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Clinical Pathways Never Replace Clinical Judgement

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

Pathway commenced Date: .........................................Time: ........................Initials: ..............................

Has patient transferred from another facility? Yes STEMI date: .............................. Time: .............................. Initials:....................

If STEMI > two days ago, commence daily care on page 5

Late presentation: Yes Date: ...............................Time: ...................................

Pathway ceased Date: .........................................Time: ........................Reason: ...................................................................Initials:.................

Treating consultant (print name): ................................................................................................................

Procedures:

Thrombolysis: Yes Date: ............................... Time: .............................. Type: ................................................................................................................

No

Chest x-ray: Yes Date: ...............................

Echocardiogram:

Scheduled? Yes Date: ............................... Not for echocardiogram, Reason: ................................................................................

Performed? Yes Date: ...............................

Angiogram:

Scheduled? Yes Date: ............................... Not for angiogram, Reason: ...............................................................................................


Angioplasty (PCI): Scheduled? Yes Date: ............................... Not for PCI, Reason: .................................................................................................................


Coronary Artery Bypass Grafts (CABG):

Surgical referral completed? Yes Date: ................................

Cardiac surgeon review? Yes Date:................................

Scheduled for CABG? Yes Date: ................................ Not for CABG, Reason: .............................................................

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 fag itin the Variance

column, then document in the free text area as instructed.

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 mustsupply a sample of their initials and signature below.

Signature Log:Initials Signature Print name Role

STEMIPATHWAY

INTE

RVENTIONAL

The

Stateo

fQueens

lan

d(Queens

lan

dH

ea

lth)2012Con

tac

tCIM@hea

lth

.qld

.gov.au

Patient with chest pain

ED Chest

Pain Medical

Assessment Tool

Cardiac Chest Pain Risk Stratication Pathway

Acute Coronary Syndrome suspected/under investigation

Intermediate Risk Chest Pain Clinical Pathway

Acute Coronary Syndrome diagnosed

NSTEACS Mgt. Plan

NSTEACS Pathway STEMI Pathway

STEMI Mgt. PlanOR

(Afx identication label here)

URN:

Family name:

Given name(s):

Address:

Date of birth: Sex: M F I

STEMI Clinical Pathway(ST-Elevation Myocardial Infarction)

For InterventionalCardiac Facilities

Facility:


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Signature Log (continued):

Initials Signature Print name Role


URN:

Family name:

Given name(s):

Address:





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

Discharge Checklist Initials Date

Rehabilitation / Education

Review withpatient 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 Eatingeducation 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 Lifebook 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 identied? 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


Beta Blockers: Indicated? Yes No Given? Yes No


Clopidogrel (or alternative): Indicated? Yes No Given? Yes No


Statins: Indicated? Yes No Given? Yes No


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

CardiologistOther (specify):

.......................................................Forms

Medical discharge summary

Travel forms, if required ( not required)

Medical certicate, if required ( not required)


URN:

Family name:

Given name(s):

Address:





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CategoryEmergency (ED) Presentation Date: Time:

Day 1 Admission to CCUAM 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 (observe for signs of

reocclusion post PCI)

If had Lysis, conduct ECGs 90 mins 6 hrs and 12 hrs post Lysis N/A

Continuous cardiac monitoring (ST segments if available)

TnI (68hrs after presentation) ELFT FBC COAGS BGL

Request for next day: TFT Fasting glucose / Lipids

Medications

and PainManagement

Check the allergy status of the patient by referring to the medication chart

Record weight and height on medication chart

Conrm Aspirin given

Conrm Clopidogrel (or alternative) given

Glyceryl Trinitrate prescribed? Yes No Contraindicated (eg. Aortic stenosis)

If Yes, Intravenous Sublingual prn

Other intravenous infusions:

Reviewneed for:

Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs)

IV Heparin (or alternative)

Observations

Treatments

Follow post PCI / 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 uid balance chart N/A

Check angiogram puncture site 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 (1224 hours post successful PCI/

Lysis, patient may go to toilet on wheelchair with telemetry [must be supervised],provided they are pain free, and off ionotropic and oxygen therapy) Record

alterations in mobility:

Sponge in bed

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 Lifebook or similar

Complete patient assessments (eg. falls risk and Waterlow assessment)Expected

OutcomesPatient demonstrates: A - Achieved V - Variance A V

Painfree

ST segment or T wave changes resolving

Other (specify):


URN:

Family name:

Given name(s):

Address:





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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)

Considered for angiography(if Yes, withhold AM subcut anticoagulation,

Metformin and others as indicated)

Preparation and education completed as per angiogram pathway

Medications

and PainManagement

Conrm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or

alternative) and ACE inhibitors

Glyceryl Trinitrate

prescribed?

Yes No Contraindicated (eg. Aortic stenosis)

If Yes, Intravenous Sublingual


Review

need for:

Enoxaparin (or alternative)(refer to STEMI Management Plan, p.2, 0-24hrs)


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


(if newly diagnosed, refer to Diabetic Educator)

Daily weight and/or uid 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


If fasting bloods, conrm 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

ExpectedOutcomes Patient demonstrates: A - Achieved V - VarianceA V

Painfree


Other (specify):


URN:

Family name:

Given name(s):

Address:





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Investigations



Telemetry

Monitoring ceased - time:

Daily Bloods as requested(FBC if on IV or subcut antithrombotic)



Preparation and education completed as per angiogram pathway Other test:

Medications

and Pain

Management


alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate


Reviewneed for:



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




Patent IVC resite date: OR IVC removed



Mobility /


Increase mobilisation if painfree

Self care Other Record alterations in mobility/hygiene:

Other Care

(specify)

Education and

Discharge Plan


Review discharge checklist on p.3

ExpectedOutcomes

Patient demonstrates: A - Achieved V - Variance A V

Painfree


Other (specify):


URN:

Family name:

Given name(s):

Address:





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Investigations



Telemetry






Medications

and Pain

Management




Reviewneed for:



Observations

Treatments



circulation








Mobility /




Other Care

(specify)

Education and

Discharge Plan



ExpectedOutcomes


Painfree


Other (specify):


URN:

Family name:

Given name(s):

Address:





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Investigations



Telemetry






Medications

and Pain

Management




Reviewneed for:



Observations

Treatments



circulation








Mobility /




Other Care

(specify)

Education and

Discharge Plan



ExpectedOutcomes


Painfree


Other (specify):


URN:

Family name:

Given name(s):

Address:





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Insert additional days here if applicable.


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URN:

Family name:

Given name(s):

Address:




Variance Codes

A. Patient Variances Actions

A:1 Recurrent chest pain (Differentiate Chest

Pain Type; ischaemic, pericarditis or chest wall

pain)

Administer O2if indicated (SaO

2< 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 Debrillation

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): callMedical 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: 1560 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 antihypertensiveagent

Strict uid balance chart, consider IDC

A:5 Pericarditis MO review

Consider analgesia

Consider echocardiogram

A:6 Pulmonary embolus (PE) / Deep veinthrombosis (DVT)

Urgent MO review Anticoagulation

CTPA or VQ Scan +/- Leg Ultrasound

O2if indicated

Bed rest

A:7 Renal failure (Signicant worsening of renal

function as dened by rising creatinine or

worsening GFR)

Assess volume state and urine output

Urgent MO review; 12hrs

Strict uid 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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URN:

Family name:

Given name(s):

Address:




Variance Codes (continued)

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 ofcer / ICU input early)

Urgent MO review

Consider inotropes

Urgent Echocardiogram

Fluid balance chart and consider urinary catheter

Consider intra-aortic balloon pump

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 transferB: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-rayB: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 / ordersB: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 / TimeVariance

Code

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

Document as Variance / Action / OutcomeInitials


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Clinical Events / Variance (continued)

Date / TimeVariance

Code

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

Document as Variance / Action / OutcomeInitials


URN:

Family name:

Given name(s):

Address:




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