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Five Rivers Vascular Network
Operational Policy
Introduction
With the drive by the Vascular Society of Great Britain and Ireland (VSGBI) to
halve the elective mortality rate for Abdominal Aortic Aneurysm (AAA) surgery
by 2013, the framework for improvement of quality for elective AAA repair
recommended that hospitals undertaking fewer than 100 elective AAA
interventions in a three year period should not continue to offer these
procedures.
The Ipswich and Colchester hospitals have worked together successfully since
April 2007 to provide an emergency (unplanned) vascular surgery service to
people living in the areas of east Suffolk, north east Essex and the Colne
Valley, serving a population overall in excess of 700,000
Subsequently, to achieve optimal surgical outcomes, all major arterial and all
emergency vascular surgery was centralised to the Colchester Hospital
University Foundation Trust (CHUFT) site as from July 2012. An Abdominal
Aortic Aneurysm (AAA) screening service was also set up in April 2012 as part
of the National AAA Screening Programme to incorporate North East Essex,
East Suffolk and parts of Mid Essex in the Colne Valley.
Following the review by the Royal College of Surgeons in June 2014 a number
of recommendations and changes in service provision have been made.
These have been included in this operational policy and are denoted as (RCS)
Patient Cohorts
All major arterial surgery is undertaken at the Colchester Hospital site. This
includes:
AAA Surgery (Open, Laparoscopic, and EVAR’s)
Carotid surgery
Arterial surgical procedures.
All emergency vascular referrals from IHT site will be treated and transferred for
definitive treatment at CGH site.
In addition a staged move of interventional radiology from IHT to the CGH site is
planned as capacity is developed ( RCS ).
The Vascular team
Mr Adam Howard is the Clinical Lead for Vascular Network and is responsible
for the clinical organization and governance of the service, with reporting
relationships to the clinical management in both trusts. The Network has a
fulltime service manager, Mrs R Burt who has day to day management
responsibility for working with the clinical lead in the organisation of the service
Vascular network operational policy December 2014 V1 AH/JB
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and the development of future plans.
Mr S Choksy is the Director of the AAA Screening programme and Mr A
Assar the MDT convenor.
Consultant Vascular Surgeons
The 6 Vascular Surgeons are partnered in two teams of three
consultants to provide optimal cross-cover as follows:
Abdusalam Abu-Own, Chris Backhouse and Sohail Choksy
Adam Howard, Isam Osman and Ahmed Assar
As far as practicable the teams provide cover for fixed hybrid theatre. If
sessions cannot be covered in this way the other team will be involved in
using the lists. Annual and study leave will be booked in accordance with
the leave policy and notified to the vascular service manager for coordination a minimum of 6 weeks in advance. Cover for emergencies and
at the two sites is as follows:
Vascular Surgeon on-call (VSOC)
The Vascular Surgeon on call will be based at CGH between 8.00am and
6.00pm Monday to Friday and weekend day mornings for ward rounds. The
VSOC will manage all aspects of the emergency vascular service at both sites
(RCS). The oncall team (consultant and SpR) will be available for emergency
opinion (telephone or in person) for any emergency within 30 minutes. All six
surgeons contribute equally to the VSOC rota.
Vascular Surgeon for the wards (VSW) at IHT site
At the Ipswich site there will be a presence from one of the vascular
consultants or middle grade (VSW) on site during most sessions 9am-5pm
Monday to Friday. They can be contacted via switchboard rota.
The VSW should be contacted for urgent and elective referralsemergencies should be triaged via the VSOC as above.
Occasionally surgeons in other specialties undertaking otherwise routine
elective and emergency procedures require the assistance of a vascular
surgeon to address extreme bleeding problems .In the event of a vascular
emergency presenting at IHT site (e.g. uncontrolled bleed in theatre) then the
VSW surgeon will respond whilst the VSOC is contacted.
Conversely,if the VSW is not available for non-emergency cases the VSOC will
be contacted. Generally the historically IHT based surgeons have provided the
majority of this cover however a schedule for rotation of all surgeons to the IHT
is under development and will be commenced in January 2015.(RCS)
A summary rota for the vascular teams across the network including VSOC
and VSW is held by switchboard at both IHT and CHUFT sites.
Vascular Anaesthetists
Scheduled lists in the Hybrid theatre are normally be covered by
experienced vascular anaesthetists drawn from the CGH and IHT
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anaesthetic departments as follows:
Colchester:
Ipswich:
Peter Patient, Simon McKenzie, Tamas Malaj
Ian Driver, Prakesh Bhagwat
In addition to theatre sessions the vascular anaesthetic team attends
vascular MDT on a rotating basis and undertake pre-operative
assessments on high risk patients.
Vascular Interventional Radiology
There are six Consultant Vascular Interventional Radiologists who provide
a 1:6 rota for emergency vascular radiology cover, four of whom undertake
EVARs and attend the MDT meetings.
Colchester:
Ipswich:
Arun Sebastian, Nagendra Thayur, Mohammed Al-Dabbagh
Gary Picken, Avi Basu, Patrick Whitear
The vascular interventional radiology service includes all aspects of
emergency and elective interventional radiology that relates to the treatment
of vascular conditions. This includes provision of a 24hr on call radiology
nurse to support the Consultant Radiologist rota.
The guidance from the BSR states that elective IR, non-EVARs and noncombined procedures could stay in the local hospital. However, all high
risk cases will be discussed by the MDT and a decision made by the MDT
on the appropriateness of undertaking the procedure on the nonemergency site
In addition all interventional radiology procedures arising from
emergency admissions will be undertaken at CGH. Any planned high
risk procedure at IHT site have an available VSW for support.(RCS)
with a plan to centralize all such procedures as capacity increases at
the CGH site.
Junior Medical staffing
Junior medical staff training is undertaken across the network. A hybrid middle
grade rota commenced in December 2014 which ensures dedicated middle
grade cover for vascular emergencies at the CGH site with support from the
general surgical rota with a view to fully dedicated rota being developed in
2015.
Nursing support and Clinical Nurse Specialist
The vascular ward at CGH site has developed a strong cohort of nursing staff
with specialist skills in caring for vascular patients. Both sites have support from
clinical nurse specialists who provide five main domains of specialist practice,
namely patient care, information, education research and management.
They possess advanced knowledge and skills in the field of vascular
surgery including advanced communication skills and provide a pivotal role
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in the team.
Specialist Podiatrist
There are specialist vascular podiatrists at both sites who also contribute
to the diabetes MDT work.
Multi-Disciplinary Team Arrangements
Key decisions on the planning and optimisation of patient care for all major
elective cases will be made within the framework of a structured
Multidisciplinary Team (MDT).
The MDT comprises:
Consultant Vascular Surgeons
Consultant Interventional Vascular Radiologists
Vascular Clinical Nurse Specialists
Consultant Anaesthetist
Vascular Admissions Officer
Attendance at MDT is not discretionary for surgeons or the radiologists
who perform EVAR procedures. One Anaesthetist will normally attend all
MDT meetings.
The group will meet every Wednesday afternoon from 14.00hrs to
17.00hrs. Meetings will utilise teleconferencing facilities in the Colchester
Telemedicine room, linked with the diagnostic telemedicine room at IHT.
Meetings will be chaired by a MDT lead consultant and supported by the
Vascular MDT Co-ordinator.
The schedule of required information for each case under review at the MDT
is included at Appendix 4.
Decisions of the MDT on individual patient treatments will be recorded in
the patient notes and in a formal record of each meeting.
Patient Pathways
The principle routes into the service
are: Elective Pathway:
GP referral
Ward referral
Clinic referral
referral via the AAA screening Programme
tertiary referrals: nationally for laparoscopic vascular surgery and thoracic
outlet compression syndrome
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Elective patients
There is an integrated referral pathway across the network where referrals are
received from different sources at both sites. Urgent cases are pooled via the MDT to
allow optimal treatment times.
All elective patients for vascular surgery and interventional radiology are discussed in
the MDT and are treated in accordance with the 18 week pathway across the network.
(RCS)
GP Outpatient Referral
Primary care referrals for patients requiring a vascular specialist opinion will
be made to the contact centre at CHUFT or the call centre at Ipswich Hospital
Trust (IHT). Referrals are prioritised as appropriate from information in the GP
communication and assigned to a Consultant and a clinic appointment.
Screening Programme referral
Patients identified from the screening programme with abnormal aortic features
will be referred to the next available consultant outpatient slot. Essex residents
will normally be given CHUFT appointments; Suffolk residents will normally be
given IHT appointments. The referral should be made by the co-ordinator within
one working day of the screening clinic, with a referral letter being sent directly to
the secretary of the vascular surgeon. Mr Choksy director of AAA screening
ensures an equal rotation of AAA referrals to each consultant.
All referrals should be seen in vascular outpatients within two weeks of the
referral. If the AAA has a diameter of over 7.5cm, an urgent referral should
be made with a view of seeing the patient at the next available outpatient
clinic- which will be within 2 weeks, followed by urgent risk assessment and
discussion at the MDT.
Patients from the screening programme will follow a common elective pathway as
those from GP referral once in the outpatient assessment pathway.
Outpatient Appointment
The first outpatient appointment will be held wherever possible at the patient’s
local hospital unless urgency of the situation dictates otherwise.
Patient assessment within the outpatient department will follow an agreed
vascular assessment pathway and use common documentation.
(Appendix 2)
Diagnostics
Patients who are being investigated for major arterial conditions will be subject to
an agreed selection of diagnostics as outlined in the pathway documentation.
(Appendix 2)
All diagnostic testing other than CPEX will be carried out at the patient’s local
hospital.
Patient requires major arterial surgery
Patients will be added to the waiting list following their outpatient appointment
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and/or following discussion at MDT.
All major arterial surgery patient treatment plans will be reviewed by the
weekly MDT.
Following the MDT the patient will formally transfer to CHUFT clinical
administration system.
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The Vascular Admissions Officer/ MDT coordinator will then work with the
consultant concerned to ensure that the administration of the next stages of the
patient’s care is planned and communicated to all parties appropriately.
Following the MDT review any IHT patient will be added to the CHUFT IP waiting
list; their Referral to Treatment pathway will continue from the initial referral point.
The vascular admissions officer will agree the date for surgery with the respective
consultants, and organise a pre-operative assessment appointment.
3.1.6 Anaesthetic Risk Assessment
Some patients will require an extensive pre-operative anaesthetic assessment.
This will be organised at the discretion of the surgeon in charge of the case. This
will be undertaken on the local hospital site and be arranged in accordance with
the agreed documentation and assessment procedures as shown in Appendix 3
3.1.7 Pre-Operative Assessment
The pre-operative assessment (POA) will be carried out at either site, though
where possible in the POA suite in the Elective care centre (ECC) at CHUFT for all
major arterial surgical cases.
POA will routinely be conducted by the POA nurses, with anaesthetic input for
patients that require this. All major vascular cases will reviewed by a Consultant
Anaeasthetist in this clinic at both sites.(RCS)
All cardio pulmonary exercise testing, (CPEX) will be carried out at CHUFT for
patients requiring this such as all AAA patients.
3.1.8 Admission
Patients, where possible, subject to clinical suitability, will be admitted on the
day of surgery via the Elective Care Centre at CHUFT. Major cases will be
admitted and managed on Wivenhoe ward, the designated vascular surgical
ward at an agreed time prior to surgery.
The ward is divided to provide clean bays and side rooms rather than separating
elective and non- elective cases to maintain good infection control practices, whilst
maintaining same sex accommodation. Only clean non-vascular patients should
be admitted onto the ward in the event of unused bed base .In 2015 refurbishment
of the ward is planned with production of 4 bedded bays an improved shower/toilet
facilities. ( RCS)
There may be exceptions to this, for example, stroke patients who will go to
theatre from the stroke unit and be managed post operatively on Wivenhoe
ward.
On the IHT site complex medical patients with vascular problems under the
care of medical teams will be reviewed by the VSW team regularly. It is
important to note that at both sites a minority of patients cared for by vascular
consultant team will have general surgical problems or undergoing
rehabilitation (RCS)
3.1.9 Theatre Scheduling
Following MDT review the patient will be booked on the theatre web system by
the vascular booking clerk who will have access to the theatre session
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timetabling in line with the patient access policy.
Any list changes should be entered on to the theatre web by the booking clerk as
they occur and wherever possible by 12:00 noon the day prior to the session as
per the CHUFT ‘Operating List Booking Procedure’ (Policy 283).
If a surgeon is unable to undertake a planned operating session the vascular
speciality should make every effort to cover the session internally.
When a session reallocation within the speciality is not possible, the Main
Theatre receptionist or deputy who attends the weekly rota meeting will have the
opportunity to offer any available sessions to alternative specialities up until the
two-week cut off point.
Emergency patient pathway
Emergency Pathway:
Referral via Emergency department (ED ‘Blue Light’) or Emergency
Assessment Units (EAU GP referred)
Ward Reviews and internal transfers- Assessment units,
Management and Transfer of emergency patients between sites ( RCS) is
outlined in the following guidance including bypass criteria:

Standard Operating Procedure: Five Rivers Vascular Network
Obtaining timely advice and intervention for emergency and urgent vascular
cases at IHT Emergency Department: IHT Inpatients, Intraoperative
emergencies, Ward and OPD emergencies
 Ambulance Protocol for the Conveyance of Vascular Emergencies
East of England Ambulance Service and Five Rivers Vascular Network
 East Suffolk vascular (AAA) pathway- primary divert (Ipswich Hospital)
Flowcharts showing the core pathway elements are attached.(Appendix 1b).
Emergencies to the vascular service may also arise from other hospital services at
CHUFT and IHT, including:
Stroke patients requiring revascularisation procedures
Diabetic patients requiring revascularisation
procedures/amputations
Patients on general wards requiring vascular management e.g.
revascularisation, ulcer management, etc.
Intraoperative surgical cases requiring urgent specialist vascular support in
theatre
The network has set new standards for management of emergency patients to ensure
timely transfer to definitive treatment ( RCS).
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Emergency cases such as ruptured AAA should reach theatres in 90 minutes of ED
referral and ischemic limbs that require surgery should reach theatre within 6 hours of
ED referral.
Cases requiring immediate (life/limb saving) Surgical Intervention
Cases requiring emergency immediate surgery will normally be admitted through
the CGH A&E services, reviewed by the Vascular Surgeon, and routed via
diagnostic CT to the operating theatre using the CEPOD list (In hours, M-F 9-5)
or the emergency theatre team (at other times).
It may, in some cases, require the Vascular Theatre to be opened for these cases
if the fixed angiography equipment (C-arm) is to be used in treatment (e.g.
emergency EVARs)
For emergency patients it is the responsibility of the vascular consultant on call to
ensure that the patient details are entered onto theatre web prior to the patient
leaving the operating theatre.
Cases that require urgent treatment
Lists in the Vascular Theatre on Wednesdays (9 to 5) will be available for all
urgent cases (e.g. CEAs, amputations, debridement, etc.). Otherwise cases will
be allocated to available capacity on planned vascular lists or use the CEPOD list
dependent on clinical need.
Multiple trauma
The VSOC will be required to support multiple trauma cases, involving vascular
damage at both CGH and IH. During Monday to Friday 8-6pm first line major
trauma support at IH will be available via the IH Based VSW on site (see 3.2.1.2
above)
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Critical care and extended recovery
There is provision for 13 critical care beds at CHUFT in addition to a 24 hour theatre
recovery, to support further high dependency care
Medical management on critical care unit
Medical management within critical care is led by the Critical Care team
(intensivists and anaesthetists),with the parent team (and other teams) being
consulted when needed. The admission and discharge of patients is decided by
the CC team in liaison with the parent team.
Post-operative patient pathways
Model patient pathways and documentation has been agreed for use with all
vascular ward patients. Details are included in Appendix 5.
Repatriation
A repatriation protocol has been developed to support the Network and has been
agreed between the trusts.
The protocol is designed to operate when a Suffolk domiciled patient is surgically
fit to leave the vascular unit at CGH but requires some element of on-going
medical management, which can be given in a setting closer to their home family
and friends.
The decision to repatriate will be taken by the patient’s consultant.
Therapy and rehabilitation services
Patients will receive general physiotherapy as inpatients as required. Patients
repatriated back to Ipswich hospital will require a discharge handover report.
Patients who are discharged home out of area will be referred to Suffolk PCT for
further rehab if required.
Amputees are currently referred to CGH for prosthetic rehab if they are within
NEEPCT. Suffolk PCT have a contract with Norfolk and Norwich for prosthetic
care so these patients will need to be referred there on discharge.
Diabetic Foot service
The diabetic foot service at both sites is NICE complaint.
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Outpatients with intermittent claudication are assessed by the vascular
consultants or CNS. Those deemed suitable for the exercise class attend twice
weekly for 8 weeks and are then reassessed.
Discharge management
Patients will be discharged from Colchester and IHT will receive a copy of their
discharge letter and appropriate medications, plus a discharge information leaflet
and will be asked to complete the electronic patient discharge questionnaire
survey.
Outpatient and telephone follow up arrangements
Patients will be followed up at the hospital OPD nearest their home. For patients
who have had an AAA repair they will also receive a telephone follow up from
their consultant or designated substitute three to four days following discharge
from hospital. The telephone contact will be documents using the pathway
template (Appendix 6)
When patients are transferred between sites, either for surgery or repatriation
purposes, the vascular health records and discharge summary will be copied in
their entirety and sent to the receiving hospital either via a secure fax or a
contract taxi will need to be booked through the service desk.
Discharge summaries are sent electronically to the GP. A further copy is
given to the patient and a copy is retained in the patient notes and a copy
faxed to IHT hospital for uploading onto the evolve electronic health record
system.
Network Governance and Audit
Vascular Services are managed within the Surgical Division at CHUFT. The
centralised services referred to in this policy will form part of the overall
responsibility of that division under the leadership of the Associate Director and
Divisional Director working in close conjunction with the Director of Surgery at
the IHT site. The Clinical Lead co-ordinates governance issues relating to
vascular services across the network and reports to the Surgical Divisional
Governance meeting.
All vascular staff can report incidents via the CHUFT DATIX system and
incidents from IHT site are reported at the governance meeting. All consultants
are encouraged to become incident investigators and undertake Serious
Incident investigation training. All deaths are to be reported on the DATIX
system for tracking purposes.
All staff are expected to be up-to-date with mandatory training.
Key Quality performance indicators have been developed and incorporated
into a dashboard to monitor service provision across the network and are
reviewed at the service governance meetings along with other relevant action
plans.
There are monthly governance meetings which cover various areas e.g. risk,
incidents, complaints.
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Whilst clinically the vascular service is substantially separated from general
surgery, junior medical staffing arrangements will require continued close liaison
with the colorectal and GI service clinical teams at both CGH and IH
AAA Screening Programme
Separate standard operating procedures exist for the AAA screening programme,
which complies with the NAAASP requirements and are in operation.
Audit
Morbidity and mortality audits are undertaken monthly and there is also a
quarterly combined audit meeting with the critical care team at CHUFT. An
annual audit plan has been agreed.
National Vascular Database
All patients undergoing reference procedure surgery will be reported to the
National vascular database.
The vascular surgical team (consultants, middle grade and nurse specialists)
are responsible for inputting data following the patient’s surgery. Any
complications that may occur are updated and the information is submitted
once the patient has been discharged. Follow up data is completed after
outpatient follow up assessment.
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15 Patient Experience
Patient communication leaflets have been developed to assist patients with
their pathway through treatment. Whilst patients are in hospital on the
vascular ward they are provided with a .patient discharge leaflet, their
discharge summary and appropriate advice. Patient are asked to complete
an electronic patient discharge questionnaire survey to audit patient
satisfaction and feedback on care.
16 Financial Arrangements
Agreement has been reached between CHUFT and IHT in relation to the
management of income and expenditure arising from the service model.
Income will accrue to the site on which the activity takes place.
The service model requires consultants and other staff to cover services at both
sites. Arrangements will be made and reviewed annually between the trusts for
payment for services rendered at the non-employing hospital site
APPENDIX
1a Model elective patient pathway flow chart for elective admission
1b Model emergency patient pathway flow chart for emergency admission
2a Patient pathway document for outpatient department assessment
2b Patient pathway document for outpatient AAA safe intervention outpatient
3
Patient pathway document for vascular pre-admission clinic assessment
4a Patient pathway document for vascular MDT assessment for AAA/limb
intervention/other
4b Patient pathway document for vascular MDT assessment for Carotids
5 Patient pathway document for vascular post-operative patient document
6 Patient pathway document for AAA telephone follow up
7 Vascular surgeons, anaesthetists and hybrid theatre timetable
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Appendix 1a Model elective patient pathway flow chart for elective
admission
AAA SCREENING
ABNORMALITY
IDENTIFIED
GP REFERRAL
CGH
IHT
ESSEX
RESIDENT
IHT OPD 1st
APPOINTMENT
CGH OPD 1st
APPOINTMENT
IHT
DIAGNOSTICS
CGH
DIAGNOSTICS
OPD REVIEW
CONSIDERING
SURGERY
SUFFOLK
RESIDENT
OPD REVIEW
CONSIDERING
SURGERY
REFER TO MDT
MDT DISCUSSION/
AGREEMENT ON
MANAGEMENT
NON-SURGICAL
MANAGEMENT
BY LOCAL
SERVICE
SURGICAL
MANAGEMENT
VIA CGH
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Appendix 1b Model emergency patient pathway flow chart for emergency admission
NORTH EAST ESSEX RESIDENTS
EAST SUFFOLK RESIDENTS
EoEAS diagnosed
vascular case
Urgent
Vascular Clinic
Referral
CGH Ward
referral
CGH GP
Referred via
EAU
CGH A&E
presentation
IHT A&E
presentation
IHT GP
Referred via
EAU
Review by VSOC
Review by VSOC
Review by GS Reg
and/or VSOC
Review by A&E
Consultant then GS
Reg and VSOC
Review by A&E
Consultant
Review by GS Reg
discuss with VSOC
Stabilise
Diagnostics
Accept referral
as vascular case
Remain
with
physicians
NO Accept referral
as vascular case
IHT Ward
referral
Review by VSW on
site
Arrange transfer to
CGH if needed
YES
NO
YES
Stabilise
Diagnostics
Stabilise
Diagnostics
CGH SAU hold –
waiting for bed or
prepare for theatre
CGH A&E hold –
waiting for bed or
prepare for theatre
Ward Admission
under VSOC
Straight to Theatre
under VSOC
(CEPOD List)
EoEAS transfer
to CGH
Remain with IHT
physicians
Urgent theatre
or
Radiology
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2a Patient pathway document for outpatient department assessment
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Reference
WOE1334
Issue date
May 2012
a
Vascular (Arterial) Outpatient Clinic
Hospital/NHS number
Consultant
Patient label
Patients name
OPCS code
Presenting complaint
Allergies & Intolerances
Current vascular symptoms, complaints & history
Duration
Left
Right
Bilateral
Past Endovascular / vascular surgery & interventions
Year
Previous anaesthetic problems?  No
 Yes – specify:
Vascular risk factors / conditions
 Smoker per day for
years
 Diabetes
 Hypertension
 CABG – coronary stent - date:
/
/
Type:
 Hypercholesterolemia
 CCF / LVF - SOB on exercise: distance:
 Rheumatic fever
 Renal failure / disease – creatinine:
 DVT / PE
 Clotting disorder
 Venous skin changes
 Malignancy:
() boxes that apply
 Ex-smoker - Given up for:
years/months
 PVD / claudication – distance:
yards / miles
 MI / Angina
 Valve replacement – mechanical? Yes  No
 Stroke / TIA / Am. Fugax – date:
/
/
 Family history AAA dx
 Pacemaker
 AF / Arrhythmia – Warfarin?
 Yes  No
 Varicose veins
 Venous ulcer
Vascular Outpatient Clinic
 Limb claudication - claudication distance:
yards/miles
 Leg or foot ulcers or tissue loss/gangrene
 Rest pain, toes / feet
 Night pain, toes / feet relieved by dependency
 Aortic Aneurysm (see details overleaf)
 TIA / CVA / Amaurosis Fugax / Asymptomatic Carotid Disease
 Popliteal Aneurysm
 Arm claudication/Raynaud’s
 Varicose veins (delete) – pain / skin changes / ulcer
Others/details:
 Duodenal / gastric ulcer
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Medications
Cerebrovascular diagnosis
()
Dysphasia/other
Symptomatic side
Date
TIA’s (Anterior / Posterior)
CVA
Amaurosis Fugax
Vertebral disease
CEA or Carotid stent
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Record patient name & ID if photocopying this page:
Aneurysmal disease
IAAA / JAAA / SAAA / TAAA?
 No  Yes – date:
AAA surveillance?
 No  Yes – date:
/
/
date:
/
/
 No  Yes – date:
/
/
Diameter (cm) on Duplex / CT:
Open operation / EVAR?
/
/
Arterial complications:
Vascular Outpatient Clinic
Clinical examination
Peripheral pulses / venous disease & tissue loss
Draw location of arterial or venous ulcers /
amputations
Recent or clinic ABPI’s / Admission ABPI’s / or
toe pressure (date
/
/
):
Right =
Carotid bruit: Right =
Left =
Left =
Right
Left
Ulcers (arterial/venous)
Rest pain
Gangrene
Buerger’s (+/-)
Right
Left
Right
Left
Management plan & further action
()
Aspirin
Clopidogrel
Warfarin
Statin
Assasantin
Dipyrimadole/
Persantin
Vocal cord
check (carotid
surgery)
Other:
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Print name / designation
Signature
Grade
Date
/
Vascular network operational policy December 2014 V1 AH/JB
/
Page 20
2b Patient pathway document for outpatient AAA safe intervention
outpatient
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Reference
WOE1333
Issue date
May 2012
b
AAA Safe for intervention
Outpatient checklist
Please complete this checklist in the op clinic.
Patient details
Consultant
Patient label
Patients name
Date of birth
Pre-admission date
/
/
/
/
Age
Procedure date
/
/
AAA Safe for intervention checklist
Questions
Y N
Has the patient had a myocardial infarct or unstable angina/ angina at rest in the last 3
months?
Has the patient had new onset of angina in the last 3 months?
Does the patient have a history of poorly controlled heart failure?
(nocturnal dyspnoea or inability to climb one flight of stairs due to SOB)
Does the patient have severe or symptomatic cardiac valve disease? (e.g. Aortic stenosis with
gradient >60mmHg or requiring valve replacement, drop attacks)
Does the patient have significant arrhythmia? (Symptomatic, ventricular, severe
bradyarrhythmias or uncontrolled supraventricular tachycardia)
If available, does the patient have any of:1. FEV1 < 1.0 L or <80% of predicted value ; 2. PO2 < 8.0 kPa; 3. PCO2 > 6.5 kPa
If the answer to any of 1 – 6 is yes, the patient is coded RED and is very high risk for surgery.
Questions
Y N
Does the patient get SOBOE climbing one flight of stairs? (short slope if lives on one floor)
Does the patient have evidence of moderate renal impairment (Creatinine >180 micromol/l) or
previous renal transplant?
Has the patient had treatment for cancer in last 6 months, or has life threatening tumour?
Does the patient have poorly controlled diabetes mellitus?
(HbAlc > 7.5%, blood sugar usually >10 mmol/l)
Does the patient have uncontrolled hypertension (i.e. SBP >190; DBP >105)
Has the patient had a TIA or CVA within the last 6 months?
If the answer to any of 7-12 is yes, the patient is coded AMBER and is higher risk for
intervention.
Questions
Y N
If the answers to all of the above are no, the patient is coded GREEN and is fit to proceed,
provided they are on appropriate preoperative medication
Other Risk Factors
Other risk factors that increase the risk (amber) or preclude (red) repair (circle): Yes / No
(e.g. dementia, cancer, stoma, adhesions - specify if yes):………………………………..
Patient is coded:  Proposed Action:
Not recommended for immediate intervention – Specialist review required if
Red
surgical treatment still to be considered.
Amber
Significant comorbidity requiring preoperative optimisation.
Green
Fit to proceed to further stage of formal assessment
Vascular network operational policy December 2014 V1 AH/JB
Vascular AAA Safe for intervention checklist
Hospital/NHS number
Page 22
N.B. It is recommended that all patients scoring red or amber should be reviewed by an
Anaesthetist with experience in Vascular anaesthesia prior to listing for intervention.
Print name / Designation
Signature
Grade
Date
/
Vascular network operational policy December 2014 V1 AH/JB
/
Page 23
3
Patient pathway document for vascular pre-admission clinic
Vascular network operational policy December 2014 V1 AH/JB
Page 24
Reference
WOE1337
Issue date
May 2012

Vascular Elective Pre-admission Clinic
Please complete this checklist and write additional details or a traditional clerking in the patient's hospital notes.
Patient details
Hospital/NHS number
Consultant
Patient label
Patients name
/
Planned procedure





Dates - Pre-admission
1.
2.
3.
4.
5.
/
/
Age
OPSC code
Open / Laparoscopic AAA / Endoleak repair
EVAR
Carotid Endarterectomy
Bypass procedure:
L R
Other:
/
TCI
/
Clerking doctor
/
Procedure
/
/
Nurse
Allergies & intolerances
Latex sensitivity?
 No  Yes – theatre notified (if required) 
MRSA status
Risk factors / conditions () boxes that apply
Cardiovascular
Venous
 Smoker per day for
years
 Ex-smoker - Given up for
years/months
 Diabetes
 PVD / claudication – distance:
yards / miles
 Hypertension
 MI / Angina
 CABG –
date:
/
/
 Valve replacement – mechanical?
 Yes  No
 Hypercholesterolemia
 Stroke / TIA / Am. Fugax– date:
/
/
 CCF / LVF - SOB on exercise: distance:
 Family history AAA dx
 Rheumatic fever
 Pacemaker
 Renal failure / disease – creatinine:
 AF / Arrhythmia – Warfarin?
 Yes  No
General
 DVT / PE
 Clotting disorder
 Varicose veins
 Venous ulcer
 Venous skin changes
 Malignancy:
 Alcohol:
units per week
 Epilepsy
 Chronic back pain
 Duodenal / gastric ulcer
 Hiatus hernia
 Gastritis / oesophagitis
 Jaundice
 Hepatitis
 Sickle Cell
 Hyper/hypo thyroidism
 Asthma / COPD / TB
 Erectile dysfunction
 Learning disabilities
Current medication
Drug
Dose
Frequency
Vascular network operational policy December 2014 V1 AH/JB
Drug
Dose
Vascular Elective Pre-admission Clinic
Date of birth
Frequency
Page 25
Drug allergies:
Medication to stop pre-operation:  Warfarin  OCP  HRT  Clopidogrel  Dipyridamole
 Others:
Vascular network operational policy December 2014 V1 AH/JB
Page 26
Record patient name & ID if photocopying this page:
Investigations requested (state reason if not requested)
Pre-admission Clinic
Blood tests
WBC
Hb
Platelets
INR
Na
K
Urea
Creatinine
Random Glucose
HbA1c
LFT
Coagulation screen
MRSA screen
Sickle cell
Thyroid function
Result
Test
Results
ECG
CXR*
CPEX
Respiratory function*
Standard echo
MUGA or stress echo*
Carotid duplex
Vein mapping
Arterial limb duplex
Other:
* Not required unless unsuitable for CPEX or specifically indicated
VTE Risk assessment
VTE Risk assessment completed?  No
 Yes – prophylaxis given?
 No
 Yes:
Measurements for anti-embolism stockings: Calf:
Ankle:
Length:
ERP? (For AAA)
 No
 Yes – Infacol / Nebs / Hibiscrub / Fresubin (delete)
Physical examination
Height
Weight
BMI
BP
L
Pulse
Resps
O2 Sats
Peak flow
R
Reg / Irreg
CVS:
GIS:
RS:
Local examination:
Summary of further action
Checklist
Clexane
None / 20mg / 40mg
Drug chart completed? Yes / No
Post-op analgesia?
Yes / No
Amputation care package given (if applicable)?
Yes / No
Previous or FH anaesthetic problems?
Yes / No
Nurse – print name
Nurse signature
Vascular network operational policy December 2014 V1 AH/JB
Grade
Date
Page 27
Appendix 4a Patient pathway document for vascular MDT assessment for AAA/limb
intervention/other
Vascular network operational policy December 2014 V1 AH/JB
Page 28
a
WOE1336
Issue date
June 2012
Vascular Multidisciplinary Team – AAA / Limb
Intervention
Vascular Multidisciplinary Team Proforma
Elective AAA / Limb Intervention / Other
Complete at MDT by Registrar.
Patient details
Team present
Hospital number
Surgeon
Patient label
NHS number
Radiologist
Patients full name
Co-ordinator
Date of birth
/
MDT meeting date
/
Age
/
Other:
/
Allergies / intolerances
Medical risk factors
()
Risk
Details
Cardiac impairment
Respiratory
impairment
Renal impairment
Other (e.g. malignancy)
Investigations completed (state reason if not requested)
()
Risk
Significant details of results (N = normal / A = abnormal)
FBC
HbA1c (if diabetic)
U&E
LFT
Coagulation screen
MRSA screen
ECG
CXR
Vascular network operational policy December 2014 V1 AH/JB
Page 29
Mortality risk:
CPEX
%
AT:
Ventilatory equivalent: normal / abnormal
Respiratory function*
Standard echo
MUGA or stress echo*
* Not required unless unsuitable for CPEX or specifically indicated
Vascular network operational policy December 2014 V1 AH/JB
Page 30
Appendix 4b Patient pathway document for vascular MDT assessment for Carotids
Vascular network operational policy December 2014 V1 AH/JB
Page 31
WOE1335
Issue date
May 2012
b
Vascular Multidisciplinary Team
Carotid disease
Complete at MDT by Registrar.
Patient details
Team present
Hospital number
Surgeon
Patient label
NHS number
Radiologist
Patients full name
Co-ordinator
Date of birth
/
/
MDT meeting date
Age
/
Other:
/
Allergies / intolerances
 No  Yes – date:
Thrombolysis?
/
/
Carotid checklist
Indication for surgery
Affected area
L
Side
R
Date of event
Amaurosis Fugax
Transient ischaemic attack (TIA)
Stroke
Asymptomatic
Other:
Current neurological status (TIA’s only)
ABCD2 score If ABCD ≥ 4 then 48 hours. If ABCD < 4 then 2 weeks.
2
2
Score
Age
≥60 years
1
Blood pressure
≥140/90 mmHg
Any unilateral weakness (face/hand/arm/leg)
Speech disturbance (without motor weakness)
≥60 minutes
10-59 minutes
Yes
1
2
1
2
1
1
Clinical features
Duration of symptoms
Diabetes mellitus
Vascular Multidisciplinary Team – Carotid
Disease
Reference
Score given
Total
Rankin Score
Vascular network operational policy December 2014 V1 AH/JB
Score

Page 32
No symptoms at all.
No significant disability despite symptoms; able to carry out all usual duties and
activities.
Slight disability; unable to carry out all previous activities but able to look after
own affairs without assistance.
Moderate disability; requiring some help but able to walk without assistance.
Moderately severe disability; unable to walk without assistance and unable to
attend to own bodily needs without assistance.
Severe disability; bedridden, incontinent and enquiring constant nursing care
and attention.
Vascular network operational policy December 2014 V1 AH/JB
0
1
2
3
4
5
Page 33
Appendix 5 Patient pathway document for vascular post-operative patient document
Vascular network operational policy December 2014 V1 AH/JB
Page 34
Reference
WOE1331
Issue date
May 2012

Operation Vascular Procedure Diagram
& Codes
To be used with the Theatre ICP
Patient details
Affix patient label below
Consultant
Hospital/NHS №
Patient label
Operation procedure diagram & codes
Patients full name
Date of birth
/
/
Age
Operative diagram
PTA Site(s)
EVAR Stent
details
Closure
devices used
& site
Comments:
Bed rest
duration
hours
Radiologist
name
Vascular network operational policy December 2014 V1 AH/JB
Page 35
Radiologist
sign
Vascular network operational policy December 2014 V1 AH/JB
Page 36
Record patient name & ID f photocopying this page:
Tick codes used in this patient’s pathway. If procedure is not listed below, look at full laminated list and
record in the blank row at the bottom of this page.
(Red = Level 3 Blue = Level 4)
Procedure codes –
 Code
AORTA
A75.2 Excision of thoracic sympathetic nerve
A79.2 Destruction of thoracic sympathetic nerve NEC
Emergency replacement of aneurysmal segment of thoracic aorta by
L18.2
anastomosis of aorta to aorta NEC
Emergency replacement of aneurysmal segment of suprarenal abdominal aorta
L18.3
by anastomosis of aorta to aorta
Emergency replacement of aneurysmal segment of abdominal aorta by
L18.5
anastomosis of aorta to aorta NEC
Emergency replacement of aneurysmal bifurcation of aorta by anastomosis of
L18.6
aorta to iliac artery
L18.8 Other specified emergency replacement of aneurysmal segment of aorta
L18.9 Unspecified emergency replacement of aneurysmal segment of aorta
L19.3
L19.4
L19.5
L19.6
L19.8
L19.9
L20.3
L20.6
L20.8
L20.9
L21.6
L21.8
L21.9
L25.8
L27.1
L27.3
L27.4
L27.5
L27.6
L27.8
L27.9
L28.1
L28.5
L28.6
L28.8
L28.9
Replacement of aneurysmal segment of suprarenal abdominal aorta by
anastomosis of aorta to aorta NEC
Replacement of aneurysmal segment of infrarenal abdominal aorta by
anastomosis of aorta to aorta NEC
Replacement of aneurysmal segment of abd. aorta by anastomosis of aorta to
aorta NEC
Replacement of aneurysmal bifurcation of aorta by anastomosis of aorta to iliac
art. NEC
Other specified other replacement of aneurysmal segment of aorta
Unspecified other replacement of aneurysmal segment of aorta
Emergency bypass of segment of suprarenal abd. aorta by anastomosis of
aorta to aorta
Emergency bypass of bifurcation of aorta by anastomosis of aorta to iliac artery
NEC
Other specified other emergency bypass of segment of aorta
Unspecified other emergency bypass of segment of aorta
Bypass of bifurcation of aorta by anastomosis of aorta to iliac artery NEC
Other specified other bypass of segment of aorta
Unspecified other bypass of segment of aorta
Other specified other open operations on aorta
Endovascular insertion of stent graft for infrarenal abdominal aortic aneurysm
Endovascular insertion of stent graft for thoracic aortic aneurysm
Endovascular insertion of stent graft for aortic dissection in any position
Endovascular insertion of stent graft for aortic aneurysm of bifurcation
Endovascular insertion of stent graft for aorto-uniiliac aneurysm
Other specified transluminal insertion of stent graft for aneurysmal segment of
aorta
Unspecified transluminal insertion of stent graft for aneurysmal segment of
aorta
Endovascular stenting for infrarenal abdominal aortic aneurysm
Endovascular stenting for aortic aneurysm of bifurcation NEC
Endovascular stenting for aorto-uniiliac aneurysm
Other specified transluminal operations on aneurysmal segment of aorta
Unspecified transluminal operations on aneurysmal segment of aorta
L42.4 Operations on aneurysm of renal artery
L45.1 Bypass of visceral branch of abdominal aorta NEC
Endarterectomy of visceral branch of abdominal aorta and patch repair of
L45.3
visceral branch of abdominal aorta NEC
L45.4 Endarterectomy of visceral branch of abdominal aorta NEC
L46.4 Operations on aneurysm of visceral branch of abdominal aorta NEC
 Code
CAROTID
L29.1 Replacement of carotid artery using graft
L29.3 Bypass to carotid artery NEC
L29.4 Endarterectomy of carotid artery and patch repair of carotid artery
L29.5 Endarterectomy of carotid artery NEC
L29.8 Other specified reconstruction of carotid artery
L31.1 Percutaneous transluminal angioplasty of carotid artery
L31.2 Arteriography of carotid artery
L31.8 Other specified transluminal operations on carotid artery
L35.2 Arteriography of cerebral artery
L29.9 Unspecified reconstruction of carotid artery
Vascular network operational policy December 2014 V1 AH/JB
 Code
L54.1
L54.2
LIMB
Percutaneous transluminal angioplasty of iliac artery
Percutaneous transluminal embolectomy of iliac artery
L54.3
Arteriography of iliac artery
L54.4
Percutaneous transluminal insertion of stent into iliac artery
Bypass of femoral artery by anastomosis of femoral artery to femoral
artery NEC
Bypass of femoral artery by anastomosis of femoral artery to popliteal
L59.2
artery using prosthesis NEC
Bypass of femoral artery by anastomosis of femoral artery to popliteal
L59.3
artery using vein graft NEC
Bypass of femoral artery by anastomosis of femoral artery to tibial artery
L59.4
using prosthesis NEC
Bypass of femoral artery by anastomosis of femoral artery to tibial artery
L59.5
using vein graft NEC
Bypass of femoral artery by anastomosis of femoral artery to
L59.6
peronealartery using prosthesis NEC
Bypass of femoral artery by anastomosis of femoral artery to peroneal
L59.7
artery using vein graft NEC
L59.1
L60.1
Endarterectomy of femoral artery and patch repair of femoral artery
L60.2
L62.2
Endarterectomy of femoral artery NEC
Open embolectomy of femoral artery
L63.1
Percutaneous transluminal angioplasty of femoral artery
L63.4
Arteriography of femoral artery
L66.5
L72.1
L74.2
L74.6
 Code
L75.1
L75.3
W06.1
Y53.1
Y53.2
Y53.3
Percutaneous transluminal balloon angioplasty of artery
Arteriography NEC
Creation of arteriovenous fistula NEC
Creation of graft fistula for dialysis
OTHER
Excision of congenital arteriovenous malformation
Embolisation of arteriovenous abnormality NEC
Total excision of cervical rib
Approach to organ under radiological control
Approach to organ under ultrasonic control
Approach to organ under CT scan control
Y53.4 Approach to organ under fluoroscopic control
Y53.5
Y53.6
Y53.7
Y74.2
Y75.2
Y78.1
Approach to organ under image intensifier
Approach to organ under video control
Approach to organ under MRI control
Thoracoscopic approach to thoracic cavity NEC
Laparoscopic approach to abdominal cavity NEC
Arteriotomy approach to organ using image guidance with fluoroscopy
Arteriotomy approach to organ using image guidance with image
Y78.4 intensifier
Y78.5 Arteriotomy approach to organ using image guidance with video control
Y78.6
Z74.3
Z94.1
Z94.2
Z94.3
 Code
L76.1
L76.3
L82.1
L84.1
L84.2
L84.3
L85.1
L87.1
L87.2
L87.4
L88.1
L88.2
Arteriotomy approach to organ using image guidance with MRI control
First rib excision
Bilateral operation
Right sided operation
Left sided operation
VENOUS
Endovascular placement of one metallic stent
Endovascular placement of two metallic stents
Transposition of valve of vein
Combined operations on primary long saphenous vein
Combined operations on primary short saphenous vein
Combined operations on primary long and short saphenous vein
Ligation of long saphenous vein
Stripping of long saphenous vein
Stripping of short saphenous vein
Avulsion of varicose vein of leg
Percutaneous transluminal laser ablation of long saphenous vein
Radiofrequency ablation of varicose vein of leg
Page 37
L88.3
Vascular network operational policy December 2014 V1 AH/JB
Percutaneous transluminal laser ablation of varicose vein of leg NEC
Page 38
Appendix 6 Patient pathway document for AAA telephone follow up
Vascular network operational policy December 2014 V1 AH/JB
Page 39
Reference
WOE1339
Issue date
May 2012

AAA Telephone follow-up
Patient details
Affix patient label below
Telephone followup date
Hospital/NHS number
Patient label
Patients name
/
/
Name of clinician carrying
out telephone follow-up
Operation date
/
/
Signature / GMC №
Discharge date
/
/
Procedure
Expected post-operative symptoms
Patients will still be sore and having difficulty moving, but should be coping with oral
painkillers.
Does patient require painkillers?
 Yes
Does patient require a flu vaccination?  No
Question
Details / notes
How are you feeling following your
surgery?
(If patient is feeling ill, clarify if it is pain or
illness, such as upset tummy/chest
problems/cough)
Do you have a family member / carer
looking after you?
 Yes
 No
Telephone follow-up
This proforma is to be used as a guide for telephone follow-ups for AAA procedures on
patients who have been discharged from hospital 48hrs to 1 week after discharge
(depending on a locally agreed protocol).
(If no, suggest they seek help from family or
friends)
Were you prescribed pain killers
upon discharge?
 Yes
 No - ACTION - send new prescription
 Yes
 No
Have you got any pain?
Are you managing pain adequately with the
painkillers provided?
 Yes
 No
Vascular network operational policy December 2014 V1 AH/JB
Page 40
Are you clear about the medication
you should be taking?
 Yes
 No
(i.e. statins)
Vascular network operational policy December 2014 V1 AH/JB
Page 41
Record patient name & ID if photocopying page:
Are you clear about what happened
during your operation?
 Yes
 No
(i.e. any complications and how long it should
take you to recover)
 Yes
 No
Is your wound healing
satisfactorily?
Do you have any stitches or clips
still in place?
Telepho
ne
followup
Are you aware of when your next
follow-up appointment is?
Did you get written information
given to you before or after your
operation?
Is your wound dry?
 Yes
 No
Is there any surrounding redness or discharge?
 No
 Yes – ACTION – book
early follow-up appointment
 No
 Yes – have you a date for having them removed
by the District Nurse (usually 10 – 14 days)?
 No – ACTION – follow this up
 Yes - / /
 Yes
 No – ACTION – check & let patient know
 Yes
 No – ACTION – send leaflet
Are there any concerns I can help
you with today?
Actions required
()
Re-send prescription
 Pain killer
 Statin
Re-send patient information leaflet
Ensure patient has District Nurse appointment & inform them
Book for early follow-up appointment
Book for standard follow-up appointment
Telephone GP
Contact Consultant Surgeon
Vascular network operational policy December 2014 V1 AH/JB
Required
Completed
Page 42
Notes:
Vascular network operational policy December 2014 V1 AH/JB
Page 43
Appendix 7 Vascular surgeons, anaesthetists and hybrid theatre timetable
Vascular network operational policy December 2014 V1 AH/JB
Page 44
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Backhouse
Choksy
Choksy
Choksy
Abu‐Own
Abu‐Own
Assar
Assar
Backhouse
Choksy
Hybrid Theatre
Bagwat
Bagwat
Malaj
Malaj
TBC
TBC
Patient
Patient
McKenzie
McKenzie
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Osman
Osman
Abu‐Own
Abu‐Own
Choksy
Choksy
Backhouse
Backhouse
Howard
Howard
Driver
Driver
Malaj
Malaj
TBC
TBC
Patient
Patient
McKenzie
McKenzie
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Abu‐Own
Abu‐Own
Choksy
Choksy
Backhouse
Backhouse
Assar
Assar
Howard
Howard
Bagwat
Bagwat
Malaj
Malaj
TBC
TBC
Patient
Patient
McKenzie
McKenzie
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Osman
Osman
Choksy
Abu‐Own
Howard
Howard
Backhouse
Backhouse
Howard
Howard
Driver
Driver
Malaj
Malaj
TBC
TBC
Patient
Patient
McKenzie
McKenzie
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Backhouse
Abu‐Own
Choksy
Choksy
Osman
Osman
Assar
Assar
Howard
Howard
Bagwat
Bagwat
Malaj
Malaj
TBC
TBC
Patient
Patient
McKenzie
McKenzie
AM
PM
AM
PM
AM
PM
AM
PM
AM
PM
Osman
Osman
Choksy
Abu‐Own
Assar
Assar
Backhouse
Backhouse
Howard
Howard
Driver
Driver
Malaj
Malaj
TBC
TBC
Patient
Patient
McKenzie
WEEK 1
Monday
Tuesday
Wednesday
Thursday
Friday
WEEK 2
Monday
Tuesday
Wednesday
Thursday
Friday
WEEK 3
Monday
Tuesday
Wednesday
Thursday
Friday
WEEK 4
Monday
Tuesday
Wednesday
Thursday
Friday
WEEK 5
Monday
Tuesday
Wednesday
Thursday
Friday
WEEK 6
Monday
Tuesday
Wednesday
Thursday
Friday
Vascular network operational policy December 2014 V1 AH/JB
Page 45
Vascular network operational policy December 2014 V1 AH/JB
Page 46
Vascular network operational policy December 2014 V1 AH/JB
Page 47