HOW TO USE THE CLINICAL PATHWAY

Transcription

1 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID INCLUSION CRITERIA Patients who present with chest pain that is subsequently diagnosed as Acute Coronary Syndrome (Myocardial Infarction or Unstable Angina) Patient discharge criteria should be met by: Unstable Angina - Day 3 Myocardial Infarction - Day HOW TO USE THE CLINICAL PATHWAY This is a proactive tool to avoid delays in treatment and discharge. These are not orders, only a guide to usual orders. Place the Clinical Pathway in the nurses clinical area of the chart. All health care professionals should fill in the master signature sheet at the front of the Pathway. Addressograph/sticker each page of the Pathway PHYSICIANS: Add or delete tasks according to individual patient complexity, and initial all changes. HEALTH CARE PROFESSIONALS: Initial tasks as completed. Place N/A and initial any box where the task is not applicable to the patient. Additional tasks due to patient individuality can be added to the pathway in OTHER boxes and/or Progress Notes. 5. TRANSFER PATIENTS: If patient is transferred to another hospital in Grey-Bruce or to CCAC, send the following: Discharge Criteria - copy with patient to receiving hospital - original to stay on patient chart MAR Sheet - copy with patient to receiving hospital - original to stay on patient chart Teaching Checklist - copy with patient to receiving hospital - original to stay on patient chart Grey Bruce Health Network 1

2 POSITION NAME (Please Print) INITIAL SIGNATURE NURSE PT DIETITIAN DISCHARGE PLANNER CCAC OTHER (Specify) All rights reserved. No part of this document may be reproduced or transmitted, in any form or by any means, without the prior permission of the copyright owner Grey Bruce Health Network 2

3 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID COMORBID CONDITIONS: PROCESS ADMISSION DAY - FIRST TWO HOURS PERFORMANCE INDICATORS * 1 THROMBOLYTICS WITHIN 30 MIN OF ENTERING HOSPITAL Met Not Met N/A 2 CHEWABLE ASA GIVEN WITHIN FIRST 2 HOURS OF ENTERING HOSPITAL Met Not Met N/A IV ACCESS AND SITE CHECKS #1: #2: CONTINUOUS CARDIAC MONITORING FREQUENT VITALS WITH 0 2 SATS ASSESSMENT RHYTHM STRIPS CHEST ASSESSMENT PAIN ASSESSMENT (0-10) SEE CODE SHEET IF APPLICABLE CONSULTS DIAGNOSTICS/ LABORATORY CHEST X-RAY BLOOD WORK AS ORDERED ECG MEDICATIONS TREATMENTS/ INTERVENTIONS SEE MAR SHEET 0 2 THERAPY AS ORDERED CHEST AUSCULTATION MONITOR BLEEDING IF ON THROMBOLYTIC / GLYCOPROTEIN FOLEY Grey Bruce Health Network 3

4 PROCESS NUTRITION MOBILITY/ACTIVITY * PSYCHOSOCIAL SUPPORT/ EDUCATION * DISCHARGE PLANNING * BED REST ADMISSION DAY - FIRST TWO HOURS INFORM FAMILY AND PATIENT OF DIAGNOSIS ADDRESS IMMEDIATE CONCERNS REVIEW PAIN SCALE REVIEW IMPORTANCE OF INFORMING NURSE OF CHEST PAIN Grey Bruce Health Network 4

5 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS PERFORMANCE INDICATORS * ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY ADMISSION DAY > TWO HOURS 3 LIPID MEASUREMENT DONE IN FIRST 24 HOURS OF ADMISSION CONTINUOUS CARDIAC MONITORING / TELEMETRY VITAL SIGNS & 0 2 SATS Q4H AND PRN (Q2H FOR THROMBOLYTIC PTS) CHEST ASSESSMENT PAIN ASSESSMENT (0-10) ASSESS FOR SIGNS OF HEART FAILURE ASSESS FOR SIGNS OF BLEEDING MONITOR INTAKE / OUTPUT MENTAL STATUS ORIENTED TO PERSON/PLACE/TIME FAMILY PHYSICIAN NOTIFIED ECG & CARDIAC MARKERS ECG WITH PAIN CHEST X-RAY IF NOT DONE IN ER Met Not Met N/A MEDICATIONS TREATMENTS/ INTERVENTIONS SEE MAR SHEET O 2 AT PRONGS PERIPHERAL IV / SALINE LOCK CHEST AUSCULTATION MASK NUTRITION CLEAR FLUIDS FULL FLUIDS HEALTHY HEART DIET AS TOLERATED Grey Bruce Health Network 5

6 PROCESS ADMISSION DAY > TWO HOURS BED REST MOBILITY/ACTIVITY * ACTIVITY LEVEL 1 AS TOLERATED (MI & ANGINA PATIENTS): ACTIVITY LEVEL 2 AS TOLERATED (ANGINA PATIENTS ONLY): BED SIDE COMMODE PRIVILEGE IF STABLE FEED SELF ASSISTED BATH ANKLE / FOOT EXERCISES DEEP BREATHING / COUGHING / CALF PUMPING SIT UP 20 MIN (TID / MEALS) BATHROOM PRIVILEGES ORIENTATION TO UNIT AND PROCEDURES PSYCHOSOCIAL SUPPORT/ EDUCATION * INTRODUCE PATIENT PATHWAY BEGIN TEACHING CHECKLIST ENCOURAGE QUESTIONS REVIEW PAIN SCALE AND NEED TO REPORT PAIN TO NURSE REVIEW VISITING GUIDELINES DISCHARGE PLANNING * Activity Levels (1-4) adapted from the Guelph General Hospital AMI Activity Level Guideline Grey Bruce Health Network 6

7 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS DAY 1 CONTINUOUS CARDIAC MONITORING / TELEMETRY VITALS WITH O 2 SATS Q4H AND PRN CHEST ASSESSMENT PAIN ASSESSMENT (0-10) ASSESS FOR SIGNS OF HEART FAILURE ASSESS FOR SIGNS OF BLEEDING MONITOR INTAKE / OUTPUT ASSESS BOWEL ROUTINE PERIPHERAL EDEMA MENTAL STATUS ORIENTED TO PERSON/PLACE/TIME ECHOCARDIOGRAM STRESS TEST DISCHARGE PLANNING PRN DIETITIAN KINESIOLOGIST / PHYSIOTHERAPIST IF ORDERED PHARMACIST IF ORDERED ECG ECG FOR RECURRENT CHEST PAIN BLOOD WORK AS ORDERED SEE MAR SHEET O 2 DISCONTINUE 24 HOURS POST PAIN FREE O 2 PRN WITH PAIN IV / SALINE LOCK Grey Bruce Health Network 7

8 PROCESS NUTRITION DAY 1 HEALTHY HEART DIET OR SPECIAL DIET IF REQUIRED MOBILITY/ACTIVITY * ACTIVITY LEVEL 2 IF PAIN FREE (MI & ANGINA PATIENTS): ACTIVITY LEVEL 3 AS TOLERATED (ANGINA PATIENTS ONLY): SIT UP 20 MIN (TID / MEALS) BATHROOM PRIVILEGES ASSISTED BATH UP IN ROOM AD LIB SIT UP FOR MEALS SHOWER WALK IN HALL PSYCHOSOCIAL SUPPORT/ EDUCATION * DISCHARGE PLANNING * REINFORCE ACTIVITY LEVELS REVIEW PATIENT PATHWAY CONTINUE TEACHING CHECKLIST ASSESS FOR TRANSFER TO TELEMETRY FAMILY PHYSICIAN NOTIFIED ASSESS DISCHARGE CRITERIA DAILY Grey Bruce Health Network 8

9 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS DAY 2 ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION CONTINUOUS CARDIAC MONITORING (ANGINA PATIENTS SHOULD BE DISCONTINUED IF APPLICABLE) VITALS WITH O 2 SATS Q4H AND PRN CHEST ASSESSMENT PAIN ASSESSMENT (0-10) ASSESS FOR SIGNS OF HEART FAILURE ASSESS FOR SIGNS OF BLEEDING MONITOR INTAKE / OUTPUT ASSESS BOWEL ROUTINE PERIPHERAL EDEMA MENTAL STATUS ORIENTED TO PERSON/PLACE/TIME ECG WITH PAIN CHEST X-RAY IF NOT DONE PREVIOUSLY BLOOD WORK AS ORDERED SEE MAR SHEET O 2 PRN IV / SALINE LOCK (DISCONTINUE IN ANGINA PATIENTS) HEALTHY HEART DIET OR SPECIAL DIET IF REQUIRED Grey Bruce Health Network 9

10 PROCESS DAY 2 MOBILITY/ACTIVITY * ACTIVITY LEVEL 2 AS TOLERATED (MI & ANGINA PATIENTS): ACTIVITY LEVEL 3 AS TOLERATED (MI & ANGINA PATIENTS): ACTIVITY LEVEL 4 AS TOLERATED (ANGINA PATIENTS ONLY): SIT UP 20 MIN (TID / MEALS) BATHROOM PRIVILEGES ASSISTED BATH UP IN ROOM AD LIB SIT UP FOR MEALS SHOWER WALK IN HALL ACTIVITY AS TOLERATED REINFORCE ACTIVITY LEVELS PSYCHOSOCIAL SUPPORT/ EDUCATION * REVIEW PATIENT PATHWAY TEACHING CHECKLIST: CONTINUE TEACHING CHECKLIST (MI PATIENTS ONLY) COMPLETE TEACHING CHECKLIST (ANGINA PATIENTS ONLY) PATIENT ENCOURAGED TO ASK QUESTIONS ECHO APPOINTMENT ARRANGED DISCHARGE PLANNING * ANGINA PATIENTS ONLY: STRESS APPOINTMENT ARRANGED DISCHARGE PLANS ARRANGED DISCHARGE PLANS DISCUSSED WITH PATIENT/FAMILY DISCHARGE ORDER SECURED FOR DAY 3 ASSESS DISCHARGE CRITERIA DAILY - ANGINA PATIENTS COULD BE READY FOR DISCHARGE Grey Bruce Health Network 10

11 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS DAY 3 ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION VITALS WITH O 2 SATS Q8H AND PRN CHEST ASSESSMENT PAIN ASSESSMENT (0-10) PERIPHERAL EDEMA MENTAL STATUS ORIENTED TO PERSON/PLACE/TIME ECG WITH PAIN BLOOD WORK AS ORDERED INR IF ON WARFARIN SEE MAR SHEET SALINE LOCK HEALTHY HEART DIET OR SPECIAL DIET IF REQUIRED UP IN ROOM AD LIB MOBILITY/ACTIVITY * ACTIVITY LEVEL 3 AS TOLERATED SIT UP FOR MEALS BATHROOM PRIVILEGES SHOWER WALK IN HALL REINFORCE ACTIVITY LEVELS Grey Bruce Health Network 11

12 PROCESS DAY 3 PSYCHOSOCIAL SUPPORT/ EDUCATION * DISCHARGE PLANNING * REVIEW PATIENT PATHWAY CONTINUE TEACHING CHECKLIST ASSESS NEED FOR TELEMETRY ASSESS FOR TRANSFER TO MEDICAL UNIT ASSESS NEEDS FOR DISCHARGE ASSESS DISCHARGE CRITERIA DAILY Grey Bruce Health Network 12

13 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PATIENT ID PROCESS DAY 4 VITALS WITH O 2 SATS BID AND PRN ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CHEST ASSESSMENT PAIN ASSESSMENT (0-10) PERIPHERAL EDEMA MENTAL STATUS ORIENTED TO PERSON/PLACE/TIME CONSULTS DIAGNOSTICS/ LABORATORY MEDICATIONS TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY * PSYCHOSOCIAL SUPPORT/ EDUCATION * FOLLOW UP APPOINTMENTS IF NECESSARY ECG WITH PAIN SEE MAR SHEET DISCONTINUE SALINE LOCK CONSIDER SHOWER IF STABLE HEALTHY HEART DIET OR SPECIAL DIET IF REQUIRED ACTIVITY LEVEL 4: REINFORCE ACTIVITY LEVELS REVIEW PATIENT PATHWAY FINISH TEACHING CHECKLIST ACTIVITY AS TOLERATED PATIENT ENCOURAGED TO ASK QUESTIONS ECHOCARDIOGRAM APPOINTMENT ARRANGED DISCHARGE PLANNING * STRESS TEST ARRANGED ASSESS DISCHARGE CRITERIA DAILY SECURE DISCHARGE ORDER FOR DAY Grey Bruce Health Network 13

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15 ACUTE CORONARY SYNDROMES CLINICAL PATHWAY ACUTE STAGE GREY BRUCE HEALTH SERVICES Lion's Head Markdale Meaford Owen Sound Southampton Tobermory Wiarton PROCESS PERFORMANCE INDICATORS ASSESSMENT (OBSERVATIONS/ MEASUREMENTS/ ELIMINATION) CONSULTS DIAGNOSTICS/ LABORATORY DISCHARGE CRITERIA PATIENT ID 4 ACE INHIBITOR PRESCRIBED AT DISCHARGE Met Not Met N/A 5 STATIN PRESCRIBED AT DISCHARGE Met Not Met N/A 6 BETA BLOCKER PRESCRIBED AT DISCHARGE Met Not Met N/A 7 ASA PRESCRIBED AT DISCHARGE Met Not Met N/A 8 SMOKING CESSATION ADVICE/COUNSELLING COMPLETED Met Not Met N/A VITALS STABLE NO CHEST PAIN MET INITIAL MEDICATIONS REVIEW DISCHARGE MEDS REASSESS HOME MEDS TREATMENTS/ INTERVENTIONS NUTRITION MOBILITY/ACTIVITY ACTIVITY LEVEL 4: PATIENT UNDERSTANDS HEALTHY HEART DIET AND ITS IMPORTANCE (OR REFERRAL TO DIETITIAN HAS BEEN MADE) PATIENT ABLE TO PERFORM ACTIVITIES OF DAILY LIVING INDEPENDENTLY OR AT PRE-HOSPITALIZATION LEVEL ACTIVITY AS TOLERATED REVIEW ACCEPTABLE ACTIVITY LEVELS AT HOME RISK FACTORS PSYCHOSOCIAL SUPPORT/ EDUCATION DISCHARGE PLANNING PATIENT DEMONSTRATES KNOWLEDGE OF: LIFESTYLE CHANGES WARNING SIGNS OF CHEST PAIN HOW/WHEN TO SEEK MEDICAL ASSISTANCE NITROGLYCERIN USAGE AWARE OF COMMUNITY RESOURCES Grey Bruce Health Network 15

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