INTEGRATED CARE PATHWAY

Transcription

1 Gwent Healthcare NHS Trust INTEGRATED CARE PATHWAY SUSPECTED MYOCARDIAL INFARCTION/ACUTE CORONARY SYNDROME Patient Name: Address: (Patient sticker) Hospital Number: Date of birth: Next of kin: Relationship: Contact number: General practitioner: Date of Admission ( if admitted): Admitting Consultant(s):.. Anticipated length of stay : Myocardial Infarction - OR Troponin + acute coronary syndrome nights Stable angina/non-cardiac chest pain - 24 hours Summary of Guidelines for Use 1. This is a multiprofessional record and replaces all other documentation relating to this episode of care. 2. It is evidence based but it is not a rigid document and clinicians are free to use their own professional judgement as appropriate. 3. Any deviation from the expected plan of treatment should be recorded as a variance on the appropriate page of the document. 1

2 A & E DEPARTMENT/MEDICAL ASSESSMENT UNIT DATE:.... TIME. TRIAGE NURSE..TRIAGE CATEGORY SOURCE OF PATIENT Self-referral Saw GP (surgery) (walk in) Self-referral GP house visit (999) NHS Direct Phoned GP 999 PATIENT ID LABEL NHS Direct - GP Co-Op/DDS NURSE RESUSCITATION ROOM TIME Symptom onset Date Time Immediate ECG INFORM A&E DOCTOR Call for Ambulance Date Time Ambulance arrival Date Time Pulse. BP. Hospital arrival Date Time RR. 0 2 SATS. Pain to needle time TEMP. BM. Call to door time Door to needle time A&E Doctor: Time: HOPC: Allergies: Drugs: PMH: 2

3 Examination ECG Findings: Aspirin Opiate Antiemetic Nitrate Drug Dose Date Time Signed Signed ECG CRITERIA OF ACUTE MYOCARDIAL INFARCTION ANY of the following:- ST elevation 2mm in two or more adjacent chest leads ST elevation 1mm in two or more limb leads (I,II,III,AVL,AVF) New LBBB True posterior MI (ST depression in V1-V3 with ST elevation 1mm in posterior leadsv7-v9) Tick One FINDINGS ACTION Chest pain suggestive of MI for Proceed to THROMBOLYSIS <12 hrs AND ECG criteria for MI met Chest pain suggestive of MI for Proceed to THROMBOLYSIS >12 hrs with continuing pain and ECG evidence of evolving infarct ECG criteria met BUT history atypical Obtain senior opinion within 5 mins ECG criteria met BUT contraindication exists Pain suggestive of MI BUT ECG criteria not met? ACUTE CORONARY SYNDROME Atypical chest pain and normal ECG Obtain senior opinion within 5 mins (In selected cases transfer for PTCA may be appropriate) Repeat ECG at 15mins, 1 hour and in pain REFER to flow chart on Page 6 Investigate for non-cardiac causes of chest pain REFER to flow chart on Page 6 3

4 CONTRAINDICATIONS TO THROMBOLYSIS NB. CONSIDER ALL contraindications as RELATIVE and discuss with senior doctor (A&E or Medicine) IMMEDIATELY Absolute contraindications Suspected Aortic Dissection or pericarditis Active Internal Bleeding Haemorrhagic CVA/SAH/ intracranial lesion Embolic CVA <3/12 Major Trauma / Head injury 3 weeks Major Surgery 14 days GI Bleed < 14 days Relative contraindications Internal organ biopsy/large artery puncture within last 2 weeks Known bleeding disorder Oral anti-coagulant therapy INR >2-3 Prolonged or Traumatic CPR Acute pancreatitis/active peptic ulcer Diabetic proliferative retinopathy Pregnancy or within 1 week post partum BP >180/110 IF NO CONTRAINDICATION EXISTS PROCEED TO THROMBOLYSIS IMMEDIATELY Obtain informed VERBAL consent Reason for NOT thrombolysing immediately: Time(s) senior doctor contacted: Name of senior doctor(s): Decision to thrombolyse: Time decision made: Notes: YES / NO CHOICE OF THROMBOLYTIC Give TENECTEPLASE as first choice (see over (page 5) for protocol) If perceived higher risk of stroke eg. : Advanced age Significant hypertension Consider Streptokinase and discuss with SpR or Consultant Thrombolytic Dose / Time Signed Given By Heparin Transfer to: Time left Department: 4

5 Protocol for administration of single bolus thrombolytic - Tenecteplase (TNK) STEP 1: Give intravenous unfractionated heparin bolus: Patient s body weight Heparin IV bolus dose < 67 kg (10st 7lbs) 4,000 IU bolus >67 kg (>10st 7lbs) 5,000 IU bolus Heparin should be administered as soon as possible after the diagnosis of AMI has been confirmed. STEP 2: Administer tenecteplase as intravenous bolus over approximately 10 seconds: Patients body weight category Dose and reconstituted volume Tenecteplase vial size < 60 kg (<9st 6lbs) 6,000 units (30mg) in 6 ml 8,000 unit pack 60 to 69 kg (9st 6lbs-10st 12lbs) 7,000 units (35mg) in 7 ml 8,000 unit pack 70 to 79 kg (11 st -12st 6lbs) 8,000 units (40mg) in 8 ml 8,000 unit pack 80 to 89 kg (12st 8lbs 14 st) 9,000 units (45mg) in 9 ml 10,000 unit pack > 90 kg (>14st 2lbs) 10,000 units (50mg) in 10 ml 10,000 unit pack NB. Tenecteplase is incompatible with glucose solutions. STEP 3: Continue weight adjusted intravenous unfractionated heparin: 1. The heparin infusion is prepared by utilising 20,000 IU in 20 ml. (PUMP HEP). The final concentration is 1000 IU heparin in 1mL. Patient s body weight Initial Heparin IV infusion rate < 67 kg (10st 7lbs) 800 IU per hour >67 kg (>10st 7lbs) 1000 IU per hour 2. Ensure infusion commenced within 30 minutes of Tenecteplase administration. 3. APTT monitoring essential to maintain a ratio of APTT ratio should be determined 6 hours after commencing heparin treatment, 6 hours after each dose adjustment and subsequently on a daily basis. 5. The results should be used to adjust the heparin dose according to the following table: References 1 European Heart Journal 2003; 24: ASSENT 3 Lancet 2001; 358: APTT ratio Heparin infusion rate STOP infusion for 1 hour then reduce by 0.6 ml/hour Reduce by 0.2 ml/hour Reduce by 0.1 ml/hour No change Increase by 0.4 ml/hour < 1.2 Increase by 0.8 ml/hour 5

6 Suspected NSTEMI/Acute coronary syndrome ECG & troponin on admission No ECG ST Normal ECG, Troponin on admission ECG ischaemic or raised Troponin on admission or 12 hours Suspected acute coronary syndrome Confirmed acute coronary syndrome ECG/ troponin at 12 hours: if normal consider discharge Stress test If any are abnormal Stable for 48 h with no high risk features REFER TO CARDIOLOGY (NSF) Admit CCU/cardiac ward ECG monitor aspirin/lmwh/beta blocker /consider clopidogrel 300mg PO loading 75 mg maintenance Level of risk* (Bruce) Low Intermediate high >3 mins + no ST 3 mins or ST 3 mins + ST Recurrent symptoms or ECG changes or other indication of high risk* (consider GP llb/llla blocker with Consultant Cardiologist approval) OR +/- Coronary angiography Cardiology OP review Revascularisation or medical treatment (as appropriate) Discharge * Level of risk determined after Cardiology review using: Tropomin status/ecg changes/timi score ± ETT results HIGH RISK FEATURES INCLUDE: a) Dynamic ST changes b) Raised Trop I c) Ongoing symptoms d) Pulmonary oedema and ischaemic ECG e) Post MI angina f) Diabetes 6

7 ADMISSION TO CORONARY CARE/MEDICAL ASSESSMENT UNIT MEDICAL / NURSING ASSESSMENT Date... Time of admission to CCU Admitted from - transfer A&E Clinic Routine GP MRSA status - positive Allergies - negative NO contact YES Please list: unknown HOPC Age of patient:.. 7

8 RISK FACTORS FOR IHD YES NO NOTES Smoking current ex Hyperlipidaemia Hypertension Diabetes Type I Type II Family history of CHD (<65 yrs) PMH/PSH never DRUGS & DOSAGE SH Occupation: Alcohol units per week: Marital status: Home situation: 8

9 Additional information: OBSERVATIONS Temperature Blood pressure Heart rate O 2 saturation Height Weight BMI CVS JVP BP R ARM BP L ARM Auscultation Peripheral pulses (check for carotid/femoral bruit) RIGHT LEFT BRUIT Carotid Brachial Femoral Posterior Tibial Dorsalis Pedis Oedema RESP ABDOMEN CNS 9

10 IMPRESSION/DIAGNOSIS MEDICAL OFFICER PLAN/TASKS (only tick if plan/task has been completed or initiated) FBC ECG U&Es CXR COAG ECHO GLUCOSE EXERCISE TEST LIPID PROFILE LFTs Troponin SpR OR SENIOR REVIEW ELECTROCARDIOGRAM FINDINGS RADIOLOGICAL FINDINGS INITIAL BLOOD RESULTS Name of admitting nurse (PRINT):.. Signature:.. Name of admitting doctor (PRINT): ): Signature: BLEEP.. 10

11 DATE.. TIME MULTIDISCIPLINARY COMMENTS SIGNATURE 11

12 DATE... DAY 1/POST TAKE WARD ROUND SELECT APROPRIATE DIAGNOSIS ٱ ST Elevation MI / new LBBB ٱ Non ST Elevation MI / Unstable angina ٱ Check 12 hour troponin ٱ Aspirin ٱ 90 minutes ECG post-thrombolysis ٱ Beta blocker ٱ Regular aspirin 75 mg od ٱ Clopidogrel ٱ Consider Atenolol (target heart rate 55) ٱ Consider GTN infusion ٱ Consider Ramipril (1.25 mg bd start, target 5 mg bd) ٱ IIb/IIIa (regime approved by Consultant ٱ Sliding scale insulin if BM 10) Cardiologist) ٱ Stable angina or non-cardiac chest pain OTHER DIAGNOSIS ٱ Early Discharge ٱ Consider OPD exercise test if CHD possible ٱ Follow up arrangements if required TIME NOTES SIGNATURE AND BLEEP TIME VARIANCE & REASON FOR VARIANCE SIGNATURE 12

13 DAY 1: NURSING DATE:. Activity Time Sign Reason for variance and action taken Patient on bed rest (out to commode only) Observe cardiac monitor - record rhythm 4 times daily Assess pain levels and administer analgesia as required (document progress in multidisciplinary notes) Request ECG Monitor BP and saturations QDS (within patients baseline parameters) Monitor temperature BD Full assistance with hygiene needs Monitor fluid balance Ensure patient assessment completed fully Refer to social worker if appropriate Any additional activities TIME MULTIDISCIPLINARY COMMENTS SIGNATURE 13

14 DAY 2: MEDICAL REVIEW DATE:. DIAGNOSIS: ٱ ST elevation MI ٱ Non ST elevation MI or unstable angina ٱ Repeat U&E s ٱ Simvastatin 40mg nocté ٱ Reconsider Atenolol and Ramipril ٱ Discuss diagnosis & management plan with patient ٱ Written information provided ٱ Stable angina or non cardiac chest pain OTHER DIAGNOSIS ٱ Discharge ٱ Review medication ٱ Consider OPD exercise test if CHD possible ٱ Follow up arrangements if required 14

15 TIME NOTES SIGNATURE AND BLEEP TIME VARIANCE & REASON FOR VARIANCE SIGNATURE DAY 2: NURSING DATE: Activity Time Sign Reason for variance and action taken Request ECG Patient mobile around bed area Provision of hygiene facilities Observe cardiac monitor - record rhythm 4 times daily Assess pain level and administer analgesia as required (document progress in multi-disciplinary notes) Monitor BP QDS (within 15

16 patient s baseline parameters) Monitor temperature (signs of pyrexia or hypothermia) Monitor O2 sats (signs of hypoxia) Assess fluid balance Assess cannula site (signs of inflammation) Refer to cardiac rehabilitation Consider referral to dietician Give written health promotion and other information Give Streptokinase card Give Cardiac Rehabilitation information 16

17 DAY 3: MEDICAL REVIEW DATE:. DIAGNOSIS: ٱ ST ELEVATION MI ٱ NON-ST ELEVATION MI ٱ UNSTABLE ANGINA If on sliding scale for diabetes review need for insulin for 12 months (Digami) If uncomplicated unstable angina, non-st elevation MI and symptoms settled consider ETT on Day 5 and consult guidance on page 4. MOST acute coronary syndromes should be under care of cardiologist but if not seek advice 17

18 TIME NOTES SIGNATURE AND BLEEP TIME VARIANCE & REASON FOR VARIANCE SIGNATURE DAY 3: NURSING DATE:. Activity Time Sign Reason for variance and action taken Request ECG Assess pain Monitor BP QDS (within patient s baseline) Monitor temperature BD 18

19 (signs of pyrexia or hypothermia) Patient self caring with hygiene needs Patient mobile one way to bathroom Cardiac monitor is discontinued Cannula removed Assess bowel habits (deviation from normal bowel habits) Activities carried over: Activity Time Sign Reason for variance and action taken DIETICIAN Seen by dietician Written information given Notes DAY 3. DATE Activity Time Sign Reason for variance and action taken Cardiac rehabilitation Seen by cardiac rehabilitation staff 19

20 Written information given Notes TIME MULTIDISCIPLINARY COMMENTS SIGNATURE DATE.. TIME MULTIDISCIPLINARY COMMENTS SIGNATURE 20

21 DAY 4: MEDICAL REVIEW DATE:. ٱ Discharge advice (with partner/ carer as appropriate eg. Shopping, housework, gardening) 21

22 Daily tasks: progressive increase over 4-6 weeks Walking: gradually increase each day Sex: resume within 2-4 weeks, but may be longer Driving: at least 4 weeks off. Inform insurance company but not DVLA Work : return after 6 weeks, or 8-12 weeks for heavy manual work Heavy lifting : avoid for at least 6 weeks Use of GTN ٱ ٱ Exercise test pre or post discharge Written information provided (BHF leaflets etc) TIME NOTES SIGNATURE AND BLEEP TIME VARIANCE & REASON FOR VARIANCE SIGNATURE DAY 4: NURSING DATE:. 22

23 Activity Time Sign Reason for variance and action taken Patient freely mobile around the ward Patient self caring with hygiene needs Patient is pain free Discuss discharge with relatives and patient Reactive support services Arrange transport for discharge TIME MULTIDISCIPLINARY COMMENTS SIGNATURE DAY 5 DATE:. Patient to be discharged if mobile and condition stable 23

24 Medical check list: Discharge Medication ٱ Aspirin ٱ Beta Blocker ٱ Statin ٱ ACE inhibitor ٱ GTN ٱ Clopidogrel Reason for not prescribing Follow up ٱ TTA s ٱ Discharge summary ٱ Exercise test 4 weeks post discharge (unless contraindicated or done prior to discharge) ٱ Patients to continue all drugs, only omit beta blockers 24 hours pre exercise test if diagnosis CHD in doubt (eg chest pain? cause). ٱ OPA 6 weeks after discharge ٱ Refer cardiology Nurse checklist ٱ Discuss TTA s ٱ Ensure patient is pain free ٱ Ensure patient can maintain own hygiene ٱ Valuables returned ٱ Cannula removed ٱ Pre discharge ECG ٱ Lifestyle advice ٱ Written information provided ٱ Check cardiac rehab referral made DAY 5 DATE:. 24

25 TIME NOTES SIGNATURE TIME VARIANCE & REASON FOR VARIANCE SIGNATURE TIME MULTIDISCIPLINARY COMMENTS SIGNATURE SERIAL PATHOLOGY RESULTS Appendix I 25

26 DATE TIME TROPONIN I CHOLESTEROL Na K CHLORIDE UREA CREATININE R.GLUCOSE F.GLUCOSE Hb WBC PLT. INR KCCT Mg ESR OTHERS 26