SOUTH EAST WALES CARDIAC NETWORK INTEGRATED CARE PATHWAY CARDIAC REHABILITATION MAY 2005

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1 Name Address SOUTH EAST WALES CARDIAC NETWORK INTEGRATED CARE PATHWAY CARDIAC REHABILITATION MAY 2005 Ms / Miss / Mr / Mrs Addressograph Known as Telephone Number of Birth Hospital No. NHS No. Cardiac Rehab No. Consultant/s G.P. Address of Admission of Outpatient appointment/consultant Referral received invited to join Education of Discharge Post Discharge Tel. No. of home visit Hospital Transport Y/N Escort Y/N Exercise assessment date Attended Y/N Programme Booking Number Attended Y/N Attended Y/N Referral Source Still wish to attend letter sent Yes / No : to reply: Wishes / Does not wish to attend Emergency Contact.. Relationship. Address. Contact Number Ethnic Origin White British White Irish White other Chinese Other ethnic group Mixed white/ black Caribbean Black Caribbean Mixed other Not stated Mixed white/black African Black African Black Other Indian Pakistani Bangladeshi Other Asian background Mixed white/asian Name: Hospital Number: 1

2 Social History Lives with.. Accommodation Type. Problem with access: Yes / No Referral to:- Occupation: Employed full-time Employed part-time Self employed full-time Self employed part-time Unemployed looking for work Retired Leisure activities: Health status of significant other. Marital Status: Single Widowed Married Unknown Divorced Permanent partnership Government training course Looking after family/home Permanently sick/disabled Temporarily sick or injured Student Other Plan to return: Yes / No / Undecided Driving: HGV / PSV Yes / No Driver Yes / No Returned to driving Yes / No Initiating Event: Myocardial Infarction Acute Coronary Syndrome Angioplasty Angina CABG Other Surgery Heart Failure Cardiac Arrest Pacemaker ICD Congenital Heart Transplant Stents LV Assist Device Other 1 st Troponin Level 2 nd Troponin Level Thrombolysis Yes / No Type Onset date: Type: Region: Type: Intervention / Transfer to tertiary centre Allergies Name: Hospital Number: 2

3 History of presenting condition Past Medical History Angina Stroke Chronic bronchitis Rheumatism (rheumatoid arthritis) Osteoarthritis HIV Emphysema Other: Heart attack Other / : Diabetes Osteoporosis Arthritis Cancer Claudication Asthma Chronic Back Problem Hypertension Assessment will be made of Family History and CHD First Degree relative history of CHD First Degree relative history of Diabetes Male < 55 years Yes / No Male < 55 years Yes / No Female < 65 years Yes / No Female < 65 years Yes / No : : : CLINICAL STATUS Current Symptoms and Concerns Phase I/II Start Phase III End Phase III Chest Discomfort Shortness of Breath NYHA Score = NYHA Score = NYHA Score = NYHA Score = Arrhythmias/Palpitations Sleep Pattern New York Association Functional Classification Class I: Physical activity not limited Class II: Slight limitation of physical activity Class III: Marked limitation of physical activity Class IV: Inability to carry out any physical activity without discomfort Name: Hospital Number: 3

4 Medication Pre Event Inpatient/post discharge Start rehab programme Changes during rehab programme End rehab programme Drug Dose Drug Dose Drug Dose Drug Dose Drug Dose Aspirin Statin B Blocker Ace Inhibitor Digoxin CC Blocker Warfarin Anti-arrythmic Diuretic Nitrate GTN Spray Clopidogrel ACE II Other & Non Prescription Supplement This patient should be offered all phases of cardiac rehabilitation. Phase I In Patient Name, signature & designation Yes / No During this phase the following Yes/ No aspects should be discussed / addressed:- Understanding of diagnosis Risk Factors assessed/discussed Secondary prevention targets set Management of symptoms discussed Activity discussed & goals set Psychological needs assessed/discussed Support offered to partner Hand held record commenced/updated Phase 3 encouraged. Written info given /video/audio tapes Social needs discussed Contact number reinforced Further visit/contact arranged Update patient profile Referred to phase II cardiac rehab : : Name: Hospital Number: 4

5 Phase II Home Visit / Telephone Contact Telephone call within 7 days Yes /No Home visit within 7 days Yes /No During this the following Yes/ No aspects should be discussed and identified: Understanding of diagnosis Risk Factors assessed/discussed Secondary prevention targets set Management of symptoms discussed; Chest discomfort Shortness of breath Angina Palpitations Sleep pattern Other Activity discussed & goals set Psychological needs assessed/discussed Support offered to partner Hand held record commenced/updated Phase 3 encouraged. Written info given /video/audio tapes Social needs discussed Contact number reinforced Further visit/contact arranged Update patient profile Referred to phase III cardiac rehab : : Phase III This patient will be offered Phase III Cardiac Rehabilitation Programme Yes / No If no:- Declined letter sent Yes / No Failed to attend letter sent Yes / No Rehab Type: Home based Hospital based Community based Heart Manual Name: Hospital Number: 5

6 Risk Factors and Lifestyle This patient should have an assessment and review of cardiovascular risk factors throughout all phases Phases 1 IV Risk Factor Smoking Smoker Inpatient/ post discharge Yes/ No Start Rehab programme End Rehab programme Yes/ No Yes/ No Yes/ No Community follow up Smoker Ex Smoker How long stopped? How long stopped? Referred to Smoking Cessation service if applicable Yes /No Yes /No Yes /No Yes /No This patient should have a target cholesterol of < 5.0 LDL < 2.5 HDL >1 Trig < 2 Chol HDL LDL Trig Chol HDL LDL Trig Chol HDL LDL Trig Chol HDL LDL Trig If lipids not within target range medical advice will be sought Yes / No Yes / No Yes / No Yes / No Referred to Dietician Yes /No Yes /No Yes /No Yes /No This patient will have weight / height / BMI / hip/waist ratio assessed and given appropriate advice Target: BMI < 25 Hip/waist ratio: Men < 37'' Women < 31.5'' Height Weight Weight Weight Weight BMI BMI BMI BMI Hip / Waist Ratio Hip / Waist Ratio Hip / Waist Ratio Hip / Waist Ratio Name: Hospital Number: 6

7 Diet How many meals containing oily fish do you eat a week? Inpatient/ post discharge Start Rehab programme End Rehab programme Community follow up How many times per day do you eat fruit? How many times a day do you eat vegetables? How many units of alcohol do you drink per week? How many times per week do you drink alcohol? This patient will have their blood pressure recorded and aim to have a target blood pressure of 140/85 130/80(Diabetes) Known Hypertensive Recording Recording Recording Recording Yes / No Treatment Treatment Treatment Treatment If not within target range medical advice will be sought Yes / No Yes / No Yes / No Yes / No This patient should be screened for Diabetes Target :- HbA1c / < 6.0 mmol Yes/No Yes/No Yes/No Yes/No Fasting Glucose Referred to Diabetes CNS Variance Name: Hospital Number: 7

8 This patient will have psychological and health related quality of life measured Inpatient / Start Rehab End Rehab Community post discharge programme programme follow up Yes / No Yes / No Yes / No HAD Score Result A = D = A = D = A = D = A = D = Emotions Referred to Psychologist / Counsellor/O.T. PHYSICAL ACTIVITY QUESTIONNAIRE Start of Programme 12 Weeks 12 Months : : : 1a Vigorous 1b Moderate 1c Mild 1a Vigorous 1b Moderate 1c Mild 1a Vigorous 1b Moderate 1c Mild 2a Often 2b Sometimes 2c Never/Rarely Physical Activity 30 min duration Yes/No 2a Often 2b Sometimes 2c Never/Rarely Physical Activity 30 min duration Yes/No 2a Often 2b Sometimes 2c Never/Rarely Physical Activity 30 min duration Yes/No : : : Quality of Life (Dartmouth COOP charts and UK national Census data for economic activity Start of Programme 12 Weeks 12 Months : : : Physical Fitness: Physical Fitness: Physical Fitness: Feelings: Feelings: Feelings: Daily Activities: Daily Activities: Daily Activities: Social Activities: Social Activities: Social Activities: Pain: Pain: Social Support: Social Support: Change in Health: Change in Health: Change in Health: Overall Health: Overall Health: Overall Health: Social Support: Social Support: Social Support: Quality of Life: Quality of Life: Quality of Life: : : : Name: Hospital Number: 8

9 Investigations Type Exercise Test Yes / No / On waiting list of test Results Exercise time: R: Max : % of : METS: RBP: Max BP: On Ex: At : Reasons for stopping: Angiogram Yes / No / On waiting list of test Results: : Echocardiogram Yes / No / On waiting list of test Results: : Risk Stratification Low Medium High Not Known (According to American College of Sports Medicine) : Name: Hospital Number: 9

10 ACTIVITY ASSESSMENT Pre Event: : Sig: Work /Leisure / Daily activities: Activity Levels: Perceived Fitness Perceived Confidence Post Event: Work /Leisure / Daily activities: Activity Levels: Perceived Fitness Perceived Confidence Current limiting factors: Mid Rehab: R RBP : Sig: Work /Leisure / Daily activities: Activity Levels: Perceived Fitness Perceived Confidence Post Rehab: R RBP : Sig: Work /Leisure / Daily activities: Activity Levels: Perceived Fitness Perceived Confidence Patient Goals : Progress mid rehab : Progress post rehab : Name: Hospital Number: 10

11 Prior to exercise and commencement of the programme, this patient will have a functional capacity test if appropriate. Checklist : : Borg Scale given and explained: Exercise Guidelines: Home Exercise: Heart Rates Beta Blockers Yes / No Dose: Resting Age Predicted Maximum 80% 70% 60% Chester Step Test Pre rehab : Readiness to exercise check Pre BP Post BP R I II III IV V 60% 70% 80% /reason test not performed: Post rehab : Readiness to exercise check Pre BP Post BP R I II III IV V 60% 70% 80% /reason test not performed: Sig: Sig: Initial Advice : Initial Exercise Plan : Sig: Name: Hospital Number: 11

12 Pre Exs : Post Exs : : Pre Exs : Post Exs : : Pre Exs : Post Exs : : Pre Exs : Post Exs : : Pre Exs : Post Exs : : Name: Hospital Number: 12

13 Multidisciplinary Progress Notes Name: Hospital Number: 13

14 Pre Exs : Post Exs : : Pre Exs : Post Exs : : Pre Exs : Post Exs : : Pre Exs : Post Exs : : Pre Exs : Post Exs : : Name: Hospital Number: 14

15 Multidisciplinary Progress Notes Name: Hospital Number: 15

16 Completion of phase III On completion of phase III this patient will be given the opportunity for feedback and discussion of progress. Yes No Partially Percentage completed: 0% 1-25% 26-50% 51-75% 76-99% 100% Did not attend-unknown reason Returned to work Left this area Achieved aims Planned/emergency intervention Too ill Died Other : Did not complete letter sent Yes / No & signature: Menu/s attended: (record of the elements of rehab patient experienced, 50% attendance required to qualify) Group exercise classes Individual exercise programme Home exercise plan Lifestyle eduation-written Lifestyle education-talks/video Dietary-group class Dietary-individual Relaxation training Psychological-group talk Psychological-individual counsellor Individual clinical psychology OT groups session OT individual referral Vocational assessment Heart manual Home visits Angina plan Other home programme Other Onward referral: Phase IV community class Social services Patient support group Primary care CHD clinic nurse Medical speciality-medical treat Sexual problems GP- medical treat Community programme No Smoking clinic Voluntary body & signature: Referral made to Phase IV class Yes / No :- Name of class: This patient will have:- Yes/ No Long Term exercise maintenance and risk factor management discussed Reinforce use of hand held record Follow up clinic arranged On completion of phase III a formal referral pathway / link with primary care will be completed within 10 days of finishing programme. Completed Sent Phase IV G.P./ Practice Nurse Consultant Rehab notes Name: Hospital Number: 16

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