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Care Outlined In This Pathway Must be Altered If It Is Not Clinically Appropriate For The Individual Patient

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:

Thrombolysis: Yes Date:

Time:

Type:

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.

•

N/A - 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

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 P AT h W AY No N -I N ter ve N tIo N al

© The State of Queensland (Queensland

Patient with chest pain ED Chest

Pain Medical Assessment Tool

Cardiac Chest Pain Risk Stratification Pathway Acute Coronary Syndrome suspected/under investigation

Intermediate Risk Chest Pain Clinical Pathway

Acute Coronary Syndrome diagnosed NSTEACS Mgt. Plan

NSTEACS Pathway STEMI PathwaySTEMI Mgt. Plan OR

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Initials Signature Print name Role

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Discharge Checklist

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)

• 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: Consumer Medicines Information

Discharge Medication Record (DMR)

• Cardiac rehab OPD referral completed? Yes No

• heart Failure Service referral completed? Yes N/A

• 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 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)

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Category First 24 hours From: hrs To: hrs

Day 1 Admission to CCU AM PM ND V

Investigations • 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 N/A

• 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 Medications

and Pain Management

• 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)

Observations

Treatments • 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), SaO₂, 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: N/A (if newly diagnosed, refer to Diabetic Educator)

• Daily weight and/or fluid balance chart N/A

• Deep breathing, coughing and leg exercises Nutrition • healthy heart diet Other (specify):

• If for fasting lipids / glucose, no food after 8pm (may have H₂O) N/A Mobility /

Elimination / Hygiene

• 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

• Falls risk score: Waterlow score:

• Mouth care after meals and prn Other Care

(specify) Education and

Discharge Plan • Basic explanation to be given of: AMI Diagnostic procedures Mobilisation and bed exercises Risk factors My Heart My Life book or similar 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

• Other (specify):

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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:

• Review

need for: Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs) IV heparin (or alternative)

Observations

Treatments • 4 hourly (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO₂ (on room air) and circulation

*Record alternate frequency:

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency: N/A (if newly diagnosed, refer to Diabetic Educator)

• Daily weight and/or fluid balance chart, if indicated N/A

• 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 N/A Mobility /

Elimination / Hygiene

• Gentle mobilisation, shower with supervision, toilet privileges permitted (if pain free and TnI reducing). - Record alterations in mobility:

Other Care (specify)

Education and Discharge Plan

• Discuss treatment plan with patient / carer

• Commence discharge checklist on p.3 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):

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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

• 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)

Observations

Treatments • QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO₂ (on room air) and circulation

*Record alternate frequency:

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency: N/A

• Daily weight and/or fluid balance chart, if indicated N/A

• Patent IVC Resite date: OR IVC removed Nutrition • healthy heart diet Other (specify):

• If fasting bloods, confirm blood collection before breakfast N/A Mobility /

Elimination / Hygiene

• Increase mobilisation if painfree

• Self care Other – Record alterations in mobility/hygiene:

Other Care (specify)

Education and Discharge Plan

• Discuss treatment plan with patient / carer

• Review discharge checklist on p.3 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):

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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:

Medications and Pain Management

• 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)

Observations

Treatments • QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO₂ (on room air) and circulation

*Record alternate frequency:

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency: N/A

• Daily weight and/or fluid balance chart, if indicated N/A

• Patent IVC Resite date: OR IVC removed Nutrition • healthy heart diet Other (specify):

• If fasting bloods, confirm blood collection before breakfast N/A Mobility /

Elimination / Hygiene

• Increase mobilisation if painfree

• Self care Other – Record alterations in mobility/hygiene:

Other Care (specify)

Education and Discharge Plan

• Discuss treatment plan with patient / carer

• Review discharge checklist on p.3 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):

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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

• 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)

Observations

Treatments • QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath sounds, heart sounds, SaO₂ (on room air) and circulation

*Record alternate frequency:

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency: N/A

• Daily weight and/or fluid balance chart, if indicated N/A

• Patent IVC Resite date: OR IVC removed Nutrition • healthy heart diet Other (specify):

• If fasting bloods, confirm blood collection before breakfast N/A Mobility /

Elimination / Hygiene

• Increase mobilisation if painfree

• Self care Other – Record alterations in mobility/hygiene:

Other Care (specify)

Education and Discharge Plan

• Discuss treatment plan with patient / carer

• Review discharge checklist on p.3 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):

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A. Patient Variances Actions

A:1 Recurrent chest pain (Differentiate Chest Pain Type; ischaemic, pericarditis or chest wall pain)

• Administer O₂ if indicated – (SaO₂ < 93% or evidence of shock)

• Administer Sublingual Glyceryl Trinitrate

• Perform ECG

• MO Review

• Repeat TnI

• If re-infarction, consider urgent PCI A:2 Cardiac arrest

A:2.1 Ventricular Fibrillation (VF) or Pulseless

Ventricular Tachycardia (VT) • Basic Life Support — CPR

• Code Blue

• Advanced Life Support — Defibrillation A:2.2 Unconscious Complete heart Block /

Asystole • Basic Life Support — CPR

• Code Blue

• Emergency transthoracic pacing, transvenous pacing A:2.3 Pulseless Electrical Activity • Basic Life Support — CPR

• Code Blue A:3 Other arrhythmias:

A:3.1 Conscious sustained Ventricular

Tachycardia • Urgent MO review: - unstable patient (hypotensive): call Medical Emergency Team;

- stable patient within 5 mins A:3.2 First episode of Atrial Fibrillation (AF) or

other Supra Ventricular Tachycardia (SVT) • Urgent MO review: - unstable patient: within 5 mins;

- stable patient: 15–60 mins A:3.3 First episode of heart Block; 2nd or 3rd

degree AV Block • Urgent MO review: - unstable patient (hypotensive/syncope):

call Medical Emergency Team;

- stable patient within 5 mins

• Prepare for transthoracic pacing, transvenous pacing A:4 Left ventricular failure (with Pulmonary

Oedema) • Sit patient upright

• Administer O₂, 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

A:5 Pericarditis • MO review

• Consider analgesia

• Consider echocardiogram A:6 Pulmonary embolus (PE) / Deep vein

thrombosis (DVT) • Urgent MO review

• Anticoagulation

• CTPA or VQ Scan +/- Leg Ultrasound

• O₂ if indicated

• Bed rest A:7 Renal failure (Significant worsening of renal

function as defined by rising creatinine or worsening GFR)

• Assess volume state and urine output

• Urgent MO review; 1–2hrs

• Strict Fluid Balance Chart, consider IDC

• Treat hyperkalaemia A:8 Pulmonary complications (Cough, sputum

production, fever and pleuritic chest pain) • 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

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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 Retro-peritoneal bleeding (hypotension, abdominal

pain, poor urine output) A:13.3 Other bleeding

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

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

B:11 Transfer to private hospital B:12 Change of plan / orders B:13 Self discharge

B:14 Overnight stay

C. Staff Variances

C:1 Medical C:2 Nursing

C:3 Allied health

C:4 Unable to provide patient education

Clinical Events / Variance

Date / Time Variance

Code Describe variances to clinical path and any other patient related notes.

Document as Variance / Action / Outcome Initials

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Code Describe variances to clinical path and any other patient related notes.

Document as Variance / Action / Outcome Initials