Documentation Instructions:•

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Care Outlined in this Pathway Must Be Altered if it is not Clinically Appropriate for the Individual Patient Pathway commenced Date:

Time:

Initials:

Pathway ceased Date:

Time:

Reason:

Initials:

Principal (Final) diagnosis:

Initials:

Treating consultant (print name):

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 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.

• Every person documenting in this clinical pathway must supply a sample of their initials and signature below.

Signature Log:

Initial Signature Print Name Role IN tER m E d IA tE R IS k Ch ES t P AIN Cl INICA l P Ath W Ay

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 v5.00 - 02/2012 Mat. No.: 10206019

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All care givers who initial are to sign signature log Key Allied Health Medical Nursing Pharmacy

Discharge Planning Checklist

Risk Factor Identification and Intervention

Reinforce instructions with patient and carer on CAd Risk Reduction Strategies. Utilise the heart Foundation booklet ‘How to Have a Healthy Heart’ or similar to discuss the following:

Current smoking (comments):

Cholesterol (comments): Weight (comments):

Stress (comments):

hypertension (comments):

Diet (low fat / low salt) (comments): Exercise (comments):

Alcohol (comments):

Refer to Outpatient Services: yes No

dietitian Weight loss “lighten Up” Queensland health Program Cardiologist / Physician Endoscopy Psychologist / Stress management Cardiac Rehabilitation Referral Physiotherapist Other:

Patient Education and Discharge Planning

Reinforce chest pain home management plan with patient and carer

Aboriginal and Islander Liaison Officer required? yes No (if Yes, notify)

Emotional and Social Assessment required? yes No (if Yes, notify Social Worker) Review medications for discharge

Reinforce with patient and carer:

discharge diagnosis diagnostic and therapeutic options general prognosis return to work

discuss ability to drive Check complete and give to patient:

Medical certificate discharge medications and medication use discharge summary and ECG Travel forms (if required)

(copy)

medical follow-up arrangements:

General Practitioner Fax discharge Summary and ECG to GP

Cardiologist Other:

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Category ADMISSION From: hrs ^To: hrs Shift: AM PM ND V

Reviews discharge planning commenced yes No

Investigations ECG + TnI (0 hours and 6 to 8 hours)

Second TnI positive? yes No

ST - T waves changes at 6 to 8 hours? yes No

If yes to either of the above, refer for Cardiology / Physician Registrar review, change to NSTEACS pathway.

If further chest pain, administer glyceryl trinitrate (if not contraindicated), organise medical review (within 10 mins) and perform ECG

EST request form

If EST inappropriate, consider alternate objective testing. Complete EST or alternate testing within 72 hours of presentation.

ESt time booked:... date: ...

Results: Positive (change to NSTEACS pathway) Negative Equivocal Unable to complete Not done, reason: ...

Medications and Pain Management

Review medications

Observations

Treatments Continuous cardiac monitoring (where available)

Cease continuous cardiac monitor if the second tnI is negative.

Pulse, resps and BP frequent if unstable then 4 hourly deep breathing, coughing and leg exercises

Physical assessment (document in medical record) Nutrition Consider appropriate preparation for investigations:

If for EST avoid food for 2 hours prior to test If for MPS, no caffeine 24 hours prior to test

Other: ...

healthy heart / special requirements: ...

Mobility / Elimination / Hygiene

Toilet privileges and bed rest or equivalent

may mobilise after medical review if second tnI normal, painfree and ECGs NAd.

Education and Discharge Plan

Basic explanation of mobilisation and bed exercises

Explanation of: Coronary Artery Disease (CAD) Risk factors

Basic cardiac A&P Potential investigations Provide heart Foundation booklet or similar

Expected Outcome (complete at end of 24 hour period)

Patient demonstrates: A – Achieved V – Variance A V

No further chest pain

haemodynamically stable post cardiac investigations Cardiac rhythm stable post cardiac investigations

Patient verbalises understanding of diagnosis and treatment

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All care givers who initial are to sign signature log Key Allied Health Medical Nursing Pharmacy

Category DAy 2 Date: to Shift: AM PM ND V

Reviews discharge planning commenced yes No Investigations

(if not completed on the previous day)

Second TnI positive? yes No

ST - T waves changes at 6 to 8 hours? yes No

If yes to either of the above, refer for Cardiology / Physician Registrar review, change to NSTEACS pathway.

If further chest pain, administer glyceryl trinitrate (if not contraindicated), organise medical review (within 10 mins) and perform ECG

EST request form

If EST inappropriate, consider alternate objective testing. Complete EST or alternate testing within 72 hours of presentation.

ESt time booked:... date: ...

Results: Positive (change to NSTEACS pathway) Negative Equivocal Unable to complete Not done, reason: ...

Medications and Pain Management

Review medications

Observations

Treatments Continuous cardiac monitoring (where available)

Cease continuous cardiac monitor if the second tnI is negative.

Pulse, resps and BP frequent if unstable then 4 hourly deep breathing, coughing and leg exercises

Physical assessment (document in medical record) Nutrition Consider appropriate preparation for investigations:

If for EST avoid food for 2 hours prior to test If for MPS, no caffeine 24 hours prior to test

Other: ...

healthy heart / special requirements: ...

Mobility / Elimination / Hygiene

Toilet privileges and bed rest or equivalent

may mobilise after medical review if second tnI normal, painfree and ECGs NAd.

Education and Discharge Plan

Basic explanation of mobilisation and bed exercises

Explanation of: Coronary Artery Disease (CAD) Risk factors

Basic cardiac A&P Potential investigations Provide heart Foundation booklet or similar

Expected Outcome (complete at end of 24 hour period)

Patient demonstrates: A – Achieved V – Variance A V

No further chest pain

haemodynamically stable post cardiac investigations Cardiac rhythm stable post cardiac investigations

Patient verbalises understanding of diagnosis and treatment

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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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DO n O t write in this bin D ing margin D O nO t w rite in this bin D ing margin Variance Codes (continued)

B. Discharge / Treatment Delay Variances

B:1 treatment delay

B:1.1 Exercise stress test 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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