Acute Coronary Syndrome Quality Measures Length of Stay RCC Costs per Case Critical Event(s) Evaluation /Acute Phase ECG ASA on arrival (unless documented contraindication) Troponin STAT, repeat once in 6 hrs. Anticoagulant Therapy Cardiac Cath if indicated Cardiology consult Medication reconciliation addressed Documentation of screening for pneumococcal/influenza (seasonal) vaccine Baseline pain assessment VTE/(DVT) risk assessment Appropriate VTE/(DVT) prophylaxis if applicable Initiate stress testing or cardiac catherization if indicated Progressive Phase Change from IV to PO vasodilator Smoking Cessation Advice/Counseling if indicated Administration of Pneumococcal/Influenza (seasonal) vaccine if eligible Discharge Phase Medication reconciliation addressed Assess understanding of discharge instructions
Complete Day 1 Comprehensive history and physical P Baseline skin assessment and documentation of present on admission P,N Baseline pain assessment** N VTE(DVT) risk assessment ** P,N ACS algorithm/ TIMI risk score (as guides to initial site of treatment) P Cardiology consult** P Education Complete Day 1 Assess barriers to learning P,N Orientation to environment, safety protocols N Infection control procedures/ protocols P,N Medication teaching as appropriate N Evaluation/Acute Phase (1-2 days) Tests Complete Day 1 ECG** (baseline and when symptomatic) Troponin STAT, repeat once in 6 hrs. ** Comprehensive Metabolic Profile, Chest X-ray, CPK PT/PTT/ INR if indicated if on anticoagulants CBC with diff and platelets Guiac stools x 1 as indicated Treatments Cardiac monitoring IV /Tubes/Drains IV access Medications Complete Day 1 Medication Reconciliation addressed** P,N Appropriate VTE(DVT) prophylaxis if applicable** Nasal O2 as ordered Anticoagulant Therapy** ASA on arrival (unless documented contraindication)** Consider ACE I / ARB for LVSD less than 40% (If LVSD known) Nitrate therapy (oral/topical) Clopidogrel daily unless contraindicated GPIIb/IIIa Inhibitors at discretion of interventional cardiologist Activity Ambulate unless specifically ordered to the contrary -p Pyschosocial Patient Outcomes Cardiac discomfort relieved/controlled Admission assessment including smoking history N Initiate plan of care P,N Fall / Risk assessment P,N MRSA/VRE screen if indicated N Documentation of screening for pneumococcal / influenza (seasonal) vaccine** N Explain all tests, procedures, plan of care and expected length of stay P,N Patient and family education as it relates to medications, diet, smoking cessation, diagnosis, activity and signs & symptoms requiring intervention P,N,D,T-p,Ph Fasting lipid profile Initiate stress testing or cardiac catherization if indicated ** Consider stress testing as an outpatient if patient is low risk ASA unless documented contraindication Lipid lowering therapy Evaluate need for GI prophylaxis Appropriate VTE(DVT) prophylaxis if applicable** Diet As Ordered P,N,D Consider Low cholesterol, low fat, low sodium diet P I & O if indicated N Monitor and document bowel and bladder elimination N Assess support network N,CM,SW Initiate discharge plan including appropriate referrals N,CM,SW Safety maintained Assessments completed Acceptable patient comfort level Patient &/or family aware of plan of care ** critical event P = LIP D = Dietician (nutrition) T-r = Respiratory Therapist N = Registered nurse CM = Case Manager T-p = Physical Therapist Ph = Pharmacist SW = Social Worker T-s = Speech/Swallow Therapist
Education Tests Treatments IV /Tubes/Drains Medications Activity Psychosocial Progressive Phase (1-2 days) Reassessment of response to treatment and patient care P,N Monitor effects of medication and assess for adverse drug reactions P,N Pain management P,N Patient and family education as it relates to discharge plan, diagnosis, activity, medications, diet, smoking cessation, signs & symptoms requiring intervention. P,N,T-p,D,SW,T-r Reinforce anticipated length of stay and discharge plan P N,T-r, SW Smoking cessation advice/counseling if indicated** ECG PT,PTT,INR if on anticoagulants CBC with diff and platelets if on glycoprotein inhibitors Consider ECHO if LVSD unknown or not documented Cardiac monitoring IV access Consider conversion of IV meds to PO meds Administration of pneumococcal/influenza(seasonal) vaccine if eligible** N Evaluate for stool softener/laxative ASA (unless documented contraindication) Anticoagulant Therapy Nitrate therapy (oral/topical) Change from IV to PO vasodilator** GPIIb/IIIa Inhibitors Reassess need for nasal O 2 Diet as ordered - Advance as tolerated P,N,D I & O if indicated N Monitor and document bowel and bladder elimination N Ambulate unless specifically ordered to the contrary N,T-p Promote independence with ADL's N N, CM,SW Reassess discharge planning needs Discharge notification P,N,CM,SW Consider discharge if appropriate P Patient Outcomes Safety maintained Ambulating/Performing ADL's w/optimal independence Acceptable patient comfort level ** critical event P = LIP D = Dietician (nutrition) T-s = Speech/Swallow Therapist N = Registered nurse CM = Case Manager Ph = Pharmacist SW = Social Worker T-r = Respiratory Therapist T-p = Physical Therapist
Education Tests Treatments Discharge Phase Reassessment of response to treatment and patient care P,N Monitor effects of medication and assess for adverse drug reactions P,N Pain management P,N Assess patient and family understanding of discharge instructions including diagnosis, activity, medications, pain management, diet, smoking cessation, signs & symptoms requiring intervention, and follow up medical appointment** P,N,D,Ph,T-p,SW (use teach back method) Patient identifies personal risk factors and P,N assists with modification Patient understands importance of activity progression P,N ECG if needed PT/PTT/INR if on anticoagulants D/C cardiac monitor IV /Tubes/Drains D/C IV access Medications Medication reconciliation addressed** P,N ASA (unless documented contraindication) D/C Anticoagulant Therapy if indicated Nitrate therapy (Oral/topical) if clinically indicated D/C Nasal O 2 if ordered Activity Diet as ordered P,N,D Ambulate N,T-p N,CM, SW Psychosocial Discharge plan confirmed Provide referral, support information P,N,CM,SW Patient Outcomes Hemodynamic stability Stable and safe appropriate discharge Patient/family demonstrates understanding of discharge instructions Cardiac discomfort relieved/controlled ** critical event P = LIP D = Dietician (nutrition) T-s = Speech/Swallow Therapist N = Registered nurse CM = Case Manager Ph = Pharmacist SW = Social Worker T-r = Respiratory Therapist T-p = Physical Therapist
References ACS Guideline 1. Uptodate. (2009, September 30). Overview of the management of unstable angina and acute non-st elevation myocardial infarction. Retrieved February 3, 2010, from http://www.uptodate.com 2. Uptodate. (2008, April 21). Cholesterol lowering after an acute coronary syndrome. Retrieved February 18, 2010, from http://www.uptodate.com 3. National Guideline Clearinghouse. (2007). Acute coronary syndromes. A national clinical guideline. Retrieved February 1, 2010, from http://www.guideline.gov 4. Milliman Care Guidelines Inpatient and Surgical Care 14th edition. (2010, February 9). Angina and Acute Coronary Syndromes. Retrieved February 23, 2010, from http://careweb.careguidelines.com/ed14isc/0428100b.htm 5. Hills, D. L., & Lange, R. A. (2009). Optimal Management of Acute Coronary Syndromes. The New England Journal of Medicine, 360(21), 2237-2240. 6. Murphy, S. A., Cannon, C. P., Wiviott, S. D., De Lemos, J. A., Blazing, M. A., McCabe, C. H., et al. (2007). Effect of Intensive Lipid-Lowering Therapy on Mortality after Acute Coronary Syndrome ( a Patient-Level Analysis of the Aggrastat to Zocor and Pravastatin or atorvastatin Evaluation and Infection Therapy- Thrombolysis in Myocardial Infarction 22 Trials). The American Journal of Cardiology, 100, 1047-1051. This Clinical Guideline has been developed with support from your institution as a member of Long Island Health Network. It is strongly recommended for the treatment of patients with this diagnosis. It does not take into account unusual patient needs which may dictate different plans of care.