URN: Family name: Given name(s): Address:

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1 The State of Queensland (Queensland Health) 2012 Contact Facility: Clinical Pathways Never Replace Clinical Judgement Care Outlined In This Pathway Must be Altered If It Is Not Clinically Appropriate For The Individual Patient If contraindication to thrombolysis, thrombolysis failure or cardiogenic shock; arrange immediate transfer. If thrombolysis successful; arrange transfer to cardiac catheter laboratory within 48 hours. Pathway commenced Date: Time:... Initials:... Pathway ceased Date: Time:... Reason:... Initials:... Treating consultant (print name):... Procedures: (Affix identification label here) Thrombolysis: Yes Date:... Time:... Type:... No Do Not Write in this binding margin v /2012 Mat. No.: Chest x-ray: Yes Date:... Angiogram: Scheduled? Yes Date:... Not for angiogram, Reason:... Performed? Yes Date:... Documentation Instructions: Initials - Indicates action / care has been ordered / administered. - Indicates preceding care / order is not applicable. Crossing out - Indicates that there is a change in the care outlined. V - Indicates a variation from the pathway on that day, in that section. When applicable flag it in the Variance column, then document in the free text area as instructed. If this variance occurs more than once daily, document the additional times of the variance in the variance free text area and in the patient s progress notes as applicable. Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Symbols guide care to a primary professional stream, it is a visual guide only and its direction is not intended to be absolute. When signing in a split box, first signature should be entered in the left box and the second in the right. Every person documenting in this clinical pathway must supply a sample of their initials and signature below. Signature Log: Initials Signature Print name Role STEMI Pathway Non-Interventional ÌSW043b\Î SW043b Patient with chest pain ED Chest Pain Medical Assessment Tool Acute Coronary Syndrome suspected/under investigation Cardiac Chest Pain Risk Stratification Pathway Intermediate Risk Chest Pain Clinical Pathway Page 1 of 12 Acute Coronary Syndrome diagnosed NSTEACS Mgt. Plan STEMI Mgt. Plan NSTEACS Pathway OR STEMI Pathway

2 Signature Log (continued): Initials Signature Print name Role DO not write in this binding margin Page 2 of 12

3 All care givers who initial are to sign signature log Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Discharge Checklist Initials Date Rehabilitation / Education Review with patient and carer: Resumption of lifestyle activities (sexual activity, physical activity, return to work) Driving / pilot / commercial licensing Current status, diagnostic and therapeutic options and general prognosis Chest pain home management plan Education and counselling for all current medications Group Healthy Eating education session attended? Yes (specify): No (refer to community health or outpatient group session) Do Not Write in this binding margin Given: Written and personalised risk factor control information (smoking, nutrition, diabetes, stress management, high blood pressure and cholesterol) Information on disease process (eg. atherosclerosis) My Heart My Life book or similar Written medication information: Cardiac rehab OPD referral completed? Yes No Heart Failure Service referral completed? Yes Consumer Medicines Information Discharge Medication Record (DMR) Stress / Depression identified? Yes No (if Yes, refer to psychologist / social worker) Medications Discharge medications review for: ACE inhibitors: Indicated? Yes No Given? Yes No If Not Given, specify reason: Aspirin: Indicated? Yes No Given? Yes No If Not Given, specify reason: Beta Blockers: Indicated? Yes No Given? Yes No If Not Given, specify reason: Clopidogrel (or alternative): Indicated? Yes No Given? Yes No v /2012 Mat. No.: ÌSW043b\Î SW043b If Not Given, specify reason: Statins: Indicated? Yes No Given? Yes No If Not Given, specify reason: Sublingual Glyceryl Trinitrate PRN: Supplied at discharge? Yes No Discharge script completed and sent to pharmacy? Yes No (If No, reason: ) Appointments Patient to make appointment with General Practitioner within one week Cardiologist Other (specify): Forms Medical discharge summary Travel forms, if required ( not required) Medical certificate, if required ( not required) Page 3 of 12

4 All care givers who initial are to sign signature log Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Category Investigations Medications and Pain Management Observations Treatments First 24 hours From: hrs To: hrs Day 1 Admission to CCU ECG on arrival to CCU (right sided ECG V4R if inferior mycoardial infarction), repeat with pain or clinical deterioration and review by MO If had Lysis, conduct ECGs 90 mins 6 hrs and 12 hrs post Lysis If reperfusion unsuccessful at 90 mins, arrange emergency transfer for PCI (percutaneous coronary intervention) Continuous cardiac monitoring (ST segments if available) TnI (6 8hrs after presentation) ELFT FBC COAGS BGL Request for next day: TFT Fasting glucose / Lipids If re-occlusion, refer immediately for emergency rescue PCI Check the allergy status of the patient by referring to the medication chart Record weight and height on medication chart Confirm Aspirin given Confirm Clopidogrel (or alternative) given Confirm prescription of PRN medication Other intravenous infusions: Review need for: Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0 24hrs) IV Heparin (or alternative) If successful lysis, refer immediately angiography recommended within 48 hours Follow post Lysis protocol, then if stable Q4H (or as per MO order*) TPR, BP, heart sounds (HS) and breath sounds (BS), SaO 2, rhythm check, circulation and pain assessment. Neurological observations post-lysis *Record alternate frequency: Assess, manage and report chest pain Blood glucose level (BGL) monitoring - frequency: (if newly diagnosed, refer to Diabetic Educator) Daily weight and/or fluid balance chart Deep breathing, coughing and leg exercises Nutrition Healthy Heart diet Other (specify): AM PM ND V DO not write in this binding margin Mobility / Elimination / Hygiene If for fasting lipids / glucose, no food after 8pm (may have H 2 O) Strict rest in bed for 12 hrs post STEMI (12 24 hours post successful thrombolysis, patient may go to toilet on wheelchair with telemetry [must be supervised], provided they are pain free, and off inotropic and oxygen therapy) Record alterations in mobility: Sponge in bed Other Care (specify) Falls risk score: Mouth care after meals and prn Waterlow score: Education and Discharge Plan Expected Outcomes (complete at end of 24 hour period) Basic explanation to be given of: AMI Diagnostic procedures Mobilisation and bed exercises Risk factors My Heart My Life book or similar Patient demonstrates: A - Achieved V - Variance A V Painfree ST segment or T wave changes resolving Other (specify): Page 4 of 12

5 All care givers who initial are to sign signature log Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Category Day 2 of pathway Days post STEMI: Date: Ward: AM PM ND V Investigations ECG performed daily, repeat with pain or clinical deterioration and review by MO Continuous cardiac monitoring FBC ELFT TnI APTT (if on IV anticoagulation as Fasting Lipids / glucose TFT per protocol/nomogram) Refer to interventional cardiac facility for coronary angiography Medications and Pain Management Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate Other intravenous infusions: Do Not Write in this binding margin Observations Treatments Review need for: Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs) IV Heparin (or alternative) 4 hourly (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO 2 (on room air) and circulation *Record alternate frequency: Assess, manage and report chest pain Blood glucose level (BGL) monitoring - frequency: (if newly diagnosed, refer to Diabetic Educator) Daily weight and/or fluid balance chart, if indicated Patent IVC change if cubital fossa inserted in DEM / ED (remove if not required) Insertion date: Resite date: Deep breathing, coughing and leg exercises Nutrition Healthy Heart diet Other (specify): If fasting bloods, confirm blood collection before breakfast Mobility / Elimination / Hygiene Gentle mobilisation, shower with supervision, toilet privileges permitted (if pain free and TnI reducing). - Record alterations in mobility: v /2012 Mat. No.: ÌSW043b\Î SW043b Other Care (specify) Education and Discharge Plan Expected Outcomes (complete at end of 24 hour period) Discuss treatment plan with patient / carer Commence discharge checklist on p.3 Patient demonstrates: A - Achieved V - Variance A V Painfree ST segment or T wave changes resolving Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography. Other (specify): Page 5 of 12

6 All care givers who initial are to sign signature log Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Category Day 3 of pathway Days post STEMI: Date: Ward: AM PM ND V Investigations ECG performed daily, repeat with pain or clinical deterioration and review by MO Continuous cardiac monitoring Telemetry Monitoring ceased - time: Daily Bloods as requested (FBC if on IV or subcut antithrombotic) Other test: Medications and Pain Management Observations Treatments Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate Other intravenous infusions: Review need for: Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs) IV Heparin (or alternative) QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO 2 (on room air) and circulation *Record alternate frequency: Assess, manage and report chest pain Blood glucose level (BGL) monitoring - frequency: Daily weight and/or fluid balance chart, if indicated Patent IVC Resite date: OR IVC removed Nutrition Healthy Heart diet Other (specify): If fasting bloods, confirm blood collection before breakfast DO not write in this binding margin Mobility / Elimination / Hygiene Increase mobilisation if painfree Self care Other Record alterations in mobility/hygiene: Other Care (specify) Education and Discharge Plan Expected Outcomes (complete at end of 24 hour period) Discuss treatment plan with patient / carer Review discharge checklist on p.3 Patient demonstrates: A - Achieved V - Variance A V Painfree ST segment or T wave changes resolving Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography. Other (specify): Page 6 of 12

7 All care givers who initial are to sign signature log Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Category Day 4 of pathway Days post STEMI: Date: Ward: AM PM ND V Investigations ECG performed daily, repeat with pain or clinical deterioration and review by MO Continuous cardiac monitoring Telemetry Monitoring ceased - time: Daily Bloods as requested (FBC if on IV or subcut antithrombotic) Other test: Do Not Write in this binding margin Medications and Pain Management Observations Treatments Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate Other intravenous infusions: Review need for: Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs) IV Heparin (or alternative) QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO 2 (on room air) and circulation *Record alternate frequency: Assess, manage and report chest pain Blood glucose level (BGL) monitoring - frequency: Daily weight and/or fluid balance chart, if indicated Patent IVC Resite date: OR IVC removed Nutrition Healthy Heart diet Other (specify): If fasting bloods, confirm blood collection before breakfast Mobility / Elimination / Hygiene Increase mobilisation if painfree Self care Other Record alterations in mobility/hygiene: Other Care (specify) v /2012 Mat. No.: Education and Discharge Plan Discuss treatment plan with patient / carer Review discharge checklist on p.3 ÌSW043b\Î SW043b Expected Outcomes (complete at end of 24 hour period) Patient demonstrates: A - Achieved V - Variance A V Painfree ST segment or T wave changes resolving Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography. Other (specify): Page 7 of 12

8 All care givers who initial are to sign signature log Key Medical Nursing Pharmacy Allied Health Cardiac Rehab Category Day 5 of pathway Days post STEMI: Date: Ward: AM PM ND V Investigations ECG performed daily, repeat with pain or clinical deterioration and review by MO Continuous cardiac monitoring Telemetry Monitoring ceased - time: Daily Bloods as requested (FBC if on IV or subcut antithrombotic) Other test: Medications and Pain Management Observations Treatments Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate Other intravenous infusions: Review need for: Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs) IV Heparin (or alternative) QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO 2 (on room air) and circulation *Record alternate frequency: Assess, manage and report chest pain Blood glucose level (BGL) monitoring - frequency: Daily weight and/or fluid balance chart, if indicated Patent IVC Resite date: OR IVC removed Nutrition Healthy Heart diet Other (specify): If fasting bloods, confirm blood collection before breakfast DO not write in this binding margin Mobility / Elimination / Hygiene Increase mobilisation if painfree Self care Other Record alterations in mobility/hygiene: Other Care (specify) Education and Discharge Plan Expected Outcomes (complete at end of 24 hour period) Discuss treatment plan with patient / carer Review discharge checklist on p.3 Patient demonstrates: A - Achieved V - Variance A V Painfree ST segment or T wave changes resolving Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography. Other (specify): Page 8 of 12

9 Insert additional days here if applicable. ÌSW043b\Î SW043b v /2012 Mat. No.: Do Not Write in this binding margin

10 Variance Codes A. Patient Variances Actions A:1 Recurrent chest pain (Differentiate Chest Pain Type; ischaemic, pericarditis or chest wall pain) A:2 Cardiac arrest Administer O 2 if indicated (SaO 2 < 93% or evidence of shock) Administer Sublingual Glyceryl Trinitrate Perform ECG MO Review Repeat TnI If re-infarction, consider urgent PCI A:2.1 Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT) A:2.2 Unconscious Complete Heart Block / Asystole A:2.3 Pulseless Electrical Activity A:3 Other arrhythmias: A:3.1 Conscious sustained Ventricular Tachycardia A:3.2 First episode of Atrial Fibrillation (AF) or other Supra Ventricular Tachycardia (SVT) A:3.3 First episode of Heart Block; 2nd or 3rd degree AV Block A:4 Left ventricular failure (with Pulmonary Oedema) Basic Life Support CPR Code Blue Advanced Life Support Defibrillation Basic Life Support CPR Code Blue Emergency transthoracic pacing, transvenous pacing Basic Life Support CPR Code Blue A:5 Pericarditis MO review Consider analgesia Consider echocardiogram A:6 Pulmonary embolus (PE) / Deep vein thrombosis (DVT) A:7 Renal failure (Significant worsening of renal function as defined by rising creatinine or worsening GFR) A:8 Pulmonary complications (Cough, sputum production, fever and pleuritic chest pain) Urgent MO review: - unstable patient (hypotensive): call Medical Emergency Team; - stable patient within 5 mins Urgent MO review: - unstable patient: within 5 mins; - stable patient: mins Urgent MO review: - unstable patient (hypotensive/syncope): call Medical Emergency Team; - stable patient within 5 mins Prepare for transthoracic pacing, transvenous pacing Sit patient upright Administer O 2, consider CPAP / BiPAP Urgent MO review Immediate S/L nitrate as bridge to IV titrated nitrates Morphine PRN Diuretics Correction of hypertension with nitrate +/- additional antihypertensive agent Strict Fluid Balance Chart, consider IDC Urgent MO review Anticoagulation CTPA or VQ Scan +/- Leg Ultrasound O 2 if indicated Bed rest Assess volume state and urine output Urgent MO review; 1 2hrs Strict Fluid Balance Chart, consider IDC Treat hyperkalaemia MO review Chest X-ray Sputum M/C/S Assessment for pneumonia Exclusion of pulmonary embolism A:9 Severe nausea MO review Consider anti-emetic A:10 Adverse drug reactions MO review Cease and / or withhold drug A:11 ACS medications contraindicated / Withheld Check with MO A:99 Other DO not write in this binding margin Page 10 of 12

11 Variance Codes (continued) A. Patient Variances Actions A:12 Cardiogenic shock (Hypotension with peripheral shutdown and poor urine output, assess age of patient and comorbidities, seek senior medical officer / ICU input early) Urgent MO review Consider inotropes Urgent Echocardiogram Fluid balance chart and consider urinary catheter A:13 Haemorrhage A:13.1 Post PCI, access site haematoma / bleed Follow hospital angiogram protocol A:13.2 A:13.3 Retro-peritoneal bleeding (hypotension, abdominal pain, poor urine output) Other bleeding Do Not Write in this binding margin A:13.4 Post Lysis (STEMI), change in neurological status Urgent MO review Frequent neurological observations Cease anti-coagulants CT Head Neurosurgical review A:14 Coronary artery bypass surgery B. Discharge / Treatment Delay Variances B:1 Treatment delay B:2 Delay in transfer B:3 No bed available B:4 No monitored bed available B:5 Interdepartmental issues involving care C. Staff Variances C:1 Medical C:2 Nursing Clinical Events / Variance B:6 Blood tests delayed B:7 Delay in chest X-ray B:8 Delay in stress test B:9 Medication not available B:10 Patient discharged home off pathway C:3 Allied Health C:4 Unable to provide patient education B:11 Transfer to private hospital B:12 Change of plan / orders B:13 Self discharge B:14 Overnight stay Date / Time Variance Code Describe variances to clinical path and any other patient related notes. Document as Variance / Action / Outcome Initials ÌSW043b\Î SW043b v /2012 Mat. No.: Page 11 of 12

12 Clinical Events / Variance (continued) Date / Time Variance Code Describe variances to clinical path and any other patient related notes. Document as Variance / Action / Outcome Initials DO not write in this binding margin Page 12 of 12