ACUTE CORONARY SYNDROME - wdhb.org.nz · ACUTE CORONARY SYNDROME PATHWAY. Page 2 of 40 STAT 0033CAT...
-
Upload
phungkhuong -
Category
Documents
-
view
217 -
download
0
Transcript of ACUTE CORONARY SYNDROME - wdhb.org.nz · ACUTE CORONARY SYNDROME PATHWAY. Page 2 of 40 STAT 0033CAT...
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 1 of 40
Clinical Pathway
ACUTE CORONARY SYNDROME
Whanganui District Health Board
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
STEMIST Elevation Myocardial
Infarction
NSTEACSNon ST Elevation Acute Coronary
Syndrome
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
PATH
WAY
Page 2 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
ACUTE CORONARY SYNDROME ALGORITHM
(A) DIAGNOSTIC CRITERIA History of angina or
equivalent Assess Risk Factors New or presumed ST elevation at J point in 2 or more contiguous leads ST elevation > 0.2 mv in leads V1 V2 V3 or > 0.1 mv in other leads New LBBB with presence of one of the following ST elevation > 1mv in
leads with +ve QRS ST depression > 0.5
mv in V1 – V3 ST elevation > 0.5mv
in leads with -ve QRS Inferior infarcts must
have V3R & V4R leads recorded to detect RV infarct
Posterior V7 V8 V9 should be performed if Posterior MI suspected
Posterior wall infarct ST depression V1 V2 with upright T waves or presence ST elevation in posterior chest leads
(V7 V8 V9) (STEMI/NSTEMI 2005 NZ management
(B) REQUIREMENTS for THROMBOLYSIS Resuscitation status Eligibility sheet
completed (see page 3) Assess need for URGENT
PCI (p11)
(C) TROPONIN >0.04 elevation also noticed in - Significant renal failure - PE (usually < 0.2 and
associated with significant PE - Severe COPD - Muscle disease - CKMB preferred for
diagnosis of reinfarction
- Sepsis - Myocarditis
(D) DECISION to MONITOR Ongoing pain
requiring GTN Arrhythmia Co – morbidities Quality of life Location of monitored beds CCU 6 beds Telemetry 6 units AAU 6 beds
(E) RISK STRATIFICATION
Add TIMI score points Age >65 years 1 3 risk factors for 1 IHD Prior coronary 1 stenosis >50% >0.5mm ST 1 deviation on ECG >angina 1 episodes past 24 hours Aspirin use past 1 7 days Elevated serum 1
cardiac markers 0 – 2 low risk 3 – 4 intermediate risk 5 – 7 high risk NB Admission is at
the discretion of the Consultant
PATIENT ARRIVES IN EMERGENCY WITH SUSPECTED ISCHAEMIC CHESTPAIN
Obtain ECG on arrival, document time and assess for changes
Review by doctor within 10 minutes
Monitor lead 11 O2 @ 2-6L/min via nasal prongs OR 6-8 L/min via Hudson mask
to keep SpO2 94-96% in COPD 88-94% (pending ABG) Insert 18g IV cannula x2 Aspirin 300mgs to chew stat Bloods – Creatinine, Electrolytes, FBC, Troponin T, Coagulation profile, INR if on Warfarin, C Reactive Protein BP both arms Glyceryl Trinitrate/Morphine/anti emetic
ECG shows ST elevation
or new LBBB see (A) STEMI
ECG shows New
ST depression Or
New T wave inversion
NSTEMI
ECG -ve
Troponin +ve
see ( C )
ECG -ve
Troponin -ve
see ( C )
Discuss with consultant
Reperfusion Therapy
Follow STEMI NZ guidelines
see ( B )
Monitor
see ( D )
Monitor 6 hours ED / AAU
Repeat ECG /
Trop 6-8 hours
NSTEMI / ongoing chest pain
Low risk see ( E )
(D/W consultant)
YES NO YES NO
Admit CCU Admit ward on telemetry
Discharge with
Referrals for OPD
investigations
+ve -ve
Oral Metoprolol unless contraindicated
Chest X-ray
Thrombolysis criteria met (see page 3) STK 1.5mu
over 30 mins OR
Tenectaplase As per protocol
See p 10
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 3 of 40
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
ELIGIB
ILITY
FOR
THR
OM
BO
LYS
IS
Absolute Contraindications YES √ NO √ • AnypriorIntracranialHaemorrhage • Knownstructuralcerebralvascularlesion(e.g.ateriovenousmalformation) • Knownmalignantintracranialneoplasm(primaryormetastatic) • Ischemicstrokewithin6monthsEXCEPTacuteischemicstrokewithin3hours • Suspectedaorticdissection • Activebleedingorbleedingdiathesis(excludingmenses) • Significantclosed-headorfacialtraumawithin3weeksRelative contraindications • Historyofchronic,severe,poorlycontrolledhypertension • Severeuncontrolledhypertensiononpresentation (SystolicBP>180mmHgofdiastolicBP>110mmHg) • Historyofpriorischemicstrokegreaterthan3months,dementia,orknownintracranialpathology
not covered in contraindications or TIA within 6 months • Traumaticorprolonged(>10min)CPRormajorsurgery(<3weeks) • Recent(within2-4weeks)internalbleeding • Noncompressiblevascularpunctures • Forstreptokinase:priorexposure(morethan5daysago)orpriorallergicreactiontotheseagents • Pregnancyor1weekpostpartum • Activepepticulcer • Currentuseofanticoagulants:thehighertheINR,thehighertheriskofbleeding/Advancedliver
disease Source: American College of Cardiology
n Patients with ongoing chest pain > 12 hours may be eligible for streptokinase – discuss with Consultant
n Informed Consent obtained VERBALLY n STREPTOKINASE charted on medication form Date __________________
Medical Signature ___________________________________ Name _______________________________________ & Time ________________ (Printed)
ASSESSMENT OF ELIGIBILITY FOR THROMBOLYSIS
YES NO Has the patient experienced chest discomfort for greater than 15 minutes from onset?
Has pain persisted for less than 12 hours?
Time of onset of pain ___________________________
Discuss with consultant assoon as possibleYES NO
Are there contraindications to fibrinolysis? If ANY of the following are checked “YES” fibrinolysis MAY be CONTRAINDICATED
Thrombolysis Audit Tool Door to Needle Time √ Avoidable Delays √ Unavoidable delays √ 0-20 minutes Delayto1stECG Language
21-30 minutes InterpretingECG Contraindications
31-40 minutes Contactingkeyperson Other…(specify)
41-60 minutes Other
≥60 minutes
WhanganuiDistrict Health Board
Page 4 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DO
NO
T R
ES
US
CITA
TE O
RD
ER
DO NOT RESUSCITATE ORDER
If _______________________________________________________________________________________________________________
(Patientname)
becomesunresponsiveandiswithoutapulseornotbreathing:
1. DO NOT INITIATE CARDIOPULMONARY RESUSCITATION
(chestcompressionsand/ormechanicalventilation)
2. DO NOT CALL A CARDIAC OR PULMONARY ARREST
Indication(s)forDoNotResuscitateorder:
At the request of __________________________________________________________________________________________________________ (Patient’sname)
_________________________________________________________________________________________________________________________________
(Patientsignatureorparents/guardianifminor)
Witnessed By ________________________________________________________________________________________________________________
(Doctor’snameandsignature)OR
Medically Contraindicated Yes / No
Doctor’sname: _________________________________________________________________________________________________________________
(Print)
Doctor’ssignature: ___________________________________________ Date: _______ / ________ / ________ Time: _________________
Designation:(circleone) Physician Consultant MOSS Registrar
If this is a telephone order, 2 Registered Nurse and/or Medical Practitioner Confirmation:
_______________________________________________________________ ______________________________________________________________
(Nameanddesignation) (Nameanddesignation)
Date of decision: _____________________________________________ Date reviewed: ______________________________________________
Decisiondiscussedwithpatientand/ornominatednextofkin Yes / No
If not discussed, reason:
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page5of40
MED
ICA
L HIS
TOR
Y A
ND
EX
AM
INA
TIO
NSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Dateandtimeofdiscomfort/pain/tightnessonset:
Site:
Precipitatingeventandduration:
Character:
Radiation:
Course of Pain:
Relievingorexacerbatingfactors:
Similarepisodesinthepast:
Associatedsymptoms:
Frequency of anigina/use of GTN:
Past Cardiac History:
Previous Cardiac Events: includedatesofangio,CABG,Stentsandwhichhospitalhasprovidedmanagement
Ongoing Cardiac Medical Conditions:
Medical History and Examination: To be completed following administration of thrombolysis
Presentation: History of this episode of chest pain
WhanganuiDistrict Health Board
Page 6 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
MED
ICA
L HIS
TOR
Y A
ND
EX
AM
INA
TIO
N
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
BLOOD PRESSURE:
CHOLESTEROL: Never tested Other:
HISTORY OF DIABETES: No
TypeI/II:Duration:CurrentTreatment:
FAMILY HISTORY premature IHD and other conditions:
SMOKER: Current Ex-Smoker Never Pack/Years ___________________
STRESS:
Other Medical History
Social History
EMPLOYMENT: VOCATIONAL DRIVERS LICENSE:
Medications Drug Drug
ALLERGIES/ADVERSE DRUG REACTIONS
General ExaminationBP: Pulse: Rhythm: RR: SpO2:
Colour: Pain: SOB: Skinconditioni.e.cold,clammy
Risk Factors:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 7 of 40
MED
ICA
L HIS
TOR
Y A
ND
EX
AM
INA
TIO
NSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
CNS:
CVS:
JVP: Carotid Bruits:
CardiacExam: Peripheraloedema:
HeartSounds PeripheralPulses:
Respiratory:
Effortofbreathing:
ChestExam:
Abdominal
Diagnostic Tests
X-Ray
RESULTS:
Na Hb Other:
K Hct
Cr Plat
Urea WCC
Ca INR
Phos Troponin
Mg CRP
RESUSCITATION STATUS DISCUSSED
YES NO
DO NOT RESUSCITATE FORM COMPLETE
YES NO
WhanganuiDistrict Health Board
Page8of40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
MED
ICA
L HIS
TOR
Y A
ND
EX
AM
INA
TIO
N
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
DIAGNOSIS / IMPRESSION
PLAN OF CARE
Prescribe on Admission - If not prescribing, state reason for contraindication –
Aspirin Metoclopromide
ACEinhibitor GTN
BetaBlocker Statin(e.g.Simvastatin)
MorphineIVprn Clopidogrel
Diabetics–considerIVinsulininfusionaccordingtoslidingscale
Admitting Consultant Contacted: Time: ________________
CCU informed: Nurse: ____________________________________________________________________ Time: ________________________
Admitting Doctor: ________________________________________________________________________________________________________
Signed: ___________________________________ Designation: ____________________________________ Date: ________________________
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 9 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
GU
IDE
LINE
SSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
CORONARY SYNDROME PREFERRED TREATMENT GUIDELINES • PatientswithuncomplicatedMI/NSTEACSmaybedischargedafter4-6daysinhospital. • PatientswithUNSTABLEANGINAmaybedischargedafter3daysinhospital. • AnExerciseToleranceTest(ETT)maybedonebeforedischargeorarrangedforasanOutpatient. • Cardiologyreview/follow-upforpatientsidentifiedasHighorIntermediateRiskpostMI.
• ConsideredforpatientswithevidenceofLeftVentriculardysfunction,oratdiscretionofPhysician• Startwithin48hoursofMI;Cilazapril0.5mg,Quinapril2.5mg,Enalapril2.5mgorCaptopril6.25mgdaily,
increase daily as tolerated
• GlycerylTrinitratespray2puffs/tablets0.3–0.6mgat5minuteintervalsdependingonassessmentofseverityofpainandBP(systolic>90mmHg)
Morphine2.5–5mgIV incrementsprntoachievepainrelief,monitoringrespiratorystatus(RR>8)andBP(systolic>90mmHg) (administrationaccordingtoCCUProtocolguidelines)
• IVMetoclopramide10mgq6h• Temazepam10-20mgorZopiclone3.75mg–7.5mgorpatientsusualmedication
• Aspirin150to300mgshouldbegivenonday1ofSTEMIandintheabsenceofcontra-indicationsshouldbecontinuedindefinitelyonadailybasisatadoseof100mg,entericcoated.(LevelofEvidence:A)
• Clopidogrelshouldbeadministeredtopatientswhoareunabletotakeaspirinbecauseofhypersensitivityormajorgastrointestinalintolerance.(LevelofEvidence:C)
• Angiogram+/-PCI<48hoursClopidogrel600mgoralloading,then150mgpood• NoAngiogramwithin48hours–Clopidogrel300mgoralloading,andthen75mgpood• (assessbleedingriskinallpatients;NOCLOPIDOGRELLOADINGINPATIENTSOVER75yo)• ClopidogrelmaybegiventoSTEMI(Clarity-Timi28)postfibrinolytictherapy
• Anxiolytics can play an important role in patient management in this setting. Treatment withbenzodiazepinesshouldbelimitedtotheminimaldoseforalimitedperiodoftime.
• Patientsexperiencingnicotinewithdrawalcanbenefit fromAnxiolytics.Useofbupropionandnicotinereplacementtherapyintheacutesettingshouldalsobeconsideredasoptions
• Alwayscheckelectrolytes(K+,Na+,Ca++,Mg+)andoxygensaturations• IdentifyarrhythmiaandfollowGHWResuscitationguidelines
• Checknocontra-indicationspresent(i.e.Asthma,LVF,HR<60/m,BP<100mmHgSystolic;CardiogenicShock;>1°HeartBlock)
• Carvidolol(dosedecidedbyphysician)ORMetoprololCR23.75mg–47.5mgorallystatandthencharteddaily(Normallygivenimmediatelypost-thrombolysis)
• FBC,Electrolytes,Creatinine,Glucose,LFT,Troponin,TFTs(ifindicated),coagprofile• Electrolytes,Creatinine,Glucose,CK,Troponin(POSTSTKandNSTEAC)• FBC,Electrolytes,Creatinine,Glucose,Troponin,FastingLipids• Electrolytes,Creatinine• NOTE: REPORT ACUTE DROP OF HB of 20% &/OR < 90g/L to RMO
• LBBB:FullthicknessMIdiagnosedonclinicalgroundsÕThrombolysis RBBB:doesnotmaskfullthicknessMI.ThedevelopmentofRBBB+LAHBmayindicateneedforpacing
• DefinedasBP<100mmHgsystolic,LVF,coolperipheries,lowurineoutput• Thrombolysismaynotbeeffective,discusswithConsultantreearlyangiography• SupportivetreatmentwithIVinotropes NB: In presence of inferior MI, low CO may reflect RV infarction. Rx IV fluid challenge/IV
inotropes
• Presenceofsymptoms:chestpain,SOB,palpitations• Presenceofsigns:newmurmur(MR,VSD),evidenceofCardiacFailure,pericardialrub• Presenceofarrhythmias:ECG,telemetry
• Considerinsulininfusionasperseparateprotocolifglucoselevel ≥ 11mmol / L (only if NBM otherwise regular medication with sub cut. If insulin treated and
NBM insulin infusion as per iv insulin protocol. If eating as per sub cut protocol.
ACEInhibitor
Analgesia (ischaemia)
Anti-emeticNight Sedation
Antiplatelets
Anxiolytics
Arrhythmia
Beta-blocker
Bloods0-24hrs(onadmission) 6–8hrs Day 1 Day 2
Bundle Branch Blocks
Cardiogenic Shock(CGS)
Clinical Review
Diabetes&MI&/orhyperglycaemia
Guidelines continue next page 10
WhanganuiDistrict Health Board
Page 10 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
GU
IDE
LINE
S
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
PREFERRED TREATMENT GUIDELINES (CONTINUED)
Enoxaparin
LVF
OxygenTherapy
Post MI / NSTEAC chestpainmanagement in wards
Post MI / NSTEACbradycardia
Post MI / NSTEAhypotension
Thrombolysis
Patientunstablepost-thrombolysis
Statins
• LMWH(enoxaparin)usedafterSTK 1mg/kgscBDisoptionalandifpatient<75withfailedthrombolysis• Innon-STEMILMWH1mg/kgscBDuntil24–48hrspainfree
• Definedasclinicalorradiologicalevidenceofpulmonaryoedema;SOB,LowSpO2• TreatmentoptionsincludeO2,IVFrusemide,IVMorphine,IV/SLGlycerylTrinitrate,IVinotropes• BIPAP(SpO2<92%)/mechanicalventilation
• SupplementaloxygenshouldbeadministeredifSpO2<90%,respiratorydistressorhigh-riskfeaturesforhypoxaemiaviaHudsonmask6–8L/minorNasalprongs4-6l/min(LevelofEvidenceB)
• ItisreasonabletoAdministeroxygentoallACSpatientsduringfirst6hoursafterpresentation(LevelofEvidenceC)
• Monitortherapywithoxygensaturationmeasurements
• Stopactivities,rest,useGTNspray/tab,MorphineandOxygenasperpainreliefprotocolabove.• Ifpainpersists,orisseverefromthestart,take12leadECG,BP,callDoctor• Differentialdiagnosis:Re-infarction/unstableangina;pericarditis,non-cardiacpainetc• Treataccordingtodiagnosis:• Re-infarction/unstableanginatransfertoCCU• Pericarditis:paracetamolQ4h/considerNSAIDfor2days:ConsiderEchocardiography
• HR<45bpmshouldbereportedtoDoctorformedicationreview.Betablockers,calciumchannelblock-ers,digoxinmaybecontributing.Withholdifpatientsymptomatic,take12leadECGtoascertainrhythm
• SystolicBP<95mmHgshouldbereportedtoDoctorformedicationreview.Individualparametersmaythenbeset;Betablockers,Calciumchannelblockers,ACE,nitratesmayrequirereview,especiallywhenpatientsymptomatic.
• Tenecteplase use in large anterior acute STEMI OR NEW LBBBinpatients<75yo• Enoxaparin 30mg IV pre Tenecteplase patients <75yo (omit if >75yo or known creatinine
clearance <30ml/min)• Tenecteplase weight based dose over 5-10secs
Patient Weight
Dose of tenecteplase
Volume of reconstituted solution
<60kg 30mg 6ml
60-69kg 35mg 7ml
70-79kg 40mg 8ml
80-89kg 45mg 9ml
>90kg 50mg 10ml
• Clopidogrel 300mg loading dose post Tenecteplase and then 75mg per day• Enoxaparin 1mg/kg bd (0.75mg/kg in patients over 75yo maximum dose 75mg bd)• UseStreptokinase(STK)in other instances and if patient over 75yo.Give1.5MuofSTK,IVover
30 minutes• Any reaction to STK other than hypotension→ STOP infusion. Evaluate need for other thrombolytic
agent
(Refer to intranet pharmacy page for more detailed information)
• DiscusswithConsultant.Maybecandidateforinvasivetherapy
• CommenceStatin.DiscusswithConsultant• Lipid profile should be performed, preferably after fasting and within 24 hours of symptom onset (LevelofEvidence:C)
Guidelines continue next page 11
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 11 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
GU
IDE
LINE
SSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
-
Disclaimer: This tool is intended as a guideline and should not replace clinical judgement
PREFERRED TREATMENT GUIDELINES (CONTINUED)
• RelievepainwithGTNandIVMorphine(perprotocolabove)• treatLVFifpresent• UseIVBetablockerspriortothrombolysis(IVMetoprolol5mgx3,eachover5minutesand5minutesbetweendosesifBP>100mmHgSystolicandHR>60/min)
• Indicatedforpatientswith largeAnteriorMI(CK>3000), inpresenceofdocumentedmural thrombus,TIA/AFpostMI
• Continuedfor3–6monthsorasclinicallyindicated
Primary PCA• Patientsineligibleforthrombolysisandwithanticipatedarrivaltimeincathlabof<12hoursafteronsetofsymptoms
• OtherpatientsinWellingtonorHuttifdoortoneedletime<90minutesRescue PCA• Patientswhohavenot re-perfused at 90minuteswithmoderate to large territory involved andwithsymptomonset<6hoursbeforereferralismade
STEMI complicated by shock• Patients<75years;onsetofshock<12hoursago;<36hourspostSTEMIFollowingSTEMItreatedwithThrombolysis• Patientswhohavere-perfusedandstillhavemoderate-to-largeareaofmyocardiumatrisk• Patientswhohavepost–infarctanginaorapositivepre-dischargestresstest
Troponin positive ACS• GoodstoryforACS• ST depression, widespread T wave inversion, diabetes, haemodynamic changes or known coronary
artery disease• PatientswithlowprobabilityofcoronaryheartdiseaseandnoECGchangesmayundergoanin-hospitalstresstestbeforeconsideringangiography.Anechocardiogrammayalsobeappropriate.Proceedwithangiographyifstresstestpositive.
• Note;Angiogramshouldbedonewithin72hoursofadmissionandrisksversusinterventionshouldbeconsideredinpatients>75yearsandco-morbiditiese.g.Renalfailure
Troponin – negative ACS • Otherhighriskfeaturese.g.STdepression,haemodynamicchanges• PositiveStresstest,especiallyifverypositive
SystolicBP≥180mmHg
Warfarin
Wellington Regional Transfer Guidelines forSTEMI
Wellington Regional Transfer Guidelines for angiographyNSTEACS
WhanganuiDistrict Health Board
Page 12 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
0-2
4 h
ours
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Guidelines for multidisciplinary team: 0 – 24 HOURS (tick where appropriate)
STEMI NSTEACS
DIAGNOSISTick in appropriate box
STEMI NSTEMI UNSTABLE ANGINA
DATE:
Thrombolysistreatmentwithin30minofadmission BloodstakenperACSalgorithm Stat/regular medications administered and charted includingGTN,analgesia,antiemeticandClopidogrel
IVCannulax2(18gauge) ChestX-ray Medicalhistory/examinationcomplete painandassociatedsymptomsassessed rhythm monitoring lead II baselinevitalsigns5minwiththrombolysis (15minutelyinED)thenQ1-2hourly&prn
MRSAriskidentified ECG2hourspostSTK Electrolytes,creatinine,Glucose,CK,Trop4-6hourspostSTK
Fluid Balance Chart commenced Bedrest MDT referrals Explanationcondition/pathwaybookletgiventopatient/family/whanau
Bowelsopened SmokingABCassessedanddocumented
BloodstakenperACSalgorithm Stat / regular medications administered and charted includingGTN,analgesia,antiemeticClexaneandClopidogrel
IVCannulax2(18gauge) ChestX-ray Medicalhistory/examinationcomplete painandassociatedsymptomsassessed rhythm monitoring lead II baselinevitalsignsthenQ1-2hourly&prn MRSAriskidentified Electrolytes,creatinine,Glucose,FBC,TropandECG12hourspostonsetofchestpain(nottakenafter2200hoursbutnextmorning)
Bedrest MDT referrals Assessment for early Angiogram explanationcondition/pathwaybookletgiventopatient/family/whanau
Bowelsopened SmokingABCassessedanddocumented
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 13 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
0-2
4 h
ours
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 14 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
0-2
4 h
ours
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page15of40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
0-2
4 h
ours
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 16 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
PATH
WAY
SU
MM
AR
Y
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
CORONARY SYNDROME PREFERRED GUIDELINES
Summary of Clinical Pathwayn TostandardisethePracticeofNursingandMedicalCareforpatientswithAcuteCoronarySyndrome.
Criteria for Placement on Clinical Pathway n Accordingtoriskstratification
Exclusion Criterian VF Arrest and Ventilatedn DifferentialDiagnosise.g.Pericarditis,PulmonaryEmbolusn Stroke
Education includesUnderstandingbypatientof:n Patientpathwayn SmokefreeABCassessedandacteduponn Expectedlengthofstayn CardiacEducationmayincludeCardiacRehabilitation
Discharge planning n Educationcompleten Multidisciplinaryteaminvolvementn ReferraltoCardiologistWellingtonforangiographyifrequired,completedbyconsultantphysician (checklistforpatientstransferringtoCardiacCareUnitcompleted)n CardiacRehabilitationNursereferralactionedn Wardtransfersheetcompletedpriortotransfertowardn Patient/significantothersawarethatdischargecriteriahasbeenmetn Expectedlengthofstayis3daysNSTEAC,5daysSTEMI
Discharge Criteria n Painfreeaftermobilisationn Definitivediagnosis
Key Performance Indicators Target
1 Aspirinonarrival 100%
2 ECGtakenandsightedwithin10minutes 100%
3 Doortoneedletimelessthan90minutes 100%
4 LipidloweringtherapyondischargewithelevatedLDL-c 100%
5 ACEInhibitorifhypertensiveordiabetic 100%
6 Clopidogrelorotherantiplatelet 100%
7 Metoprololorotherbetablocker 100%
8 SmokingassessmentABCcomplete 100%
9 TargetLengthofStay(LOS)5daysSTEMI,3daysNSTEACachieved 100%
10 Patientreceivespathwaybookletonadmission 100%
11 Patienteducationcomplete 100%
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 17 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
ON
ESurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Guidelines for multidisciplinary team: Day One (tick where appropriate)STEMI NSTEAC
DIAGNOSISTick in appropriate box
STEMI NSTEMI UNSTABLE ANGINA
DATE:
NIGHT STAFF START NOTE ENTRY HERE:
BetaBlocker/Aspirin/regularmedscharted Clopidogrel Statin AceInhibitor APPT/INR Echobooked ChestX-rayreview IVCannulasitecheck,secure,flushed Painandassociatedsymptomsassessed Rhythm monitoring lead II VitalsignsthenQ2-4hourlyprn Elect,creatinine,Glucose,CK,Trop,FBC,fastinglipids,(TFT’sifrequired)
ECG FluidBalanceChart(weighifindicated) Monitorbloodglucose Bedrest/upinchair/walktotoiletifpainfree Seenbycardiacrehabilitationnurse explanationcondition/pathwaybookletgiventopatient/family/whanau
Takeheartbookletgiventopatient Takeheartvideoviewed Bowelsopened SmokingcessationABCdocumented
BetaBlocker/Aspirin/Clexane/regularmedscharted Clopidogrel Statin AceInhibitor APPT/INR Echobooked ChestX-rayreview Angiogramreferral/checklistcommenced IVCannulasitecheck,secure,flushed Painandassociatedsymptomsassessed Rhythm monitoring lead II VitalsignsthenQ2-4hourlyprn Elect,creatinine,Glucose,CK,Trop,FBC,fastinglipids,(TFT’sifrequired)
ECG Bowelsopened Monitorbloodglucose Bedrest/upinchair/walktotoiletifpainfree Seenbycardiacrehabilitationnurse explanationcondition/pathwaybookletgiventopatient/family/whanau
Takeheart/angiogrambookletgiventopatientandexplained
Assessmentofsuitabilityforwardtransfer SmokingcessationABCdocumented
WhanganuiDistrict Health Board
Page18of40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
ON
E
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 19 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
ON
ESurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 20 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
ON
E
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 21 of 40
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
ON
E
MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 22 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
TW
O
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Guidelines for multidisciplinary team: Day Two (tick where appropriate)
STEMI NSTEAC
DIAGNOSISTick in appropriate box
STEMI NSTEMI UNSTABLE ANGINA
DATE:
NIGHT STAFF START NOTE ENTRY HERE:
Electrolytes,creatininetaken/reviewed
Medication review
Angiographyconsidered
Transfer to ward on telemetry
ETTbooked
IVCannulasitecheck,secure,flushed
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG
FluidBalanceChart(weighifindicated)
Monitorbloodglucose
Upinchair/walktotoilet/showerifpainifpainfree
explanationcondition/pathwaybookletreviewedwithpatient/family/whanau
Takeheartvideoviewedbypatient
Cardiacrehabilitationnursereview
Bowelsopened
SmokingcessationABCdocumented
Electrolytes,creatininetaken/reviewed
Medication review
Angiographyreferral/checklistcommenced
Transfer to ward on telemetry
ETTbooked
IVCannulasitecheck,secure,flushed
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG
Monitorbloodglucose
Upinchair/walktotoilet/showerifpainifpainfree
explanationcondition/pathwaybookletreviewedwithpatient/family/whanau
Takeheartvideoviewedbypatient
Cardiacrehabilitationnursereview
Bowelsopened
SmokingcessationABCdocumented
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 23 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
TW
OSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 24 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
TW
O
MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page25of40
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
TW
O
MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 26 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
TW
O
MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 27 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
THR
EESurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Guidelines for multidisciplinary team: Day Three (tick where appropriate)
STEMI NSTEAC
DIAGNOSISTick in appropriate box
STEMI NSTEMI UNSTABLE ANGINA
DATE:
NIGHT STAFF START NOTE ENTRY HERE:
Warfarin considered
INR if on warfarin
ACEInhibitorpriortodischarge
Medication chart reviewed
Eligiblefortransfertoward/Telemetry
IVCannulasitecheck,secure,flushed
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG
FluidBalanceChart(weighifindicated)
Monitorbloodglucose
Upinchair/walktotoilet/shower/walkingincorridorifpainfree
pathwaybookletreviewedwithpatient/family/whanau
Cardiacrehabilitationnursereview
Bowelsopened
SmokingcessationABCdocumented
ACEInhibitorpriortodischarge
Medication chart reviewed
IVCannulasitecheck,secure,flushed
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG
Monitorbloodglucose
Upinchair/walktotoilet/shower/walkincorridor
pathwaybookletreviewedwithpatient/family/whanau
Cardiacrehabilitationnursereview
Discharge home / Wellington for angiogram
Dischargesummary/prescription/OPDappointment
Bowelsopened
SmokingcessationABCdocumented
WhanganuiDistrict Health Board
Page28of40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
THR
EE
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 29 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
THR
EESurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 30 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
THR
EE
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 31 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
THR
EESurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 32 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FOU
R
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Guidelines for multidisciplinary team: Day Four (tick where appropriate)
STEMI NSTEAC
DIAGNOSISTick in appropriate box
STEMI NSTEMI UNSTABLE ANGINA
DATE:
NIGHT STAFF START NOTE ENTRY HERE:
ETT arranged
Warfarin considered
INR if on warfarin
ACEInhibitorpriortodischarge
Medication chart reviewed
Eligiblefortransfertoward/Telemetry
IV Cannula removed / resited
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG Bowelsopened
FluidBalanceChart(weigh)
Monitorbloodglucose
Upinchair/walktotoilet/shower/walkingincorridor/stairsifpainfree
pathwaybookletreviewedwithpatient/family/whanau
Cardiacrehabilitationnursereview
ETT done
INR if on Warfarin
ACEInhibitorpriortodischarge
Medication chart reviewed
IV Cannula removed / resited
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG Bowelsopened
Monitorbloodglucose
Upinchair/walktotoilet/shower/walkincorridor
pathwaybookletreviewedwithpatient/family/whanau
Cardiacrehabilitationnursereview
Discharge home / Wellington for angiogram
Dischargesummary/prescription/OPD& Cardiologyappointment/smokefreefollow-up
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 33 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FOU
RSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 34 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FOU
R
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page35of40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FOU
RSurname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
Page 36 of 40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FOU
R
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 37 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FIVE
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:
Guidelines for multidisciplinary team: Day Five (tick where appropriate)
STEMI NSTEAC
DIAGNOSISTick in appropriate box
STEMI NSTEMI UNSTABLE ANGINA
DATE:
NIGHT STAFF START NOTE ENTRY HERE:
ETT arranged
INR if on Warfarin
IV Cannula removed
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG
Fluid Balance Chart Bowelsopened
Monitorbloodglucose
Upinchair/walktotoilet/shower/walkingincorridor/stairsifpainfree
pathwaybookletreviewedwithpatient/family/whanau
Cardiacrehabilitationnursereview
Dischargesummary/prescription/medicalcertificate/OPDandCardiologyappointment
Smokingcessationfollow-up
ETT arranged
INR if on Warfarin
IV Cannula removed
Painandassociatedsymptomsassessed
Rhythm monitoring lead II
VitalsignsQ-4hourlyprn
ECG
Fluid Balance Chart Bowelsopened
Monitorbloodglucose
Upinchair/walktotoilet/shower/walkingincorridor/stairsifpainfree
pathwaybookletreviewedwithpatient/family/whanau
Cardiacrehabilitationnursereview
Dischargesummary/prescription/medicalcertificate/OPDandCardiologyappointment
Smokingcessationfollow-up
WhanganuiDistrict Health Board
Page38of40STAT 0033 CAT 0063 Review Date 02/2013
Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FIVE
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES:
WhanganuiDistrict Health Board
STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 39 of 40
AC
UTE
CO
RO
NA
RY
SY
ND
RO
ME
DAY
FIVE
Surname: NHI:
First Names: Ward:
Address: DOB:
ACC No:
GP:
Consultant:MULTIDISCIPLINARY NOTES: