/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/ambulatory/,/clinical/cckm-tools/content/order-sets/ambulatory/vascular-surgery/,

/clinical/cckm-tools/content/order-sets/ambulatory/vascular-surgery/name-98513-en.cckm

20170248

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Ambulatory,Vascular Surgery

FDS - Carotid Stent Placement (Cath Lab) - Adult - Preprocedure [5322]

FDS - Carotid Stent Placement (Cath Lab) - Adult - Preprocedure [5322] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Ambulatory, Vascular Surgery


FDS - Carotid Stent Placement (Cath Lab) - Adult - Preprocedure [5322]
for Adult Patients OnlyIntended
Pre-Day of Procedure
Non-Categorized Patient Care Orders [111679]
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
237 mL, , starting 2/9/17, Normal
Medications-MRSA/MSSA Positive [138973]
Note: Please select the orders below if patient is MRSA or MSSA positive
mupirocin (BACTROBAN) 2 % ointment [45826] 1 Tube, 0, starting 2/9/17, E-Prescribe
chlorhexidine gluconate (HIBICLENS) 4 % topical
liquid [64730]
237 mL, , starting 2/9/17, E-Prescribe
Labs - MRSA and MSSA Screening [219363]
MRSA/MSSA BY PCR [HCMSSA] Status: Standing, Expires:6/11/17 Manual,Count:1,
Office collect, Routine, A Pre-Surgical screen consists
of one culturette swab from both left and right nares.
This assay cannot detect MSSA when MRSA is
present.
Laboratory [86963]
CBC WITH DIFFERENTIAL [CBC] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
ELECTROLYTES [LYTE] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
BUN [BUN] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
CREATININE [CRET] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
CALCIUM [CA] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
MAGNESIUM [MAG] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
PHOSPHATE [PHOS] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
GLUCOSE [GLU] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
PROTHROMBIN TIME/INR [PT] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
PTT [PTT] Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
URINALYSIS WITH MICROSCOPY AND
CULTURE IF >5 WBC/HPF [HCUACULT]
Status: Standing, Expires:3/26/17 MANUAL,Count:1,
Normal, Routine
Pre-Op Day of Procedure
Isolation Status [181659]
Isolation - Enhanced Contact - Clostridium
Difficile [ISO0010]
CONTINUOUS, Separate order must be placed for
isolation cart., Cardiac Cath/EP
Isolation - Contact - MRSA [ISO0039] CONTINUOUS, Separate order must be placed for
isolation cart., Cardiac Cath/EP
Isolation - Contact - VRE [ISO0051] CONTINUOUS, Separate order must be placed for
isolation cart., Cardiac Cath/EP
Isolation - Protective Precautions - Panel
[116356]
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Protective Precautions [ISO0001] CONTINUOUS
Reason for Protective Precautions:
Cardiac Cath/EP
Protective - Positive Pressure Room
[NURCOM0109]
CONTINUOUS, Cardiac Cath/EP
Isolation - Airborne - TB-Pulmonary
Confirmed/Suspect [ISO0003]
CONTINUOUS, Separate order must be placed for
isolation cart., Cardiac Cath/EP
Isolation - Contact - Multidrug Resistant
Organism - Panel [116335]
Isolation - Contact - Multidrug Resistant
Organism (MDR) [ISO0006]
CONTINUOUS, Cardiac Cath/EP
Isolation Cart [EQP0016] CONTINUOUS, Routine, Cardiac Cath/EP
Isolation - Contact - Extensively Resistant
Organism (XDR) - Panel [193206]
Isolation - Contact - Extensively Drug Resistant
Organism (XDR) [ISO0320]
CONTINUOUS
Isolation Cart [EQP0016] CONTINUOUS, Routine
VTE Prophylaxis [219373]
• If low risk for development of VTE - select VTE Prophylaxis - Reason Not Ordered
• If requires VTE prophylaxis AND
◦ LOW bleed risk - select pharmacologic agent only
◦ ABSOLUTE bleed risk - select mechanical agents only
◦ HIGH bleed risk - weigh risk of bleed vs risk of VTE development and select drug OR
mechanical agent
NOTE: Mechanical and pharmacologic agents should only be used together in patients
with a very high risk of VTE development
VTE Risk Factor Assessment Tool URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/hematology-and-
coagulation/related/name-97521-en.cckm
Sequential Compression Device (SCD) Panel
(TREATMENT AND SUPPLY) [206111]
Sequential Compression Device (SCD)
(TREATMENT) [NURTRT0028]
CONTINUOUS, Routine
Left/Right/Bilateral? Bilateral
Cardiac Cath/EP
Sequential Compression Device (SCD) / Foot
Pump (SUPPLY) [EQP0023]
CONTINUOUS, Routine
Left/Right/Bilateral?
Type: Knee High
Cardiac Cath/EP
Apply and Maintain Anti-Embolism Stocking
[NURTRT0039]
CONTINUOUS, Routine
Does this need to be inserted/placed?
Left/Right/Bilateral? Bilateral
Type: Knee high
Cardiac Cath/EP
heparin PF 5000 UNIT/0.5ML injection [156571] 5,000 units, Subcutaneous, ON CALL For 1 Doses
If patient scheduled for block, give after block placed
Cardiac Cath/EP
VTE Prophylaxis - Reason Not Ordered
[COR0008]
ONCE For 1 Occurrences, Routine
Reason Not Ordered:
Cardiac Cath/EP
Non Categorized Patient Care Orders [181661]
Insert and Maintain Peripheral IV [NURVAD0013] CONTINUOUS, Routine
Peripheral IV Size: RN Discretion
Does this need to be inserted/placed?
Cardiac Cath/EP
Page 2 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 1:42:11 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Routine, To discontinue this order,
enter a new order for "Discontinue Urinary Catheter".
To modify this order, enter a new order for "Maintain
Urinary Catheter" and make the necessary changes
in the new order.
Type:
Indication for Placement:
Details: To Dependent Drainage
Does this need to be inserted/placed?
Cardiac Cath/EP
Premedications for Needle Insertion [181660]
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.
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
IV Fluids [181781]
dextrose 5%-NaCl 0.45% infusion [51613] at 20 mL/hr, Intravenous, CONTINUOUS, Cardiac
Cath/EP
sodium chloride 0.9 % infusion [64367] at 20 mL/hr, Intravenous, CONTINUOUS, Cardiac
Cath/EP
Anti-platelets [181782]
aspirin chew tab [720164] 81 mg, Oral, ONCE For 1 Doses
Omit pre-op dose if patient took AM dose.
Cardiac Cath/EP
aspirin tab [34787] 325 mg, Oral, ONCE For 1 Doses, Cardiac Cath/EP
Page 3 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 1:42:11 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

clopidogrel (PLAVIX) tab [720168] 75 mg, Oral, ONCE For 1 Doses
Omit pre-op dose if patient took in AM
Cardiac Cath/EP
clopidogrel (PLAVIX) tab [720168] 150 mg, Oral, ONCE For 1 Doses, Cardiac Cath/EP
clopidogrel (PLAVIX) tab [720168] 300 mg, Oral, ONCE For 1 Doses, Cardiac Cath/EP
clopidogrel (PLAVIX) tab [720168] 600 mg, Oral, ONCE For 1 Doses, Cardiac Cath/EP
Laboratory [181662]
CBC WITHOUT DIFFERENTIAL [HEMO] STAT - RN COLLECT, 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
ELECTROLYTES, WHOLE BLOOD
[HCWBLYTS]
STAT - RN COLLECT, 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 - RN COLLECT, 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, WHOLE BLOOD [HCWBCRET] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
GLUCOSE, WHOLE BLOOD [HCWBGLU] STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
CALCIUM, IONIZED, WHOLE BLOOD
[HCWBICA]
STAT - RN COLLECT, Starting today For 1
Occurrences, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Cardiac Cath/EP
PROTHROMBIN TIME/INR [PT] STAT - RN COLLECT 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
PTT [PTT] STAT - RN COLLECT 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
Page 4 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 1:42:11 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

MAGNESIUM [MAG] STAT - RN COLLECT 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
PHOSPHATE [PHOS] STAT - RN COLLECT 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
Laboratory - Pregnancy Test [181663]
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] STAT - RN COLLECT, 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
Surgical Prophylaxis
First Line (Single Response) [219389]
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 40-120 kg [800000]
2 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
cefazolin (ANCEF) intraVENOUS - NOTE:
Patients who are 121 kg and greater [800000]
3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
MRSA/Documented History of MRSA (Single Response) [181828]
Patients who are 40 - 120 kg [219380]
cefazolin (ANCEF) intraVENOUS [800000] 2 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose = 2000 mg
Cardiac Cath/EP
Patients who are 121 kg or greater [219383]
cefazolin (ANCEF) intraVENOUS [800000] 3 g, Intravenous, ON CALL For 1 Doses, Cardiac
Cath/EP
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose = 2000 mg
Cardiac Cath/EP
Immediate/Severe Reactions to Penicillin or Known Cephalosporin Allergies (Single Response)
[181838]
Patients who are 40-120 kg [219402]
ciprofloxacin (CIPRO) intraVENOUS [800031] 400 mg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose = 2000 mg
Cardiac Cath/EP
Patients who are 121-160 kg [219407]
ciprofloxacin (CIPRO) intraVENOUS [800031] 600 mg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose = 2000 mg
Cardiac Cath/EP
Patients who are greater than 160 kg [219405]
Page 5 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 1:42:11 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

ciprofloxacin (CIPRO) intraVENOUS [800031] 800 mg, Intravenous, ON CALL For 1 Doses,
Cardiac Cath/EP
vancomycin (VANCOCIN) intraVENOUS
[800084]
20 mg/kg, Intravenous, ON CALL For 1 Doses
Maximum Dose = 2000 mg
Cardiac Cath/EP
IntraOp
Diagnostic Tests and Imaging [181645]
Routine EEG [EEG0004] ONCE, Routine
Reason for Monitoring: Surgical
IntraOp
Diagnosis
Diagnosis - Pre Op [711]
Pre-operative general physical examination
[255759]
Other specified pre-operative examination
Diagnosis - Smoking Cessation [134767]
Tobacco use disorder [305.1.ICD-9-CM] Tobacco use disorder
Personal history of tobacco use, presenting
hazards to health [V15.82.ICD-9-CM]
Personal history of tobacco use, presenting hazards
to health
Level of Service
Office Visit - Established Patients [30779]
99211 - Level I LOS Code
99212 - Level II LOS Code
99213 - Level III LOS Code
99214 - Level IV LOS Code
99215 - Level V LOS Code
99211 - w/ Resident (GC) - Level I LOS Code
99212 - w/ Resident (GC) - Level II LOS Code
99213 - w/ Resident (GC) - Level III LOS Code
99214 - w/ Resident (GC) - Level IV LOS Code
99215 - w/ Resident (GC) - Level V LOS Code
Office visit - New Patients [30778]
99201- Level I LOS Code
99202- Level II LOS Code
99203- Level III LOS Code
99204- Level IV LOS Code
99205 - Level V LOS Code
99201- w/ Resident (GC) - Level I LOS Code
99202- w/ Resident (GC) - Level II LOS Code
99203- w/ Resident (GC) - Level III LOS Code
99204- w/ Resident (GC) - Level IV LOS Code
99205- w/ Resident (GC) - Level V LOS Code
Consults [30780]
If Medicare patient, do not use Consult LOS. Choose an Established or New Patient LOS. Add the
appropriate additional E/M Code of 99354-99359 for prolonged office consultations in the LOS
section of the Visit Navigator.
99241 - Level I LOS Code
99242 - Level II LOS Code
Page 6 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 1:42:11 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org

99243 - Level III LOS Code
99244 - Level IV LOS Code
99245 - Level V LOS Code
99241- w/ Resident (GC) - Level I LOS Code
99242 - w/ Resident (GC)- Level II LOS Code
99243 - w/ Resident (GC) - Level III LOS Code
99244 - w/ Resident (GC) - Level IV LOS Code
99245 - w/ Resident (GC) - Level V LOS Code
Preoperative Exam (Global) [1265]
Preoperative H&P, No Charge, Surgical Package LOS Code
Page 7 of 7
Printed by O'BRIEN, RYLEY P [RPO249] at 2/9/2017 1:42:11 PM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
02/2017CCKM@uwhealth.org