/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/order-sets/,/clinical/cckm-tools/content/order-sets/inpatient/,/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/,

/clinical/cckm-tools/content/order-sets/inpatient/hospital-wide/name-98188-en.cckm

201712349

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Order Sets,Inpatient,Hospital-wide

IP - Comprehensive Brain Dead Donor (BDD) Delegation Protocol - Adult - Intensive Care - Supplemental [4078]

IP - Comprehensive Brain Dead Donor (BDD) Delegation Protocol - Adult - Intensive Care - Supplemental [4078] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Order Sets, Inpatient, Hospital-wide


IP - Comprehensive Brain Dead Donor (BDD) Delegation Protocol - Adult -
Intensive Care - Supplemental [4078]
for Adult ICU Patients OnlyIntended
set.for organ procurement must have been obtained prior to use of this order Consent
dose sedatives/barbiturates actively present at -Do NOT use on patients with paralytics or high
the time this protocol is enacted.
discussions with attending note must be written that documents the rationale for comfort care, A
with this order set.and discussion with family in order to proceed
in airways up -family regarding tachypnea not being equal to dyspnea, secretion buildEducate
unpredictability in the timing of death, and snoring, changes in skin color, bowel/bladder control,
etc.
Policy.examination must be requested per hospital mortem -Post
Patient Care Orders
Refer to Policy 4.31 Organ & Tissue Donation URL: https://uconnect.wisc.edu/policies/clinical/uwhc-
clinical/uwhc-wide/legal-affairs/431.policy
Order to Initiate Comprehensive Donation After Brain Death (BDD) Order Set [110902]
Initiate Comprehensive Donation After Brain
Death (BDD) Order Set [NURCOM0068]
All active orders prior to this ordering session (with a
few exceptions) will be discontinued when this order is
signed.
Vital Signs [17768]
Measure Blood Pressure [NURMON0019] EVERY 1 HOUR, Starting today For Until specified,
Routine
BP Source:
BP Location:
BP Position:
BP Restrictions:
Measure Heart Rate [NURMON0056] EVERY 1 HOUR, Starting today For Until specified,
Routine
Measure Temperature [NURMON0029] EVERY 1 HOUR, Starting today For Until specified,
Routine
Temperature Measurement Method:
Temperature Measurement Restrictions:
Patient Monitoring [105862]
Measure Urine Output [NURMON0012] EVERY 1 HOUR, Starting today For Until specified,
Routine
Pulse Oximetry [NURMON0009] EVERY 1 HOUR, Starting today For Until specified,
Routine
Measure Central Venous Pressure
[NURMON0002]
EVERY 2 HOURS, Starting today For Until specified,
Routine
GI/GU [107360]
NG Tube Placement - Adult [120994]
Page 1 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Insert and Maintain Nasogastric Tube
[NURTAD0014]
CONTINUOUS, Routine
Options: Low, Intermittent Suction
Flush with:
Flush Frequency: EVERY 8 HOURS
Clamp NG Tube:
Check Residual:
Does this need to be inserted/placed?
Device Status: Not Ready For Use
Refer to Policy 2.20 Enteral Tubes Used for
Instillation of Fluids, Medications, or Feeding
Recommendations for flush quantity:
For adult patients, 30 mLs of fluid should be
sufficient.
lidocaine-oxymetazoline 4%-0.05% (ADULT)
nasal spray [785081]
2 spray, Nasal, ONCE For 1 Doses
For numbing prior to feeding tube insertion.
Slowly spray the chosen nostril once, if required may
repeat x1 in opposite nostril. Angle toward back of
throat spraying the anterior nostril and wait 30-60
seconds before introducing more local
anesthetic into the nostril. Caution: Entire bottle
should not be used for insertion of tube. Discard
excess solution when procedure completed.
X-RAY ABDOMEN AP VIEW (KUB) [R74000] CONDITIONAL For 3 Days, Routine
Radiology Specialty Area: GENERAL IMAGING
Current signs and symptoms? Organ failure
What specific question(s) would you like answered
by this exam? Evaluate nasogastric tube placement
Relevant recent/past history? Organ failure
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date
in comment):
Transport Method: Floor Determined/Entered
If Conditional, What Condition? Evaluate nasogastric
tube placement. The location of nasogastric tube
should be confirmed prior to the instillation of fluids,
medications, or feedings. Refer to Policy 2.20
Enteral Tubes Used for Instillation of Fluids,
Medications, or Feeding
Insert and Maintain Urinary Catheter
[NURELM0013]
CONTINUOUS, Starting today For Until specified,
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: Indwelling Single Lumen
Indication for Placement: End of Life Care
Initiate Urinary Catheter Removal Protocol? No
Details: To Dependent Drainage
Does this need to be inserted/placed?
Respiratory [109690]
chlorhexidine (PERIDEX) soln MULTIDOSE -
NOTE: Order for patients on mechanical
ventilation [792004]
15 mL, Mouth/Throat, 2 X DAILY
Use to swab oral cavity. Discontinue when patient no
longer on ventilation
Page 2 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Elevate Head Of Bed [NURACT0002] Equal to (degrees):
Greater than (degrees): 30
Less than (degrees): 43
Other options:
Routine, CONTINUOUS, Starting today For Until
specified
Consult Pulmonary Medicine (Inpatient)
[CON0065]
ONCE
Intent: Consult and Recommend (Write Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): Bronchoscopy - To
evaluate for lung procurement. Assess all lobes and
upper airway.
X-RAY CHEST AP VIEW [R71010] ONCE-RAD NEXT AVAILABLE, Starting today For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where? Bedside
Transport Method: Floor Determined/Entered
Measure: Peak of apex to dome of diaphragm and
costophrenic angle to costophrenic angle.
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting tomorrow For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting 12/17/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Page 3 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting 12/19/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting 12/20/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting 12/21/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
X-RAY CHEST AP VIEW [R71010] ONCE-ON SPECIFIC DATE, Starting 12/22/17 For 1
Occurrences, Routine
Current signs and symptoms? Evaluate for Lung
Procurement
What specific question(s) would you like answered by
this exam? Evaluate for Lung Procurement
Relevant recent/past history? Evaluate for Lung
Procurement
Is patient pregnant? Unknown
If being performed remotely, where?
Last patient weight? (will auto pull in value and date in
comment):
Transport Method: Floor Determined/Entered
Initiate Brain Dead Donor Lung Protective
Algorithm [RT0073]
CONTINUOUS, Routine, Refer to Brain Dead Donor
Lung Protective Algorithm
Respiratory Therapy Communication (Order Sets)
[RT0073]
EVERY 4 HOURS, Routine, Perform IPV, then if weak
or absent cough use In-Exsufflator, then suction, then
recruit to 30cm water for 30 seconds.
Page 4 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Intrapulmonary Percussive Ventilation (IPV)
[RT0023]
EVERY 4 HOURS, Routine, Vest may be considered
as an alternate therapy
In-Exsufflator Treatment [RT0021] RT EVERY 4 HOURS PRN, Routine
I Time:
E Time:
Pause Time:
Positive Pressure (cmH2O):
Negative Pressure (cmH2O):
Perform Lung Recruitment Maneuver [RT0026] EVERY 4 HOURS PRN, Routine
PEEP (cmH2O): 30
Treatment Interval:
For disconnection from ventilator and with algorithm
times
Oral Care [NURCOM0022] EVERY 4 HOURS
Respiratory [114546]
Initiate Brain Dead Donor Lung Protective
Algorithm [RT0073]
CONTINUOUS, Routine, Refer to Brain Dead Donor
Lung Protective Algorithm
Cardiac [109691]
ECG - 12 Lead [EKG0008] ONCE For 1 Occurrences, Routine
Reason for exam: Heart or Lung Transplant
Disclaimer for University Hospital Only: A Stat status
for an ECG is in reference to the timing of the ECG.
The goal is to perform a STAT ECG within 10 minutes
of the order being placed. It is the responsibility of the
ordering provider to review the STAT ECGs. All ECGs
(stat or routine) will be formally reviewed within one
business day.
Consult Cardiology (Inpatient) [CON0012] ONCE
Intent: Consult and Recommend (No Orders)
Concern or Specific Question or Task to be Addressed
(Symptom, Sign, or Diagnosis): To evaluate for
cardiac procurement
Non-Categorized Patient Care Orders [105865]
Measure Height [NURMON0052] ONCE, Starting today For 1 Occurrences, Routine
Measure Weight [NURMON0015] ONCE, Starting today For 1 Occurrences, Routine
Weigh With?
Weigh when?
Maintain Arterial Line [NURVAD0001] CONTINUOUS, Starting today, Routine
Flush Solution:
Maintain Central Venous Access [NURVAD0023] CONTINUOUS, Starting today, Routine
Device Status: Not Ready For Use
Leave All Line and Catheters Provided They Are
Not Causing Discomfort For the Patient
[NURCOM0022]
CONTINUOUS, Starting today For Until specified
RN to Verify Consent for Organ Donation has
been Obtained [NURCOM0022]
ONCE, Starting today For 1 Occurrences
Order Blood Product as Needed Based on
Calculated Amount Needed in Donor Navigator
[NURCOM0022]
CONTINUOUS, Starting today
Notify OPO with positive blood, urine, or sputum
cultures [NURCOM0022]
CONTINUOUS, Starting today
Contingency Parameters [107306]
Page 5 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Notify Primary Team [NURCOM0001] Provider to Notify: Provider
If systolic blood pressure > (mmHg): 170
If systolic blood pressure < (mmHg): 100
If diastolic blood pressure > (mmHg):
If diastolic blood pressure < (mmHg):
If temperature > (C): 38
If temperature < (C): 36.5
If heart rate > (bpm): 130
If heart rate < (bpm): 60
If respiratory rate >:
If respiratory rate <:
If blood glucose > (mg/dL): 150 milligram/deciliter if
patient not on an insulin drip
If blood glucose < (mg/dL): 90
If pain score >:
Pulse Oximetry < (%): 95
If urine output < (mL): 30 milliliters/hour or greater than
250 milliliters/hour for 2 consecutive hours
Other: Mean arterial pressure less than 60
mmHg,Central venous pressure less than 4 mmHg or
greater than 14 mmHg,Cardiac index less than 2
liters/minute/meter squared,Systemic vascular
resistance less than 800 or greater than 1300 dyne-
seconds/centimeter,Hematocrit less than
24%,Hemoglobin less than 8 gram/deciliter,Platelet
count less than 50,000/microliter,Sodium greater than
150 millimole/liter,Potassium greater than 5
millimole/liter.
Intravenous Therapy
IV Fluids - sodium chloride 0.9% with KCl 20 mEq/L infusion [105845]
sodium chloride 0.9% with KCl 20 mEq/L infusion
[46261]
at 125 mL/hr, Intravenous, CONTINUOUS
IV Fluids - dextrose 5% IV Bolus [127532]
dextrose 5% BOLUS [730000] 1-2,500 mL, Intravenous, EVERY 6 HOURS PRN, free
water deficit - see Admin Instructions
Administer calculated dose displayed in Free Water
Deficit section of the Donor Navigator
IV Fluids - sodium chloride 0.9% IV Bolus [127531]
sodium chloride 0.9% BOLUS [730003] 1-2,000 mL, Intravenous, EVERY 2 HOURS PRN,
decreased CVP - see Admin Instructions
Administer calculated dose displayed in Serum
Volume Adjustment section of the Donor Navigator
Medications
Antihypertensives [109197]
labetalol (NORMODYNE;TRANDATE) injection
RANGE [750053]
10-20 mg, Intravenous, EVERY 1 HOUR PRN, MAP
(See Administration Instructions)
Administer for MAP > 120 mmHg while no
vasopressors are running. Give first line if HR greater
than or equal to 60 bpm. Do not give if heart rate is <
60 beats per minute. Wait at least 15 minutes after
any administration of bolus as needed
antihypertensives, including hydralazine, before giving
labetalol.
for 2 Minutes
Page 6 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

hydrALAZINE (APRESOLINE) injection RANGE
[750049]
10-20 mg, Intravenous, EVERY 1 HOUR PRN, MAP
(See Administration Instructions)
Administer for MAP > 120 mmHg while no
vasopressors are running. Give first line if heart rate
is < 60 beats per minute or give second line if heart
rate is greater than or equal to 60 beats per minute
and labetalol is ordered. Wait at least 15 minutes after
any administration of bolus as needed
antihypertensives, including labetalol, before giving
hydralazine.
Diabetes Insipidus [105844]
desmopressin (DDAVP) injection 1 mcg [44855] 1 mcg, Intravenous, EVERY 3 HOURS PRN, see
Admin Instructions
Administer for urine output greater than 250 mL/hr
provided furosemide has not been given within the
past 2 hours and Sodium is greater than 150 mmol/L
Diuretics [109198]
furosemide (LASIX) intraVENOUS [800046] 40 mg, Intravenous, EVERY 6 HOURS PRN, edema,
CVP greater than 12 mmHg
Electrolyte Supplementation [112673]
potassium chloride 20 mEq/ 50 mL bag
CENTRAL LINE ONLY [46256]
20 mEq, Intravenous, PRN, Potassium
supplementation - See Admin Instructions.
For central line use ONLY
For serum K between 3.6 - 3.9 mmol/L give 20 mEq
x1;
For serum K between 3.1 - 3.5 mmol/L give 20 mEq
x2;
For serum K between 2.5 - 3.0 mmol/L give 20 mEq
x3;
For serum K less than or equal to 2.4 mmol/L give 20
mEq x4
for 60 Minutes
Magnesium Supplemental Scale [950039] PRN - NOTIFY PHARMACY WHEN NEEDED,
magnesium supplementation - see Admin Instructions
Non-cardiac patients: For serum magnesium 1.6-1.8
mg/dL - do not replace
Cardiac patients: For serum magnesium 1.6-1.8
mg/dL give 0.05 g/kg IV x1
For serum magnesium 1.0-1.5 mg/dL give 0.1 g/kg IV
x1
For serum magnesium less than 1 mg/dL give 0.15
g/kg IV x1
Administer each 2 gram bag over 3 hours at a
frequency of one bag every 4 hours.
Maximum 6 grams per replacement dose
Reminder: Pharmacist to adjust per UWHC Renal
Dosing Protocol if applicable
Page 7 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Note: Phosphate SODIUM Supplemental Scale
[950018]
PRN - NOTIFY PHARMACY WHEN NEEDED,
phosphate supplementation - See Admin Instructions
For serum phosphate 2.5 - 3.0 mg/dL, give 0.16
mmol/kg IV over 2-3 hrs;
For serum phosphate 1.6 - 2.4 mg/dL, give 0.32
mmol/kg IV over 2-3 hrs;
For serum phosphate 1.0 - 1.5 mg/dL, give 15 mmol
IV x 1 over 2 hours, then 0.32 mmol/kg over 2-3 hours.
For serum phosphate less than 1.0 mg/dL, give 15
mmol IV x 1 over 2 hours, then 0.64 mmol/kg over 4-6
hours.
Hold if CrCl <30 mL/min and notify provider for
phosphate orders
calcium GLUConate 2 g in sodium chloride 0.9%
100 mL bag [800105]
2 g, Intravenous, PRN, calcium replacement - see
Admin Instructions
For ionized serum Ca between 4.38 - 4.89 mg/dL give
2 g x1;
For ionized serum Ca less than 4.38 mg/dL give 2 g
x2
Secretion Management [109202]
atropine 1% ophthalmic soln [34849] 1 drop, Sublingual, EVERY 30 MINUTES PRN,
secretions
Administer sublingually
Symptom Management [114571]
acetaMINOPHEN alcohol free (TYLENOL) oral
suspension [800005]
650 mg, Nasogastric Tube, EVERY 4 HOURS PRN,
pain/fever, for temperature greater than 38.5 degrees
Celsius
albuterol HFA 90 mcg/act inhaler [53730] 8 puff, Inhalation, EVERY 2 HOURS PRN, dyspnea
Or give through ventilator circuit
diphenhydramine (BENADRYL) injection [800106] 50 mg, Intravenous, EVERY 6 HOURS PRN, infusion
reaction during blood administration
Vasopressors [109185]
DOPamine (INTROPIN) 800 mg in dextrose 5%
250 mL infusion [50506]
2-20 mcg/kg/min, Intravenous, CONTINUOUS
Select agent per Donation After Cardiac Death
Vasopressor Algorithm.
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol
Initiate at 2 mcg/kg/min or current rate and titrate to
maintain SBP greater than goal referred to in Notify
Provider order
norepINEPHrine (LEVOPHED) 4 mg in dextrose 5
% 250 mL infusion [700247]
0.01-2 mcg/kg/min, Intravenous, CONTINUOUS
Select agent per Donation After Cardiac Death
Vasopressor Algorithm.
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol
Initiate at 0.01 mcg/kg/min or current rate and titrate to
maintain SBP greater than goal referred to in Notify
Provider order
(SHOCK) vasopressin (PITRESSIN) 20 units in
dextrose 5 % 100 mL infusion [700977]
0.01-0.04 Units/min, Intravenous, CONTINUOUS
Select agent per Donation After Cardiac Death
Vasopressor Algorithm.
Titrate per Intensive Care Vasoactive Continuous
Infusion Titration - Adult Protocol
Initiate at 0.04 units/min or current rate. Do not
increase without MD order. Wean off by 0.01
units/min
Non-categorized [109698]
Page 8 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

methylprednisolone sodium succ. (SOLU-
MEDROL) intraVENOUS [800058]
1,000 mg, Intravenous, EVERY 12 HOURS
Non-categorized [114547]
levothyroxine injection [760146] 20 mcg, Intravenous, ONCE PRN For 1 Doses, Initiate
for SBP < 100 mmHg AND dopamine,
norepinephrine, and vasopressin are maximized
based on vasoactive algorithm. Notify pharmacist
when needed.
Initiate for SBP < 100 mmHg AND dopamine,
norepinephrine, and vasopressin are maximized
based on vasoactive algorithm. Notify pharmacist
when needed.
for 1 Minutes
levothyroxine infusion [700224] 10-80 mcg/hr, Intravenous, CONTINUOUS
Initiate for SBP < 100 mmHg AND dopamine,
norepinephrine, and vasopressin are maximized
based on vasoactive algorithm. Notify pharmacist
when needed.
Neurogenic Pulmonary Edema [200910]
vecuronium (NORCURON) vial [46843] 0.1 mg/kg, Intravenous, ONCE For 1 Doses
Administer for neurogenic pulmonary edema.
Give in combination with, but 10 minutes before
naloxone
naloxone (NARCAN) injection [800199] 8 mg, Intravenous, ONCE For 1 Doses
Administer of neurogenic pulmonary edema.
Give in combination with, but 10 minutes after
vecuronium.
Insulin Infusion
Non-Categorized Patient Care Orders [17936]
Glucose, POC [IPGLUCOSE] SEE COMMENTS, Starting today For 7 Days,
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?
Every hour until within target range of 110-150 mg/dL
for 3 hours (3 readings in a row), then decrease
frequency to every 2 hours. Hourly monitoring must be
resumed if blood glucose deviates from target range.
Glucose, POC [IPGLUCOSE] AS NEEDED FOR SIGNS AND SYMPTOMS OF
HYPOGLYCEMIA, 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?
Page 9 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Glucose, POC [IPGLUCOSE] AFTER PROVIDING HYPOGLYCEMIA TREATMENT,
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?
Per hypoglycemia treatment algorithm Recheck
glucose 15 minutes after providing treatment until
glucose is greater than or equal to 70 mg/dL. If
patient has been critically low (i.e., glucose less than
40 mg/dL), recheck glucose after 1 hour to ensure
glucose remains greater than or equal to 70mg/dL.
After resolution of mild hypoglycemia (i.e., glucose 40-
69 mg/dL), consider rechecking after 1 hour if patient
has signs/symptoms of hypoglycemia or is at risk for a
subsequent hypoglycemic event (e.g., previously
administered insulin still active, altered renal status,
altered mental status, NPO or interrupted nutrition, or
any other condition that increases hypoglycemia risk).
After Priming IV Tubing with Insulin, Waste 20 mL
Insulin Drip to Saturate all IV Tubing Binding Sites
[NURVAD0053]
CONTINUOUS, Starting today
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 or greater than 400 mg/dL.
Contingency Parameters [112155]
Notify Provider - Insulin Infusion [NURCOM0001] Provider to Notify: Provider
Notify based on: Other
Other: Hypoglycemia has not resolved within 30
minutes of Insulin Infusion Algorithm hypoglycemia
treatment orders,Infusion rate is less than 1 unit/hour
with glucose values less than Target Range,ICUs
only: When patient initially meets critieria to move to
columns 7-9,If patient transferring from ICU to
general/IMC care and still requiring high dose columns
7-9
Insulin [109441]
Note: Discontinue all previous insulin orders and
oral hypoglycemic agents [950016]
ONCE For 1 Doses
Note: Discontinue all previous insulin orders and oral
hypoglycemic agents
insulin regular (human) infusion [700217] 0.2-40 Units/hr, Intravenous, CONTINUOUS
Initiate at blood glucose greater than 180 mg/dL.
Administer insulin drip in accordance with Insulin
Infusion Algorithm - Adult
Hypoglycemia Protocol [18806]
Wisconsin Insulin Infusion HIGH dose-Adult-
Practice Protocol (ICU only)
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97441-
en.cckm
Wisconsin Insulin Infusion Standard Dose-Adult
Practice Protocol
URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/delegationpractice-
protocols/practice-protocols/related/name-97442-
en.cckm
Page 10 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

Adult Hypoglycemia Treatment Algorithm URL: https://uconnect.wisc.edu/clinical/cckm-
tools/content/cpg/diabetes-and-
endocrinology/related/name-97511-en.cckm
Initiate Insulin Infusion Algorithm Hypoglycemia
Treatment Orders [NURCOM0022]
CONTINUOUS, Starting today For Until specified
dextrose injection [800233] 12.5-25 g, Intravenous, PRN, per hypoglycemia
treatment algorithm - see Admin Instructions
Use for patients who are unable to eat or swallow
safely or are NPO
For blood glucose greater than 40 mg/dL and less
than 70 mg/dL give 12.5 g;
For blood glucose 40 mg/dL or less give 25 g
glucagon 1 mg injection kit [107799] 1 mg, Subcutaneous, PRN, per hypoglycemia
treatment algorithm - see Admin Instructions
For blood glucose less than 70 mg/dL in patients who
are unable to eat or swallow safely or are NPO AND
who have NO IV access
Laboratory
Draw Now [188501]
TYPE AND SCREEN [HCTS] STAT, Starting today For 1 Occurrences, STAT, 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.
BLOOD GASES [HCBGAS] STAT, Starting today For 1 Occurrences, STAT
If source is OTHER, indicate here:
Indicate FIO2: Per DCD Protocol
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITH DIFFERENTIAL [CBC] STAT, 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?
PROTHROMBIN TIME/INR [PT] STAT, 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?
PTT [PTT] STAT, 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?
ALKALINE PHOSPHATASE [ALKP] STAT, 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?
ALT/SGPT [ALT] STAT, 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?
Page 11 of 18
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Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

AMYLASE [AMYL] STAT, 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?
AST/SGOT [AST] STAT, 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?
BILIRUBIN, DIRECT [DBIL] STAT, 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?
BILIRUBIN, TOTAL [TBIL] STAT, 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?
BUN [BUN] STAT, 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?
CALCIUM, IONIZED [XICAL] 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?
CK, TOTAL [CPK] STAT, 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?
CREATININE [CRET] STAT, 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?
ELECTROLYTES [LYTE] STAT, 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?
GGT [GGT] STAT, 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?
LD, TOTAL [LDH] STAT, 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?
LIPASE [LIPS] STAT, 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?
MAGNESIUM [MAG] STAT, 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?
PROTEIN, TOTAL [TP] STAT, 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?
Page 12 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

TROPONIN [GM2447] STAT, 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?
HEMOGLOBIN A1C [HA1C] STAT, 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?
CULTURE, SPUTUM WITH GRAM STAIN
[HCSPUCS]
ONCE, Starting today For 1 Occurrences, Routine,
For patients with an ET tube or tracheostomy,
quantitative mini-BAL by RT or bronchoscopic BAL are
the preferred methods of specimen collection.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CULTURE, URINE [URC] STAT, Starting tomorrow For 1 Occurrences, Routine
Does patient have an indwelling urinary catheter? Yes
Indication: Renal transplant patient
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
URINALYSIS, NO MICROSCOPY [UACHEM] 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?
CULTURE, BLOOD, BACTERIA/YEAST (2
SITES) [188395]
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT For 1 Occurrences, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent
days are of minimal diagnostic value. Culture
detects bacteria, Candida and Cryptococcus. If
filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
CULTURE, BLOOD, BACTERIA AND YEAST
[GM4045]
STAT For 1 Occurrences, Routine, For optimum
diagnosis of sepsis, sample 3-4 sites only on the first
day of a septic episode. Cultures on subsequent
days are of minimal diagnostic value. Culture
detects bacteria, Candida and Cryptococcus. If
filamentous fungi are suspected see Culture, Blood,
Filamentous Fungi.
Patient's Active Lines:
No Active Lines Found.
If Conditional, What Condition?
Draw Now [127534]
HCG, QUALITATIVE, URINE [UPREG] STAT, 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?
Scheduled [115120]
Page 13 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ALBUMIN [ALB] EVERY 12 HOURS, Starting today For 7 Days,
Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
HEMATOCRIT [HCT] EVERY 6 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
SODIUM [NA] EVERY 6 HOURS For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Draw Daily [129165]
BLOOD GASES [HCBGAS] NEXT AM, Starting today For 7 Days, STAT
Indicate FIO2: Per DCD Protocol
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALKALINE PHOSPHATASE [ALKP] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
ALT/SGPT [ALT] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
AST/SGOT [AST] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, DIRECT [DBIL] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BILIRUBIN, TOTAL [TBIL] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
BUN [BUN] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CALCIUM, IONIZED [XICAL] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CREATININE [CRET] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
GGT [GGT] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Page 14 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

MAGNESIUM [MAG] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
PHOSPHATE [PHOS] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CBC WITHOUT DIFFERENTIAL [HEMO] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
POTASSIUM [K] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CARBON DIOXIDE [CO2] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
CHLORIDE [CL] NEXT AM, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition?
Conditional [115121]
BLOOD GASES [HCBGAS] CONDITIONAL, Starting today For 7 Days, STAT
If source is OTHER, indicate here:
Indicate FIO2: Draw per donor algorithm. For
potential Organ Donation.
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
CBC WITH DIFFERENTIAL [CBC] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
PROTHROMBIN TIME/INR [PT] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
PTT [PTT] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
ALKALINE PHOSPHATASE [ALKP] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
Page 15 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

ALT/SGPT [ALT] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
AMYLASE [AMYL] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
AST/SGOT [AST] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
BILIRUBIN, DIRECT [DBIL] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
BILIRUBIN, TOTAL [TBIL] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
BUN [BUN] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
CALCIUM, IONIZED [XICAL] CONDITIONAL, Starting today For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
CK, TOTAL [CPK] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
CREATININE [CRET] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
ELECTROLYTES [LYTE] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
GLUCOSE [GLU] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
Page 16 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

GGT [GGT] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
LD, TOTAL [LDH] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
LIPASE [LIPS] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
MAGNESIUM [MAG] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
PROTEIN, TOTAL [TP] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
TROPONIN [GM2447] CONDITIONAL, Starting today For 7 Days, STAT
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
CULTURE, URINE [URC] CONDITIONAL, Starting tomorrow For 7 Days,
Routine
Does patient have an indwelling urinary catheter? Yes
Indication: Renal transplant patient
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Per OPO recovery
schedule.
Conditional Labs - Transfusion Reaction [151326]
DIRECT ANTIGLOBULIN TEST, TRANSFUSION
REACTION WORKUP [HCDATR]
CONDITIONAL, Starting today For 7 Days, Routine
If Conditional, What Condition? Transfusion Reaction
ABO AND RH TYPING, TRANSFUSION
REACTION WORKUP [HCGRHR]
CONDITIONAL, Starting today For 7 Days, Routine
If Conditional, What Condition? Transfusion Reaction
HEMOGLOBIN SCREEN, URINE,
TRANSFUSION REACTION WORKUP
[HCBBUS]
CONDITIONAL, Starting today For 7 Days, Routine
If Conditional, What Condition? Transfusion Reaction
Electrolyte Supplementation [103228]
POTASSIUM [K] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement and 4 hours after oral replacement
MAGNESIUM [MAG] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw AM following
completion of infusion
Page 17 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org

PHOSPHATE [PHOS] CONDITIONAL For 7 Days, Routine
If add on test, what should lab do if unable to add test
to previous specimen?
If Conditional, What Condition? Draw 1 hour after IV
replacement
Consults
Consults [186482]
Consult Spiritual Care (Inpatient) [CON0056] ONCE, Routine
Reason for Consult: End of life and organ donation
Pacemaker/ ICD Reprogramming [CARD0015] ONCE, Starting today For 1 Occurrences, Routine,
Consults are performed Monday-Friday 0700-1700.
For after hours, weekends and holidays, contact the
Cardiology Fellow on call. If order is being placed at
The American Center, please page device nurse at
pager 7954. If it is being placed at University Hospital,
please page device nurse at pager 40067.
Reason for consult: Other (Comment (Withdrawing
care, end of life)
Specify programming changes (if needed): Please turn
device off
Type of device: Unknown
Device company: Unknown
Withdrawing care, end of life
Please turn device off
Page 18 of 18
Printed by BENNETT, SARA J [SJB008] at 12/15/2017 7:13:31 AM
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
12/2017CCKM@uwhealth.org