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November 2019

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From:
"Stanley, Jeffrey M" <[log in to unmask]>
Reply To:
UVM Flownet <[log in to unmask]>
Date:
Wed, 13 Nov 2019 23:16:57 +0000
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I worked in an outpatient Vascular Surgery group for about 17 years until last year.  Our surgeons requested that any patient coming in for “new access” have a vein/artery mapping prior to the surgeon seeing the patient.  This makes sense for new patients who have never had dialysis access created in their arms.  However, we encountered many situations where a patient was scheduled for full arterial/venous mapping because they were a new patient to our group, only to find out that they had a prior AVF or AVG placed, sometimes multiple AVF/AVGs placed and they are being referred to the surgeon for revision.  So, what was originally ordered as a bilateral UE mapping turned into a dialysis access duplex.  For this to work well I think some sort of communication or triage with the referring Nephrologist group would be helpful to know exactly why they are referring the patient - is it a patient who needs access for the first time, or a patient with existing arm access that needs evaluated?  We also tried with venous reflux studies but that didn’t work out as well, so we went back to the surgeon evaluating the patient first.  I like the idea of having tests done and results available prior to seeing the surgeon – maybe it would take a PA or NP looking at notes and outside records before deciding as to what test needs to be ordered, as opposed to simply telling a scheduler to schedule vein mapping for every new dialysis patient coming in.

Jeff Stanley
Technical Director, Vascular Lab
Vanderbilt Medical Center
Heart and Vascular Institute


From: UVM Flownet <[log in to unmask]> On Behalf Of Bill Schroedter
Sent: Wednesday, November 13, 2019 12:40 PM
To: [log in to unmask]
Subject: Re: performing US prior to MD consultation

I wholeheartedly agree Nicole – sometimes ya gotta wonder.

But…..I would again argue that confirming a proper indication for the exam prior to its performance is within our Scope of Practice. Therefore, the wrong test should not be done but the proper exam for the indication is, in fact, performed.

Bill

From: UVM Flownet <[log in to unmask]<mailto:[log in to unmask]>> On Behalf Of Nicole Ball
Sent: Wednesday, November 13, 2019 12:26 PM
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Re: performing US prior to MD consultation

In order to skirt around this, our surgeons office has the referring physician order the test at the same time as they put in the referral.  The only problem is that the doc ordering the test sometimes is WAY off base and the wrong test is done.  :(


Nicole Ball, BS, RVT
Technical Director, Vascular Lab
Concord Hospital
250 Pleasant Street
Concord, NH  03301
http://nnevs.org<https://nam05.safelinks.protection.outlook.com/?url=http%3A%2F%2Fnnevs.org&data=02%7C01%7Cjeffrey.m.stanley%40VUMC.ORG%7C80941ac3ea3b44ee039608d76868f57a%7Cef57503014244ed8b83c12c533d879ab%7C0%7C0%7C637092672325807014&sdata=%2BVOVcfBPQbqZjyKug1lIFF0leDZLR79802vFC0ugCIM%3D&reserved=0>

>>> Bill Schroedter <[log in to unmask]<mailto:[log in to unmask]>> 11/13/2019 7:55 AM >>>


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I would argue that the referral to the vascular surgeon does NOT constitute an order for an ultrasound. We all agree the ultrasound is warranted. In fact, many years ago when I was with working with SVU in consultation with CMS and a variety of stakeholders in the Fistula First initiative, all were in agreement that the first step for a patient with ESRD should be a referral to the vascular surgeon AND the ultrasound. By regulation, you do need an order from the physician that has seen and examined the patient. In this case (and also in Ann Marie’s carotid scenario), while the referral and patient course are clear, it would seem inappropriate for the physician to order an exam on a patient they have never seen or have no knowledge of.

Let’s make it no more difficult than it is. It is a simple phone call to the nephrologist and explain that is this instance, it is much more efficient that in addition to the referral for consultation, simply order the mapping. Additionally, a call would likely prove good for business.

Make it a great day everyone!
Bill


William B Schroedter, BS, RVT, RPhS, FSVU
4120 Woodmere Park Blvd
Suite 8B
Venice, Florida 34293
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From: UVM Flownet <[log in to unmask]<mailto:[log in to unmask]>> On Behalf Of Ann Marie Kupinski
Sent: Tuesday, November 12, 2019 8:42 PM
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Re: performing US prior to MD consultation

HI,

I don't have any specific paper that deals with whether the patient sees the doctor first or gets an ultrasound first.  However, I routinely scan patients before they see the surgeon exactly for the example you mention.  These patients are referred to the access surgeon for possible AVF placement.  The only way the surgeon can make that decision is with the ultrasound findings.  If we did it the other way around, the patient would have to see the doc , then get the ultrasound  and then see the doc again.  If I have a patient that questions why they see me first, I explain the info is needed to know completely what options exist for the patient.  They are always ok with that explanation.

Other examples would also work - for instance a patient referred for a bruit.  The carotid ultrasound is performed first and then the doc reads the results to determine if the bruit is from the carotid.  As long as there is an appropriate indication and there is an intent to treat or diagnose the source of a symptom, then I think you are legally ok.  But - I am not a legal expert.

Ann Marie

On Tue, Nov 12, 2019 at 8:16 PM Sandra Urrea <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Hi everyone,

I would like to get your thoughts regarding performing US studies on new patients prior to MD consultation. Let me give an example: The Nephrologist refers  a patient to the Vascular Surgeon for consultation, a vein mapping is performed prior to the visit. Are there any legal implications doing this? I would think the right thing to do would be to have the patient see the doctor first then he/she will order the ultrasound. Shouldn’t be treated any differently than prescribing a medication or ordering a CT or any other test.
And, Is there any article or paper to support this topic?

Thank you in advance for your help.
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