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IP – Destination Therapy Mechanical Circulatory Device Evaluation – Adult – Supplemental [5447]

IP – Destination Therapy Mechanical Circulatory Device Evaluation – Adult – Supplemental [5447] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Cardiology/CT Surgery


IP - Destination Therapy Mechanical Circulatory Device Evaluation - Adult - Supplemental
[5447]
Qualifications
Qualifications [152091]
MCD Destination Therapy Qualifications [COR0081] ONCE, Routine
NYHA Classification:
Receiving IV inotropes and unable to wean:
Patient has an intra-aortic balloon pump preoperatively:
Reason why patient is not a heart transplant candidate:
Patient is free from infections, including history of MDRO
(multi-drug resistent organisms):
Ejection fraction (EF) is <25%:
Patient is on optimal medical management:
INTERMACS Classification (see hyperlink for definitions):
Diagnostic Tests and Imaging
Cardiopulmonary EVO2 Stress Test (Single Response) [152084]
Cardiopulmonary EVO2 Stress Test (ADULT) [181447]
Most commonly ordered for heart failure or cardiopulmonary transplant patients. This specialized exercise test includes
measurements of oxygen uptake (VO2), carbon dioxide output (VCO2), minute ventilation (VE), and other variables during
an exercise stress test. Test performed in the Echo Vascular Lab at UW Hospital. Please call Preventive Cardiology at
263.6630 with questions.
Cardiopulmonary EVO2 Stress Test (Adult) (Order 1 of
2) [EKG0023]
ONCE, Routine
Reason for exam: Other (Comment)
Type of stress: SUBMAXIMAL
Type of equipment: TREADMILL
Indicate any medication holds:
Bring comfortable shoes and wear pants.
NPO 4 hours; no caffeine or tobacco 12 hours
Cardiopulmonary EVO2 Stress Test (Adult) (Order 2 of
2) [EKG0028]
ONCE, Routine
Reason for exam: Other (Comment)
Type of stress: SUBMAXIMAL
Type of equipment: TREADMILL
Indicate any medication holds:
NPO 4 hours; no caffeine or tobacco for 12 hours
Cardiopulmonary EVO2 Stress Test Not Needed
[COR0071]
ONCE, Routine
Reason cardiopulmonary EVO2 stress test not needed:
Carotid Ultrasound (Single Response) [152085]
Order a carotid ultrasound if patient has a bruit, history of CAD, ischemic cardiomyopathy, age >60, or history of
stroke/TIA
Ultrasound Carotid Duplex (UW Hospital, East Clinic)
[VASC0002]
ONCE, Routine
Reason for exam: OTHER (COMMENT)
Other (Comment): Destination therapy mechanical circulatory
device evaluation
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Left, Right, or Bilateral?
Performed in Heart Vascular Care Echo/Vasc Lab
Carotid Ultrasound Not Needed [COR0072] ONCE, Routine
Reason carotid ultrasound not needed:
Right Heart Catheterization (Single Response) [152086]
Heart And Vascular Care Procedure - Cath Lab
[CARD0006]
ONCE, Routine
Procedure to Perform: Right Heart Cath
Reason for Cath Procedure: Other (Comment) (Destination
therapy mechanical circulatory device evaluation )
Do you want a Left Heart Pressure? No
Do you want a Right Heart Cath? Yes
State indication for Right Heart Cath: Destination therapy
Page 1 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2016CCKM@uwhealth.org

mechanical circulatory device evaluation
Allergies to IV Contrast or Iodine?
Last patient height? (will auto pull in value and date in
comment):
Last patient weight? (will auto pull in value and date in
comment):
Last creatinine value? (will auto pull in date and value in
comment):
Last e-GFR value? (will auto pull in value and date in
comment):
Last INR value? (will auto pull in date and value in comment):
Assess patient for Cardiovascular Lab Ankle Brachial Index?
Is there a preference for drug eluting stent or bare metal
stent?
Does the patient have any history of bleeding?
Does the patient have any planned surgeries or invasive
procedures?
Right Heart Catheterization Not Needed [COR0073] ONCE, Routine
Reason right heart cath not needed:
Chest CT (Single Response) [152112]
CT chest w/o IV contrast: Order if patient has a history of congenital heart disease, previous open heart surgery, or a
history of chemotherapy or radiation treatment affecting the thoracic cavity
CT CHEST W/ O IV CONTRAST [R71250] ONCE-RAD NEXT AVAILABLE, Routine
Radiology Specialty Area: CT
Current signs and symptoms?
What specific question(s) would you like answered by this
exam? Destination therapy mechanical circulatory device
evaluation
Relevant recent/past history?
Is patient pregnant?
Allergies to IV contrast or iodine?
Last creatinine value? (will auto pull in date and value in
comment):
For scheduling purposes, does the patient require general
anesthesia, sedation or anxiolytics? Note: ordering provider is
responsible for prescribing oral anxiolytics or arranging peds
anesthesia / sedation services. See reference link above.
Last patient weight? (will auto pull in value and date in
comment):
Transport Method:
Chest CT Not Needed [COR0074] ONCE, Routine
Reason chest CT not needed:
Pulmonary Function Tests (Single Response) [152115]
Pulmonary Lab Testing [999992] ONCE, Routine
Reason for Exam: Destination therapy mechanical circulatory
device evaluation
Specify Test: Spirometry, Bronchodilator if indicated
(Albuterol MDI x 4 Puffs)
Pulmonary Function Tests Not Needed [COR0075] ONCE, Routine
Reason pulmonary function tests not needed:
Transthoracic echocardiogram (Single Response) [152114]
Transthoracic Resting Echocardiogram [ECH0003] ONCE, Routine
Reason for exam:
Do you want Agitated Bubble Study?
Is patient mechanically ventilated?
Is patient ICU status?
Does patient need continuous monitoring?
Transthoracic Echocardiogram Not Needed [COR0076] ONCE, Routine
Reason transthoracic echocardiogram not needed:
Page 2 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2016CCKM@uwhealth.org

Consults
Consult Cardiac Surgery (Single Response) [152116]
Consult Cardiac Surgery (Inpatient) [CON0011] ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Destination therapy
mechanical circulatory device evaluation
Consult Cardiac Surgery Already Completed [COR0077] ONCE, Routine
Consult Heart Failure (Single Response) [152117]
Consult Congestive Heart Failure (Inpatient) [CON0017] ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Destination therapy
mechanical circulatory device evaluation
Consult Heart Failure Already Completed [COR0078] ONCE, Routine
Consult Gastroenterology (GI) (Single Response) [195545]
Consult Gastroenterology (Inpatient) [CON0027] ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Destination Therapy
mechanical circulatory device evalutation
Can this consult be done via video? No
Consult Gastroenterology Not Needed [COR0085] ONCE For 1 Occurrences, Routine
Reason consult to gastroenterology not needed:
Consult Mechanical Circulatory Device (MCD) Coordinator (Single Response) [152118]
Consult Mechanical Circulatory Device (MCD)
Coordinator [CON0203]
ONCE, Routine, The following conditions do not necessarily
exclude but may impact the assessment for MCD placement:
Currently on dialysis
Liver disease with ascites or cirrhosis
Cancer diagnosis
COPD or pulmonary diagnosis
Previous abdominal or thoracic surgeries
Previous CVA with mental or mobility deficits
Psychiatric diagnosis
General mental or learning deficits
Inadequate social support
Reason for consult:
Urgency:
Can this consult be done via video?
Consult MCD Coordinator Already Completed
[COR0079]
ONCE, Routine
Consult Palliative Care (Single Response) [194904]
Consult Palliative Care - Adult (Inpatient) [CON0055] ONCE, Routine
Reason For Consult:
Can this consult be done via video?
Consult Palliative Care Not Needed [COR0086] ONCE, Routine
Reason consult to palliative care not needed: Patient and
family unable to participate
Consult Transplant Financial Coordinator (Single Response) [152119]
Consult Transplant Financial Coordinator [CON0157] ONCE, Routine
Reason for Consult: Destination therapy mechanical
circulatory device evaluation
Consult Transplant Financial Coordinator Not Needed
[COR0080]
ONCE, Routine
Reason consult to transplant financial coordinator not
needed:
Consult Social Work (Inpatient) (Single Response) [152120]
Consult Social Work (Inpatient) [CON0076] ONCE, Routine
Page 3 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2016CCKM@uwhealth.org

Reason for Consult: OTHER (Destination therapy mechanical
circulatory device evaluation)
Consult Social Work Not Needed [COR0066] ONCE, Routine
Reason consult to social worker (inpatient) not needed:
Additional Consults [152121]
Consider ordering the following consults if clinically indicated.
Consult Health Psychology (Inpatient) [CON0033] ONCE, Routine, Please notify consulting provider if patient
needs to be seen same day (Monday-Friday) or if special
assessment needs.
Intent for Consult: Other
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Destination therapy
mechanical circulatory device evaluation
Consult Pulmonary Medicine (Inpatient) [CON0065] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Destination therapy
mechanical circulatory device evaluation
Consult Transplant Nephrology (Inpatient) [CON0083] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Destination therapy
mechanical circulatory device evaluation
Page 4 of 4
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2016CCKM@uwhealth.org