Cardivascular Labratry Scheduling TO BE COMPLETED BY CLINIC PERSONNEL If yu have questins, please cntact CV Scheduling 612-775-3295 1. Obtain required Pre-Prcedure Labs: Basic Metablic Panel, CBC with platelets, liver functin test, INR if n Cumadin (if results will be available in time fr the patient s prcedure). Lipids can be btained if the patient is fasting, therwise test will be btained when they arrive fr their prcedure. 2. Cmplete the Authrizatin fr Disclsure f Health Infrmatin frm t btain medical infrmatin frm ther facilities. Have the patient sign (signature line is at lwer left). *Fund in Patient Flder 3. Fill ut Facsimile Transmittal Sheet s that yu will have the necessary infrmatin when yu call t schedule. 4. Ensure physician cmpletes the MHI at ANW CV lab rders. 5. Ask the patient if they will need transprtatin help. Van Service is available by cntacting 1-800-258-1210. a. Patient will nt be able t drive fr 24-48 hurs after the prcedure b. After the prcedure, the patient must be accmpanied hme in the van by a respnsible adult. 6. After btaining the necessary infrmatin abve, call 612-775-3295 t speak with the CV Scheduler. 7. Cmplete Patient Instructins and review with Patient: a. EPIC users: Utilize smart phrase: mhicvptinstructins fr patient instructins/avs. Insert applicable data fr all *** as well as medicatins t be held. Remve/delete any instructins that d nt apply. (Since yu cmpleted this in EPIC, yu may discard generic Patient Instructins included in printable packet) b. Nn EPIC users: Cmplete Patient Letter/Patient Instructins that is included in printable packet. All blanks need t be filled. Yu may crss ut any instructins that d nt apply. c. Review cmpleted instructins with patient and place in Patient Flder. Review additinal flder inserts, as needed. 8. Fax r scan int Excellian the fllwing infrmatin t CV Scheduling at 612-775-3112: a. Facsimile Transmittal Sheet b. Authrizatin fr Disclsure f Health Infrmatin (must be signed by patient) c. Minneaplis Heart Institute at Abbtt Nrthwestern Hspital Cardivascular Labratry Orders d. Dear Patient Instructins Letter (nly applicable t Nn EPIC sites) 9. If the physician s dictatin is transcribed lcally, call the transcriptinist and request that the transcriptin is perfrmed STAT. If it is transcribed at the Minneaplis Heart Institute, call 612-863-3928 and request that it is perfrmed STAT. a. If the lcal transcriptin is cmpleted n the same day as the clinic visit, please fax t 612-775-3112 b. If dictatin is cmpleted utside f EPIC, please fax t 612-775-3112. 8/23/2017
Patient Label Cardivascular Labratry Orders TO BE COMPLETED BY PHYSICIAN Patient Name: DOB: MRN: Diagnsis: 1. Select prcedure t be perfrmed: Crnary (and bypass graft if present) Angigraphy Oximetry Series/Shunt Study Left Ventriculgram Artic Valvulplasty LVEDP Only Mitral Valvulplasty Pssible Percutaneus Interventin (PCI) ASD/PFO Clsure Bilateral Heart Cath fr Artic Stensis Ascending Artgraphy Bilateral Heart Cath fr Mitral Stensis Cardiac Output Bilateral Heart Cath fr Cnstrictive/Restrictive Disease Mycardial Bipsy Other 2. Other prcedures/cnsults? 3. Special scheduling instructins? (e.g. day r week, MD t perfrm, MD t fllw in hspital, etc.) 4. Des patient have a histry f allergy t idinated cntrast agents? YES NO Pre-medicatin regimen: Prednisne 60 mg night befre prcedure Prednisne 60 mg mrning f prcedure 5. Is the patient diabetic? YES NO If yes, please cntact primary care prvider fr medicatin dsing 6. Des the patient require IV hydratin fr renal prtectin? YES NO 7. Des the patient take Cumadin? YES NO If yes, INR needs t be drawn within 3 days prir t prcedure. If INR is less than 3.0, d nt stp Cumadin. If INR is 3.0 r greater, cntact MHI Triage at 612-863-3900 fr further instructins. 8. Des the patient taking a direct ral anticagulant (DOAC)? YES NO If yes, please reference MHI Periprcedural Anticagulatin Guidelines and instruct patients accrdingly 9. If scheduled fr a crnary angigram, please start daily Aspirin 325 mg if nt already prescribed. 10. Des the patient have an allergy t aspirin? YES NO If yes, patient must be desensitized prir t prcedure. 11. Has the patient had any previus studies (bypass, crnary angigram)? YES NO If yes, date/lcatin: Signature: Scheduling: 612-775-3295 Fax: 612-775-3112 9/8/2017
Page 1 f 2 Minneaplis Heart Institute Periprcedural Oral Anticagulatin Guidelines fr Cath Prcedures (updated 2/10/2017 cntact: emmanuil.brilakis@allina.cm) PROCEDURE ANTICOAGULANT ELECTIVE EMERGENT Right heart catheterizatin Warfarin Can be dne withut stpping warfarin if INR <3.0 Can be dne withut stpping warfarin DOAC* Can be dne withut stpping DOAC Can be dne withut stpping DOAC Left heart catheterizatin (such as crnary angigraphy and PCI) Warfarin Can be dne withut stpping warfarin if INR <3.0 Can be dne withut stpping warfarin DOAC* Stp DOAC befre prcedure (see belw Table) Can be dne withut stpping DOAC CTO PCI, PCI with hemdynamic supprt, Cmplex PCI Warfarin Stp warfarin INR shuld be <1.6** Can be dne withut stpping warfarin DOAC* Stp DOAC befre prcedure (see belw Table) Can be dne withut stpping DOAC Endmycardial bipsy Warfarin Stp warfarin INR shuld be <1.6** Can be dne withut stpping warfarin DOAC* Stp DOAC befre prcedure (see belw Table) Can be dne withut stpping DOAC *DOAC: direct ral anticagulants: dabigatran, rivarxaban, apixaban, edxaban **Bipsy with higher INR will be cnsidered n a case by case basis fr transplant patients after 3 mnths frm transplantatin
Page 2 f 2 Hw lng t stp a DOAC befre a cath prcedure Direct Factr Xa Inhibitrs Days t hld Apixaban (Eliquis) 2 days Edxaban (Savaysa) Creatinine clearance: 50-95 2 days Creatinine clearance: 15-49 3 days Rivarxaban (Xarelt) Creatinine clearance: > 50 2 days Creatinine clearance: 15-49 3 days Direct Thrmbin Factr IIa Inhibitr Days t hld Dabigatran (Pradaxa) Creatinine clearance: >80 2 days Creatinine clearance: 50-79 3 days Creatinine clearance: 30-49 4 days Creatinine clearance: 15-29 5 days Creatinine clearance calculatr: http://www.mdcalc.cm/creatinine-clearance-cckcrft-gault-equatin/ References http://akn.allina.cm/cntent1/grups/patient-care/@akn-pharmacy/dcuments/patient_care_dcuments/243996.pdf http://akn.allina.cm/cntent1/grups/patient-care/@akn-pharmacy/dcuments/patient_care_dcuments/243992.pdf
FACSIMILE TRANSMITTAL SHEET T: ANW Cardivascular Lab Scheduling Fax: (612) 775-3112 Patient Name: Frm: Sender's Phne/Fax: DOB: Allina MR# (if knwn): Primary Phne # Primary MD (PCP): Secndary Phne # Cardilgist: Allergies t Cntrast Dye? Latex? Special Needs: Diabetic, On Cumadin, Renal Insuff, Other: T schedule a patient fr a cardivascular prcedure at Abbtt Nrthwestern Hspital, we request that yu btain the fllwing diagnstic test results and infrmatin. Please fax r scan int Excellian as sn as pssible (24 hurs befre prcedure). Diagnstic Test/Infrmatin Timeframe Date Obtained Scanned in Faxed (Y/N) Excellian (Y/N) Within 14 days f EKG prcedure Within 14 days f Basic Metablic Panel prcedure Within 14 days f CBC with Platelets prcedure Mst recent INR (if n Cumadin ) Obtain if patient Fasting Lipid Prfile is fasting r send values if in last AST (SGOT) / ALT (SGPT) 30 days Signed "Authrizatin fr Disclsure f Health Infrmatin" Please fax ther recent available test results if nt in the Allina System (e.g. ECG, Ech, Stress Test, Cartid U/S) Transcribed H&P, if available 30 days Previus Crnary Angi/Stent & By-pass Surgery? 1. Date Lcatin: City State Hspital 2. Date Lcatin: City State Hspital 3. Date Lcatin: City State Hspital Ntes: 9/8/2017
Payment/C-Insurance Ntice Outpatient Heart Prcedures May Include: Ablatin, Angigraphy, Angiplasty and Stenting, Cardiac Catheterizatin, Implantable Cardiverter Defibrillatr and Pacemaker Insertins After yur heart prcedure, yur dctr may want yu t stay in the hspital vernight fr care. This care is knwn as Outpatient Services. Allina Hspitals are required by the gvernment and insurance cmpanies t assign patients t the apprpriate billing level. Patient billing levels include Inpatient and Outpatient. Yur billing level is imprtant fr yur insurance cverage. Insurance plans may have different cverage levels fr bservatin and Outpatient Services. Questins & Answers: Will this affect the care I receive frm the hspital? N. Yur health care team will give yu the same care regardless f yur billing level. Will my insurance cver an Outpatient Service? If Medicare is yur main insurance, Outpatient Services are cvered under Medicare Part B. Each insurance plan has its wn payment requirements fr Outpatient Services. Will I have t pay fr sme f my care? Yu may have ut-f-pcket fees (such as cpays, deductibles, and medicine charges) regardless f yur insurance plan If yu have general questins regarding Medicare yu can call 1-800-Medicare (1-800-633-4227) If yu have questins regarding yur private r supplemental insurance please call the insurance cmpany If yu have any ther questins related t payment/c-insurance, call patient financial services at 612-863-4385 9/28/2017
Dear Patient: This cnfirms yur prcedure scheduled n at Abbtt Nrthwestern Hspital. Check-in at the Heart Hspital registratin desk at am/pm, lcated within the clinic s Family Care Center, n the 2 nd flr f the Heart Hspital, ff the skyway (next t the Skyway Café). Yu will be directed t the CV Prep and Recvery area n the 3 rd flr t be prepped fr the prcedure. D nt eat any slid fds after am/pm. (8 hurs prir) Slid fds include light meals such as tast and atmeal, liquids with dairy prducts, ygurt, juice with pulp and candy shuld be held fr 8 hurs prir t yur arrival time. Yu may drink clear fluids until am/pm. (2 hurs prir) Clear fluids include water, black cffee, clear hard candies and chewing gum. Clear fluids are k until 2 hurs prir t yur arrival time. D nt drink alchl. Yu may take yur medicatins with a sip f water. If yu chew tbacc, stp 6 hurs prir t yur arrival time. In preparatin f yur prcedure: Arrange t have a respnsible adult drive yu t and frm yur prcedure. This persn will need t stay with yu fr 24 hurs after yur prcedure. Drink 4-6 eight unce glasses f water the day befre yur prcedure t help prtect yur kidneys. If yu take Cumadin, have yur INR check with yur lcal MD 3 days prir t yur prcedure. If yur INR is 3.0 r higher, call fr instructins. 612-863-3900. If yur INR is less than 3.0, DO NOT stp taking yur Cumadin. If yu take medicine t prevent bld clts, such as Pradaxa, Eliquis, Xarelt r Savaysa, fllw physician instructins abut when t stp prir t yur prcedure. Current Medicatin: Stp taking medicatin days prir t prcedure Nt Applicable
Take 1 full strength Aspirin (325 mg) the mrning f yur prcedure. If yu are allergic t Aspirin, please ntify yur cardilgy prvider immediately. Yur prcedure may need t be rescheduled after desensitizatin. 612-863-3900. If yu have a histry f a reactin t cntrast dye, yu will need t be pretreated prir t arriving. Please cntact yur cardilgy prvider fr a prescribed treatment. Yur prcedure may be cancelled if yu are nt treated prir t arrival. If yu are diabetic, d nt take any ral diabetic pills the mrning f yur prcedure. If yu take insulin, nn-insulin injectable medicines r bth, please cntact yur primary prvider wh manages yur diabetes fr instructins befre yur prcedure. D nt take the fllwing medicatins the mrning f yur prcedure: D nt use medicines fr erectile dysfunctin fr 2 days prir t prcedure. If yu take Revati t treat high bld pressure, yu may cntinue taking this medicine. Yu may take yur ther mrning medicatins with a sip f water. Cmplete the Admissin Questinnaire and bring it with yu n the day f yur prcedure t expedite yur admissin prcess. Yu have been given a scheduled arrival time, but we ask yu t understand that there may be delays prir t the start f yur prcedure. Please plan t spend yur day with us. It is a gd idea t bring a gd bk, newspaper, laptp, ipd, ipad, r deck f cards t pass the time. If yu have any questins, please cntact the Minneaplis Heart Institute Triage nurse at 612-863-3900. Best Regards, Minneaplis Heart Institute Interventinal Cardilgy Abbtt Nrthwestern Hspital