-
106. 2006.
24. Zwiebel, William J. Pellerito, John S. “Introduction to Vascular Sonography”. 5th Ed,Philidephia, Elsevier Inc.
571-82. 2005.

Aneurysms (AAA, TAA, or any artery)
25. Daigle, R. (2008) Techniques in Noninvasive Vascular Diagnosis (3rd ed). (pp. 199-201). Colorado: Summer
Publishing, LLC.
26. Hagen-Ansert, S. (2001). Textbook of Diagnostic Sonography (5th ed.). (pp. 71-77). St. Louis: Mosby, Inc.
27. Rumwell, C. & McPharlin, M. (2006) Vascular Technology: An Illustrated Review (3rd ed). (pp. 96-98).
California: Davies Publishing, Inc.
28. Zwiebel, W. (2000). Aorta, Iliac Arteries , and Inverior Vena Cava. In Zwiebel, WJ. Introduction to Vascular
Ultrasonography (4th ed). (pp. 397-415). Pennsylvania: W.B.Saunders Company
29. Francois CJ, Kramer JH, Rybicki FJ, Ray CE Jr, Bandyk DF, Burke CT, Dill KE, Gerhard-Herman MD, Hanley M,
Hohenwalter EJ, Mohler ER III, Rochon PJ, Schenker MP, Expert Panel on Vascular Imaging and Interventional
Radiology. ACR Appropriateness Criteria® abdominal aortic aneurysm: interventional planning and follow-
up. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 8 p.

Collateral Documents/Tools: N/A

Approved By:
UW Health Ambulatory Protocol Committee: April 2015; *April 2017
Clinical Knowledge Management Council: May 2015; *May 2017
UW Medical Board: June 2015; *May 2017
UW Health Chief Ambulatory Medical Officer: June 2015; *May 2017

Effective Date: May 2017

Scheduled For Review: May 2020
*Expedited Review Process

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


Glossary
AAA- Abdominal aortic aneurysm
ABI- Ankle brachial index/indices
CCA – Common carotid artery
CTA- Computed tomography angiography
Duplex- Ultrasound
DVT- Deep vein thrombosis
EMG/NCS- Electromyography/ Nerve conduction study
EVAR- Endovascular abdominal aortic repair
ICA EDV – Internal carotid artery end diastolic velocity
IVC Filter- Inferior Vena Cava Filter
MRA AIF - Magnetic resonance angiogram, arterial input function
MRA - Magnetic resonance angiogram
MRI - Magnetic resonance imaging
PFT - Pulmonary function test
PSV - Peak systolic velocity
PVR - Pulse volume recording
TAA - Thoracic aortic aneurysm
TEVAR - Thoracic endovascular aortic repair
TOS - Thoracic outlet syndrome test


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

Appendix A. Vascular Surgery Clinic Previsit Testing

A. Carotid or Subclavian Stenosis
3-8

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Cervical bruit
ii) Vertebral basilar symptoms (dizziness, ataxia, double vision)
iii) Follow-up of known disease
iv) Follow-up of carotid endarterectomy surgery or carotid stenting
v) Follow-up of cerebral vascular accident (stroke)
b) Sub-acute conditions:
i) Transient ischemic attack (TIA) symptoms (visual disturbances of one
eye, speech difficulties, numbness/tingling/weakness of an extremity,
transient paralysis of an extremity, facial dropping/drooling)
ii) Amaurosis Fugax (monocular blindness/ “window shade”)
iii) Syncope and collapse
iv) Inability to control movement of an arm or leg
c) Acute conditions:
i) Crescendo Transient ischemic attacks
ii) All suspected cerebral vascular accidents (stroke)

2) Severe stenosis - if ultrasound shows velocity >230 cm/s plus either ICA EDV
>100 cm/sec or ICA/CCA ratio >4.0, the patient has severe stenosis
1a) Order carotid ultrasound if one has not been done within the
past 6 months





1b) Within the next 24 hours, order and schedule a carotid
ultrasound if there are new or sub-acute symptoms





1c) Send patient to emergency room or call 911 immediately



3) Severe stenosis
• Order CTA of head and neck
• Order a stress test if indicated based on clinical cardiac
assessment. (This includes considering past medical history
as related to cardiac health such as CAD, prior cardiac
interventions, shortness of breath with stairs or activity,
taking cardiac medications.)









B. Inferior Vena Cava (IVC) Filter
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Indication Orders
1) Inferior Vena Cava filter placement





2) Inferior Vena Cava filter removal
1) Inferior Vena Cava filter placement
• Request from outside facility indication for filter, who is
requesting placement, and when filter is to be placed
• Order venous bilateral of the lower extremity to check for
deep vein thrombosis if not done within the last month

2) Inferior Vena Cava filter removal
• Request operative report from outside facility with model of
filter and date it was placed. Check with MD if it is
removable and in what time frame
• Order venous bilateral of the lower extremity to check for
location and deep vein thrombosis if not done within last
month
• Order CTA with venous phase to determine placement of
tines for removal

C. Lower Extremity Arterial Disease
9-13

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Claudication (pain in muscles with walking, relieved by rest)
ii) Follow-up of peripheral vascular bypass or PTA of extremity
iii) Follow-up of peripheral aneurysm, pseudoaneurysm, arterial-venous
fistula, or injury to a blood vessel
iv) Femoral bruit, thrill, or pulsatile mass
v) Vasospastic syndromes

b) Sub-acute conditions:
i) Rest pain (ischemic pain or change in toe, ball of foot, or heel at rest
(not calf pain at night))
ii) Gangrene of extremity
iii) Ulceration or sores on feet that are slow to heal
iv) “Blue toe syndrome”
v) No audible Doppler signals in foot
vi) Newly diagnosed peripheral aneurysm, arterial-venous fistula or
injury to a blood vessel
c) Acute conditions: (Sudden onset marked by the 6 P’s)
i) Pain- severe and constant
1a) Order pulse volume recording with exercise if patient is able to
exercise; if unable to exercise order PVR w/o exercise if the test has
not been done in the past 6 months. If patient has peripheral
aneurysm, pseudoaneurysm, arterial-venous fistula, injury to a blood
vessel, femoral bruit, thrill or pulsatile mass, patient will also need a
duplex scan. If the patient had previous lower extremity bypass, also
order an arterial duplex of the graft if the test has not been done in
the past 6 months.

1b) Within the next 7 days, order and schedule a pulse volume
recording with exercise if patient is able to exercise; if unable to
exercise order pulse volume recording without exercise if there are
new sub-acute symptoms. If the patient had previous LE bypass, also
order an arterial duplex of the graft if there are new sub-acute
symptoms.



1c) Send patient to emergency room immediately

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

ii) Pallor (whitening of limb)
iii) Pulselessness
iv) Paresthesia (loss of sensation)
v) Paralysis (loss of movement)
vi) Poikilothermia (coolness)
vii) Pseudoaneurysm (enlarging)

2) Abnormal PVR (0.0-0.4) and PSV of >180cm/sec; AND/OR Velocity ratio
of ≥2:1 (PSV stenotic segment: PSV pre-stenotic segment)







2)
• Order CTA of the aorta, iliac and femoral arteries with runoff
• If CTA is contraindicated, then order a MRA of the aorta and
iliac arteries with runoff
• Order a stress test if lower extremity bypass is involved and
if indicated based on clinical cardiac assessment. (This
includes considering past medical history as related to
cardiac health such as CAD, prior cardiac interventions,
shortness of breath with stairs or activity, taking cardiac
medications )


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

D. Upper Extremity Arterial Disease
14-17

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of peripheral vascular bypass or PTA of extremity
ii) Follow-up of peripheral aneurysm, pseudoaneurysm, arterial-venous
fistula, or injury to a blood vessel
iii) Vasospastic syndromes
b) Sub-acute conditions:
i) Rest pain (ischemic pain or changes in finger, hand, or arm at rest )
ii) Gangrene of extremity
iii) Ulceration or sores on hands that are slow to heal
iv) No audible Doppler signals in foot
v) Newly diagnosed peripheral aneurysm, arterial-venous fistula or
injury to a blood vessel
vi) Unilateral symptoms versus bilateral symptoms, evidence of
embolization
c) Acute conditions: (Sudden onset marked by the 7P’s)
i) Pain- severe and constant
ii) Pallor (whitening of limb)
iii) Pulselessness (new)
iv) Paresthesia (loss of sensation)
v) Paralysis (loss of movement)
vi) Poikilothermia (new coolness)
vii) Pseudoaneurysm (enlarging)

2) Patient has abnormal PVR (0.0-0.9), and sub-acute symptoms such as new
rest pain, non-healing ulcer
1a) Order upper extremity pulse volume recording with digital
waveforms if one has not been done within the past 6 months. If
patient has peripheral aneurysm, pseudoaneurysm, arterial-venous
fistula, or injury to a blood vessel, patient will also need a duplex
scan.

1b) Within 7 days, order and schedule an upper extremity pulse
volume recording with digital waveforms if there are new sub-acute
symptoms






1c) Send patient to emergency room immediately








2)
• Order MRA of chest, arch vessels, brachial cephalic and hand
• If MRA is contraindicated, then order a CTA of upper
extremity








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

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known obstructive disease
ii) Uncontrolled blood pressure on at least 3 hypertensive drugs
iii) Elevated creatinine unknown etiology
b) Sub-acute conditions:
i) Previous renal artery intervention and uncontrolled blood pressure
1a) Order direct renal artery ultrasound if one has not been done
within the past 6 months



1b) Within 7 days, order direct renal artery ultrasound if there are
new sub-acute symptoms

F. SMA/Celiac Arterial Disease
18-20

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known disease
ii) Postprandial pain
iii) Weight loss in short amount of time (i.e. 10 pounds in 3 months)
iv) Fear of eating food
v) Explosive stools or constipation
vi) Food worsens symptoms
b) Acute conditions:
i) Sudden severe abdominal pain
ii) Inability to eat
iii) Nausea or vomiting
iv) Bloody stools

2. Ultrasound results are abnormal and show >70% stenosis
Mesenteric Duplex Diagnostic Criteria
Abnormal 70% stenosis
Celiac PSV > 200 cm/s with post stenotic turbulence
SMA PSV >275 cm/s with post stenotic turbulence and SMA/Aortic PSV ratio
of 3.0 or greater

1a) After review of outside records and investigating for etiology of
abdominal pain, if no other underlying diagnosis of abdominal pain,
order visceral ultrasound scan if one has not been done within the
past 6 months




1b) Send patient to emergency room or call 911 immediately





2) Order CTA of abdomen







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

1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known disease
ii) Pain in last 3 fingers
iii) Pain in extremity with extension and elevation or repetitive motion
iv) Numbness, tingling
b) Sub-acute conditions:
i) Brachial or subclavian occlusion
ii) Significant pain, swelling, or color changes in arm
c) Acute conditions:
i) Sudden changes in pain, swelling or color in arm
ii) Effort thrombosis/upper extremity DVT
1a) Order TOS test and chest x-ray if these tests have not been done
within past 6 months





1b) Within 7 days, order thoracic outlet syndrome test and chest x-
ray if there are new sub-acute symptoms

1c) Send patient to emergency room or call 911 immediately




H. Venous Disease
9-13

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Venous ulceration
ii) Varicose veins
iii) Edema
iv) Cellulitis
v) Follow-up of known disease




b) Acute conditions:
i) Sudden shortness of breath/suspect pulmonary embolus
1a)
• If patient has worn compression stockings for 3 months or
more, set up consult with surgeon and functional venous
duplex
• If patient has not worn compression stockings, they can be
scheduled for consult without a functional venous duplex
• If patient has a venous ulcer or swelling of legs, order
functional venous duplex and consult
• If patient has no palpable pulses, order an ABI with
functional venous duplex and consult

1b) Send patient to emergency room or call 911 immediately






I. Deep Venous Thrombosis (DVT)
9-13

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

1) Symptomatic and/or new patient. Symptoms include:
a) Sub-acute conditions:
i) Unilateral swelling/edema <10 days and at least 2 cm larger
ii) Unilateral pain < 10 days
iii) Previous deep vein thrombosis with recurrent symptoms
iv) “Cord” running up leg
b) Acute conditions:
i) Sudden shortness of breath/suspect pulmonary embolus

2) Routine follow-up of chronic condition

1a) Refer to swollen leg clinic for clinical risk assessment and venous
duplex above or below the knee as indicated



1b) Send patient to emergency room or call 911 immediately


2) Order venous duplex above and below the knee if not done within
last 6 months

J. Aneurysms (AAA, TAA, or any artery)
21-24

Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known disease
b) Sub-acute conditions:
i) Waxing and waning abdominal and/or back pain with history of AAA
or TAA
c) Acute conditions:
i) Sudden, severe or new onset of abdominal and/or back pain with
history of AAA or TAA

2) If ultrasound shows aneurysm is > 5.5 cm (or > 3 cm for iliac artery)

1a) Order abdominal ultrasound if one was not already done by
referring provider within past 6 months
1b) Within 24 hours, order CT if there are new sub-acute symptoms



1c) Call 911 immediately


2) If ultrasound shows aneurysm is > 5.5 cm (or > 3 cm for iliac
artery)
• Order CTA or MRA with contrast or obtain images and report
from outside facility ensuring 1 mm cuts
• Order ankle brachial index if patient is known PAD and not
done in past year.
• Order a nuclear stress test if indicated based on
anesthesiology protocol or clinical cardiac assessment and
cardiology consult if abnormal. (This includes considering
past medical history as related to cardiac health such as
CAD, prior cardiac interventions, shortness of breath with
stairs or activity, taking cardiac medications)
• AAA: Order pulmonary function test
• TAA: Order pulmonary function test for either open or
endovascular, carotid ultrasound exam and echocardiogram
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


K. Compartment Releases
Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known disease
ii) Pain with exercise in extremities
iii) Paresthesia
b) Acute conditions:
i) Sudden, severe pain which can include the inability to walk
ii) Foot drop
iii) Significant color or temperature changes to extremities
1a) Order popliteal entrapment screen if not done within last year




1b) Send patient to emergency room or call 911 immediately

L. Dissection
Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known dissection


b) Acute conditions:
i) Ripping pain in back or chest
ii) Uncontrolled blood pressure
1a) Order a CTA if one was not previously done in the last 3 months
within one year of diagnosis. If it has been one year or more since
diagnosis, then interval is to order CTA every 6 to 24 months based
on size. (reference Instead Trial in Circulation)

1b) Send patient to emergency room or call 911 immediately


M. Raynaud’s/Buerger’s/ Vasospastic Disease
Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Extremity pallor
ii) Pain in digits; worsens in the cold
iii) Symptoms relieved with warmth
b) Sub-acute conditions:
i) Blisters
ii) Duskiness of digits
iii) Loss of feeling in digits
c) Acute conditions:
i) Sudden change or onset of blisters, duskiness of digits or loss of
feeling in digits
1a) Order PVR with digital waveforms if was one was not done
within the past 6 months



1b) Within 7 days, order PVR with digital waveforms



1c) Send patient to emergency room

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

N. Vasculitis (Takayasu’s Arteritis), Giant Cell Arteritis
Indication Orders
1) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known disease
ii) Numbness
iii) Coldness in limb
iv) High blood pressure
v) Loss of pulse
b) Acute conditions:
i) Sudden changes in numbness, coldness in limb, blood pressure, loss
of pulse
1a) Order arterial flow study (ankle brachial index or pulse volume
recording) depending on part of body affected if they have not had
one done in the previous 6 months




1b) Send patient to emergency room or call 911 immediately

O. IV Fistual
Indication Orders
2) Symptomatic and/or new patient. Symptoms include:
a) Chronic conditions:
i) Follow-up of known fistula
ii) Unable to access fistula
b) Acute conditions:
i) Occluded fistula and need dialysis
ii) Sudden change or onset of discolored, painful or swelling in limb
iii) Loss of pulse
1a) Order arterial duplex and vein mapping if they have not had
these tests done in the previous 6 months or if being evaluated for
new access for failed fistula.

1b) Send patient to emergency room or call 911 immediately

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