INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure

Transcription

1 INTERDISCIPLINARY CLINICAL MANUAL Policy and Procedure TITLE: Stress Testing by Technologists When a Physician is not Present in the Stress Lab NUMBER: CC Effective Date: November 2014 Page 1 of 5 Applies To: Stress Labs: HI Site, DGH and Cobequid Sites POLICY This is a Delegated Medical Function for Registered Cardiology Technologists that requires assessment of competency prior to performing. 1. Performing a Stress Test when the physician is not present in the Stress Lab ( tech only ) is a Delegated Medical Function (DMF) performed by a Registered Cardiology Technologist. Prior to initially performing, the Registered Cardiology Technologist is to have: 1.1 At least one year of experience working in the Stress Lab. 1.2 Been deemed competent for CC Blood Pressure Monitoring During Stress Test. 1.3 Been deemed competent to perform the procedure by a physician or physician delegate. 2. Reassessment of competency is to be done annually consisting of a review of the policy and learning module and may also include a review/ education as determined by the accountable physician. 3. A Registered Cardiac Technologist who has been deemed competent in the DMF for Stress Testing conducts a tech only Stress Test only: 3.1 when a physician is available within the immediate vicinity of the Stress Lab

2 Stress Testing by Technologists CC Page 2 of HI site: the cardiology clinic area, echo lab or viewing room DGH site: the echo lab or viewing room Cobequid site: in a room adjacent to or across the hall from the stress lab 3.2 on a stable patient with a predictable outcome (i.e. does not possess any absolute/relative contraindications) PRACTICE GUIDELINES 1. Prior to beginning a stress test, review the requisition for any conditions/reasons for excluding the patient from such a test. If any of the following are noted on the requisition, consult the supervising physician to re-evaluate the patient s appropriateness for testing: 1.1. The clinical information section is inadequate Any of the following ACC/AHA contraindications to exercise testing: Absolute Acute myocardial infarction (within 2 days). High-risk unstable angina* Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise. Symptomatic severe aortic stenosis. Uncontrolled symptomatic heart failure. Acute pulmonary embolus or pulmonary infarction. Acute myocarditis or pericarditis. Acute aortic dissection. *Prolonged, ongoing (greater than 20 min) pain at rest; pulmonary edema, most likely related to ischemia; new or worsening mitral regurgitation murmur; S3 or new worsening rales; hypotension, bradycardia, tachycardia, age older than 75 years; angina at rest with transient ST changes 0.05 mv;bbb, new or presumed new/sustained VT Relative= Left main coronary stenosis. Moderate stenotic valvular heart disease. Electrolyte abnormalities. Severe arterial hypertension Tachyarrhythmias or bradyarrhythmias. Hypertrophic cardiomyopathy and other forms of outflow tract obstruction. Mental or physical impairment leading to inability to exercise adequately. High degree atrioventricular block. ACC/AHA Guidelines for the Management of Patients with Unstable Angina/Non-ST-Segment Elevation Myocardial Infarction 2002 available at Relative contraindications can be superseded if the benefits of exercise outweigh the risks. In the absence of definitive evidence, the committee suggests a systolic blood pressure greater than 200 mm Hg and/or diastolic blood pressure greater than 110 mm Hg. Modified from Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise Standards: a statement for healthcare professionals from the American Heart Association. Special Report. Circulation. 1995;91:

3 Stress Testing by Technologists CC Page 3 of 5 2. Review the resting 12-lead ECG. If any of the following abnormalities/arrhythmias are identified, consult with the physician before proceeding: 2.1. Atrial fibrillation with ventricular rate greater than 100/min Marked bradycardia less than 40/min Heart block 2.4. High degree atrioventricular block - 2 or Left bundle branch block 2.6. Prolonged QT PVC s (frequent, multifocal, coupling, triplets etc.) 2.8. Evidence of recent MI 3. Complete the Pre-stress test assessment checklist prior to beginning the stress test. If any of the Absolute or Relative contraindications are present, consult the physician before proceeding. 4. If the baseline blood pressure is greater than or equal to 200/100mm Hg or less than or equal to 90/60mm Hg, notify the physician before proceeding with stress test. 5. STOP the stress test under the following conditions: 5.1. BP greater than or equal to 230/110 mm Hg with no accompanying symptoms Systolic BP drops 10mm Hg or more below baseline if associated with symptoms, ST change or dysrhythmia One or more of the following absolute indications is present: Increasing anginal chest pain Central nervous system symptoms (ataxia, dizziness, near syncope), Signs of poor peripheral perfusion (cyanosis or pallor) Fatigue Shortness of breath Wheezing Leg cramps, or intermittent claudication Appears significantly unwell Serious arrhythmias (i.e., high grade ventricular arrhythmias such as multiform complexes, triplets &/or more) Marked ST depression from baseline (greater than.2 mm of horizontal or downsloping) Technical difficulties monitoring the ECG or systolic BP Patient unwillingness to continue 5.4. One or more of the following relative indications is present:

4 Stress Testing by Technologists CC Page 4 of 5 ST or QRS changes such as excessive ST displacement, junctional depression, or marked axis shift Less serious arrhythmias, including supraventricular tachycardia, development of bundle branch block that cannot be distinguished from ventricular tachycardia 6. Consult the physician if there is any: 6.1. concern with the appropriateness of the protocol ordered 6.2. doubt as to whether or not the patient should be exercised 6.3. concern with the patient s condition post stress or with the test results (strongly positive test, ongoing symptoms, hemodynamic status, ongoing ECG changes or dysrhythmia) PROCEDURE Equipment: Requisition & pre-stress test assessment checklist Treadmill Monitor & console Acquisition module & leads Electrodes BP cuff & sphygmomanometer Stethoscope 70% isopropyl alcohol and omni prep Gauze Safety razor 1. Review stress test requisition for any contraindications to testing & consult physician if necessary (see Practice Guideline Statement #3). 2. Identify the patient & explain the procedure. 3. Ensure consent for stress testing has been signed by patient and witnessed. 4. Administer pre-stress test assessment checklist and consult the physician if any contraindications to testing found. 5. Prepare the skin by shaving the area and cleansing with 70% isopropyl alcohol saturated gauze, followed by a light rubbing with sandpaper. 6. Apply electrodes & cables as per protocol. 7. With the patient standing, obtain: 7.1 a resting 12-lead ECG & average median strip

5 Stress Testing by Technologists CC Page 5 of a resting BP & heart rate. 8. Verify the quality of the ECG tracing/troubleshoot. 9. Conduct stress test following prescribed protocol (Bruce/Modified Bruce/Naughton) to appropriate endpoint if possible. 10. Check the blood pressure at each workload stage (approximately 2 minutes) with each increase in the MET level within the selected protocol. 11. Observe the patient constantly for adverse symptoms (i.e. chest pain, SOB, arrhythmias). 12. Monitor the patient status for adverse signs (i.e. heart rate, blood pressure, ECG changes). 13. Document subjective (i.e. chest pain) & objective (i.e. heart rate, BP, workload, electrical response) data as testing proceeds. 14. Terminate the stress test & consult physician as per endpoints in guidelines. 15. Recovery period - With the patient seated, continue monitoring until the BP, heart rate and ECG return to baseline (usually takes 4-5 minutes). REFERENCES Boyne, T.S., (1999, January). The Hows and Whys of Stress Testing. Perspectives in Cardiology Fletcher, G.F., Froelicher, V.F., Hartley, L. H., Haskell, W.L., Pollock, M.L. (1990 December). Exercise Standards, A Statement for Health Professionals From the American Heart Association. Special Report Circulation, 82(6), Gibbons RJ, Balady GJ, Bricker JT, Chaitman, B.R., Fletcher, G.F., Froelicher VF, et al. ACC/AHA 2002 Guideline Update for Exercise Testing: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Circulation, 106(14) RELATED DOCUMENTS Policies CC Other CC Blood Pressure Monitoring During a Stress Test (PELC) Learning Module Stress Testing By Registered Cardiology Technologists When a Physician is not Present in the Stress Lab * * *