PROCEDURE FOR DIAGNOSTIC EXERCISE TOLERANCE TESTING (ETT) AT WIRRAL HEART SUPPORT CENTRE

Transcription

1 PROCEDURE FOR DIAGNOSTIC EXERCISE TOLERANCE TESTING (ETT) AT WIRRAL HEART SUPPORT CENTRE Issue History Issue Version 1 Purpose of Issue/Description of Change To provide staff with the fundamental principles involved in the procedure for Diagnostic Exercise Tolerance Testing Planned Review Date October 2015 Named Responsible Officer:- Approved by Date Heart Support Lead Quality, Patient Experience and Risk Group October 2012 Section :- CP64 Target Audience Trust staff trained in the procedure for diagnostic exercise tolerance testing UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE WIRRAL COMMUNITY NHS TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Procedure for Diagnostic Exercise Tolerance Testing (ETT) at Wirral Heart Support Centre Purpose To provide staff with the fundamental principles involved in the procedure for Diagnostic Exercise Tolerance Testing Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Wirral Heart Support Centre Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved October 2012 Date formally approved by Quality, Patient Experience and Risk Group October 2012 Method of distribution Intranet Archived Date 9 th October 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Quality and Governance Service R New document 2

3 PROCEDURE F0R DIAGNOSTIC EXERCISE TOLERANCE TESTING (ETT) INTRODUCTION Clinical Exercise Tolerance Testing (ETT) is an established non-invasive procedure that provides diagnostic and prognostic information for the evaluation of several pathologies, the most common of which being coronary heart disease. To ensure the maximum effectiveness from the ETT, it should be performed to national standards derived from current best practice (British Cardiovascular Society, 2008). Although ETT is considered a safe procedure, complications such as acute myocardial infarction and ventricular arrhythmias may occur. Whilst the statistical possibility of an adverse event is low, the severity of the event outcome further highlights the importance of following nationally approved standards (British Cardiovascular Society, 2008). TARGET GROUP All staff who supervise or assist with ETTs employed by the Trust. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trust s Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. The specific roles of the supervisor are to: Supervise the investigation Deliver effective and timely life support if required Interpret data derived from the investigation Provide an accurate report on the investigation Ensure all facilities are acceptable for use Ensure protocols regarding clinical notes and request forms are followed Ensure that all staff involved in the procedure are suitably qualified All contra-indications to completing the test have been reviewed and excluded (British Cardiovascular Society, 2008). Experience of Supervisor The supervising healthcare professional must comply with the following training requirements: Demonstrate a sound knowledge of cardiovascular physiology, cardiac pharmacology and electrocardiogram interpretation skills. 3

4 Have experience of assisting in 75 exercise test procedures and have undertaken and documented a minimum of 50 exercise tests in the supervising role whilst being overseen by a competent trainer. At least 5 of these must be formally assessed. Demonstrate the ability to use all relevant equipment within the exercise testing room. Demonstrate a clear understanding of absolute and relative contraindications to performing exercise tolerance tests and absolute and relative reasons for terminating an exercise tolerance test as per ACSM guidelines (2010). Undertake regular clinical supervision with ETT mentor and peer support with in-house Consultant Cardiologist. Assisting Role The assistant role may be provided by either a registered healthcare professional (exercise physiologist or cardiac rehab nurse) with proven competence in exercise stress testing. The assistant is required to demonstrate: Knowledge of ETTs and understand and implement relevant policies and procedures. Successful completion of resuscitation training and has current life support certification (minimum ILS). ILS must be updated annually. Have a sound knowledge of cardiovascular physiology, cardiac pharmacology and electrocardiogram interpretation skills. Have the ability to use all relevant equipment within the exercise testing room. Have a clear understanding of absolute and relative contraindications to performing exercise tolerance tests and absolute and relative reasons for terminating an exercise tolerance test as per ACSM guidelines (2010). Undertake regular clinical supervision with ETT mentor and peer support with inhouse Consultant Cardiologist. RELATED POLICIES Please refer to relevant Trust policies and procedures INDICATIONS Non-invasive diagnostic investigation used to aid diagnosis of underlying ischaemic heart disease. For use following both direct access and GP (with special interest in Cardiology) access referral for all patients living in Wirral. Patient choice. 4

5 CONTRAINDICATIONS TO EXERCISE TESTING (as per ACSM Guidelines for Exercise testing and Prescription, 2010) Absolute A recent significant change in the resting ECG suggesting significant ischemia, recent myocardial infarction (within 2 days), or other acute cardiac event. Unstable angina. Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise. Symptomatic severe aortic stenosis. Uncontrolled symptomatic heart failure. Acute pulmonary embolus or pulmonary infarction. Acute myocarditis or pericarditis. Suspected or known dissecting aneurysm. Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands. Relative Left main coronary stenosis. Moderate stenotic valvular heart disease. Electrolyte abnormalities. Severe arterial hypertension (ie systolic BP>200mm/Hg and/or diastolic BP >110mm/Hg) at rest. Tachydysrhythmia or bradydysrhythmia. Hypertrophic cardiomyopathy and other forms of outflow tract obstruction. Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise. High-degree atrioventricular block. Ventricular Aneurysm. Uncontrolled metabolic disease. Chronic infectious disease. Mental or physical impairment leading to inability to exercise adequately. CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. Refer to Trust Consent Policy for further information and guidance. 5

6 CONSIDERATIONS PRIOR TO UNDERTAKING EXERCISE TOLERANCE TEST Determine test referral route (Open-access (O/A ETT), Physician (GPSI ETT) O/A ETT (Diagnostic) Seen on day pre and post test by physician. GPSI ETT (Diagnostic) Seen previously by physician who then refers for test. Accurate completion of referral form Patients notes available Resting ECG in patients notes for comparison Obtain resting blood pressure and ECG Clear indication that patient is physically able to complete ETT consider Bruce / Modified-Bruce protocol Clear indication that no significant chest murmurs or valve abnormalities evident which would contraindicate ETT Patient has received written confirmation of appointment and written information about the test procedure prior to the test date No recent change to patient s medical condition. Patient is offered chance to ask questions prior to investigation Patient is aware of the need to sign a consent form prior to the investigation Check current medication prescription and confirm that highlighted medication has been omitted for hours as required (see list below) Ensure patient has not eaten one hour prior to investigation Ensure patient is wearing comfortable shoes and clothing Ensure resuscitation equipment is in working order and fully stocked Ensure physician is within the department whilst testing Ensure testing room is at optimal temperature of 21 C as test may need to be deferred if ambient temperature is too high. Medication to be omitted for diagnostic tests. 48 hours prior to ETT 24 hours prior to ETT Atenolol Verapramil Propranolol Diltiazem Sotalol Metoprolol Bisoprolol Isosorbide Mononitrate Timolol (not routinely used) Selectol (not routinely used) 6

7 Diagnostic Standards to Promote and Maintain Patient Safety a. How the Diagnostic Procedure is requested b. How the clinician treating the patient is informed of the results (including timescales) c. How the patient is informed of the results (including timescales) d. Taking action on the result of diagnostic tests (including timescales) :- documentation of the result interpretation of the result how patient is followed up or referred following a diagnostic test Which staff are authorised to request this test? Description of how each step in the process is undertaken The service has a referral form for general practitioners to complete The clinician conducts the test and has the results on the same day The patient is verbally informed of the results on the same day, and results documented in the patients health records The clinician will make the decision of what appropriate care / treatment is needed the same day Recorded in the patients health records the same day The same day and recorded in the patients health records The GP and or Consultant is sent a letter summarising the results and recommending relevant treatment regime The same day if urgent or 10 working days if routine. General Practitioners, General Practitioners with a Special Interest in cardiology and Consultant Cardiologists Additional comments:- The form has set fields to complete for the provision of relevant medical background Patients are offered a copy of the letter shared with the GP Results shared with GP within 10 working days Entered in health records as per Health Records Policy The letter to the GP / Consultant will indicate if further investigations are required 7

8 EQUIPMENT REQUIRED Exercise Tolerance Testing Treadmill, computer system and monitor 12 lead Acquisition Module ECG electrodes single use only ECG paper Pen Alcohol swabs Abrasive tape Single use razor Sharps box Non-clinical waste bin Clinical waste bin Paper towels Blood pressure cuff: medium and large Adult Manual sphygmomanometer Stethoscope Single use gown Detergent wipes Chair DH consent forms Emergency equipment (see below) Emergency Life Support Equipment Defibrillator and pads Ambu-bag and mask Portable Oxygen cylinder Non-rebreathe mask SPO 2 probe Airway adjuncts (size 2,3,4 Guedel) Blood glucose monitor, lancets, monitoring strips, swabs and access to Hypo Box Manual suction machine with tube connection Emergency IV medication: Administered by a GP (with a special interest in Cardiology) only: Adrenaline 1 mg in 10 ml (1:10,000) Minijet Atropine 600 micrograms in 1 ml injection Sodium Chloride 0.9% 10ml ampoule to flush Administered by a nurse authorised under patient group direction Aspirin 300 mg soluble tablets Glyceryl Trinitrate 400 micrograms sublingual spray To be available in the event of an anaphylactic reaction: Adrenaline 1 mg in 1 ml (1 in 1000) ampoules 8

9 10ml Syringe (2) Safety IV Catheter with Injection port: size 16g, 20g, 22g Tape Transfer paperwork Pen Towel Gloves Tourniquet Scissors Portable manual sphygmomanometer and stethoscope PROCEDURE F0R EXERCISE TOLERANCE TESTING (ETT) Two members of staff must be present throughout the exercise test procedure and recovery stage. PROCEDURE Collect patient and escort to ETT room. Verbally check the identity of patient against patient notes (name, date of birth, address) and referral form with the patient. If not possible check details with the patients family or carers. Consider offering chaperone if female patient Ensure patient is introduced to staff involved in the procedure by name. Clarify whether patient received written information about the procedure prior to the test date. If the patient has not received written information prior to the procedure, request that patient reads written information about the procedure prior to signing the consent form. Give clear explanation of procedure to be performed and the care that will follow. Benefits and risks of procedure to be explained. Ask whether the patient has used a treadmill before If not provide full explanation of procedure requirements. Determine whether patient has any mobility RATIONALE Insure patient in correct place for testing. To ensure correct patient identity. To promote patient dignity at all times. To ensure effective communication and reduce patient anxiety. To enable effective communication and reduce patient anxiety. Allows patient to gain better understanding of procedure and knowledge of need to sign consent form. To allow patient to gain good understanding of procedure. To enable informed consent prior to the procedure. To gain patient co-operation and enable informed and understood consent to the procedure. So that patient and carers can make an informed decision. To reduce patient anxiety and provide reassurance of test demands. To ensure correct protocol Bruce/Mod- 9

10 problems which may limit their ability to walk on a treadmill. Provide opportunity for any questions to be asked. Identify patient s symptoms prior to test and ensure the patient is aware of the need to inform staff of any symptoms during the procedure. Check patient s current medication prescription identify any medication that should have been withheld prior to the procedure. Ensure patient/carer/interpreter accurately completes the consent form prior to the procedure. Provide patient with a copy of the consent form. Test Supervisor to enter patient details into the computer system. Assisting person to decontaminate hands. Advise patient to remove top layers of clothing. If required, shave patient s chest using disposable razor dispose in sharps bin. Identify correct ECG lead positions. Mason-Likar ETT lead placement to be used for all tests unless device in situ or not appropriate (see appendix A) Prepare the skin using alcohol swab. Once dry, brush skin with abrasive tape. Place ECG electrodes over prepared skin in correct positioning. Attach acquisition module around patient waist ensuring it is not too tight. Attach ECG leads. Offer the patient a single use gown to wear. Select appropriate test protocol. BRUCE diagnostic. Mod-BRUCE doctor request, impaired mobility or clinical judgement. Bruce is used. Patients and carers need time for queries or concerns to be discussed. To ensure that any symptoms are accurately recorded with ECG to aid with correct information analysis. Test data may not be accurate if the patient has not withheld certain medication hours prior to the procedure. Consent Policy. Health Records Policy. To allow the system to calculate patient s age predicted maximum heart rate. To ensure accurate patient data on computer system. To ensure effective hand hygiene Infection Control Policy. To enable ECG electrode connection. To enable effective electrode connection. Infection Control Policy. To ensure accurate ECG trace To reduce movement artefact during the procedure. Removal of superficial layer of skin significantly reduces interference between electrode and skin connection. To ensure accurate ECG trace. To ensure patient comfort. To ensure patient dignity and respect. To ensure safety of test and to ensure as much data is obtained as possible. 10

11 Request the patient to step onto the treadmill and attach computer lead to acquisition module. Obtain resting ECG. If any changes noted, discuss with physician prior to commencing test. Obtain resting blood pressure. Request patient to place their hands on the front or side rails of the treadmill whilst undertaking the procedure. Obtain patient consent prior to beginning the treadmill. Start test procedure. Monitor ECG throughout the test. Obtain manual Blood Pressure recordings as per test protocol or as required. Monitor patient symptoms throughout the test and document any changes. If no apparent contraindications to terminating the ETT, the test supervisor should aim to achieve 85% or above of the patients age predicated maximum heart rate (Maximum heart rate = 220 patient age). Test should be terminated in the event of any of the following: Indications for terminating ETT (see appendix G). Use clinical judgement for all patients. Obtain ECG and blood pressure immediately at test termination. Recovery phase should be seated for at least five minutes and continue until symptoms and observations resolve. Use clinical judgement with regards to any ECG changes observed. Ensure the following are included: Record a blood pressure 4 minutes into recovery or as required. Ask the patient to stand at end of recovery and monitor symptoms i.e. dizziness. Record blood pressure if required and wait for symptoms to To commence the test. To compare with ECG in patients notes, ensuring no recent changes and any changes are first checked by physician. To ensure within recommended guidelines prior to commencing procedure. To enable the best available ECG trace during the procedure. To allow the patient to steady themselves during the test. So patient is aware when the test will begin. To ensure accurate data collection (See absolute and relative indications for terminating an ETT see appendix B) To ensure accurate data collection as automated BP monitors are prone to inaccuracy due to artefact. To allow comparison between patient symptoms, ECG and blood pressure. To ensure best available clinical data has been obtained. To ensure patient safety. To ensure best available clinical data has been obtained. In conjunction with ACSM (2010) guidelines. 11

12 resolve or seek medical assistance if required. Disconnect acquisition module and advise patient to safely step off the treadmill. Assisting person to remove all ECG electrodes. Advise patient to redress. Supervisor to input test results into the computer and interpret results. The Supervisor has the responsibility of discharging the patient from the testing room. Discharge should only be performed if the supervisor is satisfied that the patient is stable in regards to the result of the investigation and the patient s general symptoms. Assisting person to decontaminate ECG acquisition module, blood pressure cuff, stethoscope and treadmill rails. Assisting person to escort patient back to waiting area. Patient should be offered a drink and advised to sit in waiting area. Patient should be advised to report any problems to staff in the clinic area i.e. any symptoms of chest pain, syncope. Physician reporting of results should be as follows: O/A ETT, supervising person to give report to physician and discuss any relevant findings if necessary. GPSI ETT, to be reported by physician on next clinic session unless urgent report required. The following test findings should be discussed with physician prior to patient leaving department: Significant ST changes +/- symptoms. Significant arrhythmias. Unrelieved symptoms post test. If the patient is not required to see the doctor advise the patient that they may leave the clinic after being seated for at least five minutes if symptom free. The patient will be informed of the test results on the day either by the senior technician or the doctor as appropriate To ensure patient safety. Patient may need a few seconds to adjust once stepping of a previously moving treadmill. To indicate test end. To enable accurate report. To ensure patient safety. To adhere to infection control policy To safeguard against the late-onset development of post-exercise symptoms. To ensure best practice. To ensure staff are aware of the need to monitor patient should any adverse symptoms occur. To ensure effective communication. This will be done on the same day when the patient is on site If urgent this will be typed on the clinic day and forwarded to the most appropriate source. The physician may wish to see any positive tests and request further investigations. To ensure patient safety. To safeguard against the late-onset development of post-exercise symptoms. To ensure best practice To ensure patient is kept informed at all times 12

13 EQUIPMENT The CASE 8000 ETT console and treadmill are covered by a comprehensive service and repair contract with GE Medical. Staff are require to conduct daily cleaning checks before they use the equipment and monthly calibration checks within the correct time period. This is documented on the check list on the ETT room door. Resuscitation equipment checked and documented daily. WHERE TO GET ADVICE FROM Contact senior ETT specialists, GPwSI or GE Medical in the event of a technical problem. INCIDENT REPORTING Clinical incidents or near misses must be reported using the Trusts Incident Reporting System SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed using the Trust s incident reporting system and an appropriate action plan put in place. REFERENCES American College of Sports Medicine. (2010). Guidelines for Exercise Testing and Prescription. (8 th Ed.). Lippincott Williams & Wilkins: Philadelphia. 13

14 British Cardiovascular Society. (2008). Clinical Guidance by Consensus Recommendations for Clinical Exercise Tolerance Testing. Retrieved from on January 4, National Institute of Clinical Excellence. (2010). Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Retrieved from on January 4,

15 Appendix A: Mason-Likar ETT lead placement Position of chest leads and limb leads Alternative limb leads (from posterior view) AvL - Upper left side of torso ( infraclavicular fossa), 2cm below clavicle. AvR - Upper right side of torso (infraclavicular fossa), 2cm below clavicle AvF Lower left side of torso, half-way between costal margin and iliac crest Neutral Lower right side of torso, half-way between costal margin and iliac crest. AvL AvR AvF N 15

16 Appendix B: INDICATIONS FOR TERMINATING AN EXERCISE TOLERANCE TEST (ACSM, 2010). Absolute Relative Drop in systolic blood pressure of >10mm/Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia Moderately severe angina (defined as 3 on standard scale) Increased nervous system symptoms (e.g. ataxia, dizziness, or near syncope) Signs of poor perfusion (cyanosis or pallor) Technical difficulties monitoring the ECG or systolic blood pressure Subjects desire to stop Sustained ventricular tachycardia ST elevation (+1mm) in lead without diagnostic Q waves (other than V1 or AvR) Drop in systolic blood pressure of >10mm/Hg from baseline blood pressure despite an increase in workload in the absence of other evidence of ischemia ST or QRS changes such as excessive ST depression (>2mm horizontal or downsloping ST-segment depression) or marked axis shift Arrhythmias other than sustained ventricular tachycardiac, including multifocal PVC s, triplets of PVC s, supraventricular tachycardia, heart block or bradyarrhythmias Fatigue, shortness of breath, wheezing, leg cramps or claudication Development of bundle-branch block or intraventricular conduction delay that cannot be distinguished from ventricular tachycardia Increased chest pain Hypertensive response (Systolic blood pressure >250mm/Hg and or diastolic blood pressure of >115mm/Hg) 16

17 RISK ASSESSMENT FOR DIAGNOSTIC PROCEDURE Name of Diagnostic Procedure: Procedure for Diagnostic Exercise Tolerance Testing (ETT) Date risk assessed: 15 th August 2012 Risk assessed by: Heart Support Lead Criteria Likelihood that process will fail Low Medium High Risk identified in process Mitigation/Controls a. Process for requesting the diagnostic procedure General practitioner may not provide all relevant medical history prior to referral for the clinician to make an informed decision in order to conduct the test Referral form for test requests all relevant medical history is recorded and is returned to referrer if not adequately completed b. Process for informing the clinician treating the patient of the result c. Process for informing the patient of the result d/e. Process for action if referral required after a diagnostic test Identify risks from the process of conducting the test if relevant Letter is not sent from service to GP/ Consultant Letter may be lost in external mail Patient may not be informed of results Failure to request further action as required As patients suffer from a range of serious heart conditions, patients have in the past suffered a coronary from the exertion of undertaking the test Outcome sheets completed for each clinic by the Doctor and countersigned by the secretary when completed. e.g. Communication method Patients receives verbal results the same day and is offered a copy of the letter sent to the GP GPSI attending on the day is responsible for requesting for investigations or actions following controls process outlined in b. Clinicians undertaking the test are qualified to undertake a medical assessment, and all contraindications have been considered prior to conducting the test to reduce the likelihood of inducing a deterioration in the patient s condition