URN: Family name: Given name(s): Address: Initial Signature Print Name Role

Transcription

1 Do Not Write in this binding margin v /2012 Mat. No.: SW030b The State of Queensland (Queensland Health) 2012 Contact ÌSW030bIÎ Facility: s Never Replace Clinical Judgement Care Outlined in this Pathway Must Be Altered if it is not Clinically Appropriate for the Individual Patient Pathway commenced Date:... Time:... Initials:... Pathway ceased Date:... Time:... Reason:... Initials:... Principal (Final) diagnosis:... Initials:... Treating consultant (print name):... 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 flag it in the Variance column, then document in the free text area as instructed. If this variance occurs more than once daily, document the additional times of the variance in the variance free text area and in the patient s progress notes as applicable. 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 must supply a sample of their initials and signature below. Signature Log: Initial Signature Print Name Role Patient with chest pain ED Chest Pain Medical Assessment Tool Acute Coronary Syndrome suspected/under investigation Cardiac Chest Pain Risk Stratification Pathway Page 1 of 6 (Affix identification label here) Acute Coronary Syndrome diagnosed NSTEACS Mgt. Plan STEMI Mgt. Plan NSTEACS Pathway OR STEMI Pathway

2 All care givers who initial are to sign signature log Key Allied Health Medical Nursing Pharmacy Discharge Planning Checklist Initials Date Risk Factor Identification and Intervention Reinforce instructions with patient and carer on CAD Risk Reduction Strategies. Utilise the Heart Foundation booklet How to Have a Healthy Heart or similar to discuss the following: Current smoking (comments): Cholesterol (comments): Weight (comments): Stress (comments): Hypertension (comments): Diet (low fat / low salt) (comments): Exercise (comments): Alcohol (comments): Refer to Outpatient Services: Yes No Dietitian Weight Loss Lighten Up Queensland Health Program Cardiologist / Physician Endoscopy Psychologist / Stress Management Cardiac Rehabilitation Referral Physiotherapist Other: Patient Education and Discharge Planning Reinforce chest pain home management plan with patient and carer Aboriginal and Islander Liaison Officer required? Yes No (if Yes, notify) Emotional and Social Assessment required? Yes No (if Yes, notify Social Worker) Review medications for discharge DO not write in this binding margin Reinforce with patient and carer: discharge diagnosis general prognosis discuss ability to drive Check complete and give to patient: Medical certificate Discharge summary and ECG (copy) Medical follow-up arrangements: General Practitioner Cardiologist diagnostic and therapeutic options return to work Discharge medications and medication use Travel forms (if required) Fax Discharge Summary and ECG to GP Other: Page 2 of 6

3 All care givers who initial are to sign signature log Key Allied Health Medical Nursing Pharmacy Category ADMISSION From: hrs To: hrs Shift: AM PM ND V Reviews Investigations Discharge planning commenced Yes No ECG + TnI (0 hours and 6 to 8 hours) Second TnI positive? Yes No ST - T waves changes at 6 to 8 hours? Yes No If yes to either of the above, refer for Cardiology / Physician Registrar review, change to NSTEACS pathway. If further chest pain, administer glyceryl trinitrate (if not contraindicated), organise medical review (within 10 mins) and perform ECG Do Not Write in this binding margin Medications and Pain Management Observations Treatments Nutrition EST request form If EST inappropriate, consider alternate objective testing. Complete EST or alternate testing within 72 hours of presentation. EST Time booked:... Date:... Results: Positive (change to NSTEACS pathway) Negative Equivocal Unable to complete Not done, reason:... Review medications Continuous cardiac monitoring (where available) Cease continuous cardiac monitor if the second TnI is negative. Pulse, resps and BP frequent if unstable then 4 hourly Deep breathing, coughing and leg exercises Physical assessment (document in medical record) Consider appropriate preparation for investigations: If for EST avoid food for 2 hours prior to test If for MPS, no caffeine 24 hours prior to test Other:... Healthy heart / special requirements:... v /2012 Mat. No.: ÌSW030bIÎ SW030b Mobility / Elimination / Hygiene Education and Discharge Plan Expected Outcome (complete at end of 24 hour period) Toilet privileges and bed rest or equivalent May mobilise after medical review if second TnI normal, painfree and ECGs NAD. Basic explanation of mobilisation and bed exercises Explanation of: Coronary Artery Disease (CAD) Risk factors Basic cardiac A&P Potential investigations Provide Heart Foundation booklet or similar Patient demonstrates: A Achieved V Variance A V No further chest pain Haemodynamically stable post cardiac investigations Cardiac rhythm stable post cardiac investigations Patient verbalises understanding of diagnosis and treatment Page 3 of 6

4 All care givers who initial are to sign signature log Key Allied Health Medical Nursing Pharmacy Category Day 2 Date: to Shift: AM PM ND V Reviews Discharge planning commenced Yes No Investigations (if not completed on the previous day) Second TnI positive? Yes No ST - T waves changes at 6 to 8 hours? Yes No If yes to either of the above, refer for Cardiology / Physician Registrar review, change to NSTEACS pathway. If further chest pain, administer glyceryl trinitrate (if not contraindicated), organise medical review (within 10 mins) and perform ECG EST request form If EST inappropriate, consider alternate objective testing. Complete EST or alternate testing within 72 hours of presentation. Medications and Pain Management Observations Treatments Nutrition EST Time booked:... Date:... Results: Positive (change to NSTEACS pathway) Negative Equivocal Unable to complete Not done, reason:... Review medications Continuous cardiac monitoring (where available) Cease continuous cardiac monitor if the second TnI is negative. Pulse, resps and BP frequent if unstable then 4 hourly Deep breathing, coughing and leg exercises Physical assessment (document in medical record) Consider appropriate preparation for investigations: If for EST avoid food for 2 hours prior to test If for MPS, no caffeine 24 hours prior to test DO not write in this binding margin Other:... Mobility / Elimination / Hygiene Education and Discharge Plan Expected Outcome (complete at end of 24 hour period) Healthy heart / special requirements:... Toilet privileges and bed rest or equivalent May mobilise after medical review if second TnI normal, painfree and ECGs NAD. Basic explanation of mobilisation and bed exercises Explanation of: Coronary Artery Disease (CAD) Risk factors Basic cardiac A&P Potential investigations Provide Heart Foundation booklet or similar Patient demonstrates: A Achieved V Variance A V No further chest pain Haemodynamically stable post cardiac investigations Cardiac rhythm stable post cardiac investigations Patient verbalises understanding of diagnosis and treatment Page 4 of 6

5 Variance Codes A. Patient Variances Actions A:1 Recurrent chest pain (Differentiate Chest Pain Type; ischaemic, pericarditis or chest wall pain) A:2 Cardiac arrest Administer O 2 if indicated (SaO 2 < 93% or evidence of shock) Administer Sublingual Glyceryl Trinitrate Perform ECG MO Review Repeat TnI If re-infarction, consider urgent PCI v /2012 Do Not Write in this binding margin Mat. No.: ÌSW030bIÎ SW030b A:2.1 Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT) A:2.2 Unconscious Complete Heart Block / Asystole A:2.3 Pulseless Electrical Activity A:3 Other arrhythmias: A:3.1 Conscious sustained Ventricular Tachycardia A:3.2 First episode of Atrial Fibrillation (AF) or other Supra Ventricular Tachycardia (SVT) A:3.3 First episode of Heart Block; 2nd or 3rd degree AV Block A:4 Left ventricular failure (with Pulmonary Oedema) Basic Life Support CPR Code Blue Advanced Life Support Defibrillation Basic Life Support CPR Code Blue Emergency transthoracic pacing, transvenous pacing Basic Life Support CPR Code Blue A:5 Pericarditis MO review Consider analgesia Consider echocardiogram A:6 Pulmonary embolus (PE) / Deep vein thrombosis (DVT) A:7 Renal failure (Significant worsening of renal function as defined by rising creatinine or worsening GFR) A:8 Pulmonary complications (Cough, sputum production, fever and pleuritic chest pain) Urgent MO review: - unstable patient (hypotensive): call medical Emergency Team; - stable patient within 5 mins Urgent MO review: - unstable patient: within 5 mins; - stable patient: mins Urgent MO review: - unstable patient (hypotensive/syncope): call Medical Emergency Team; - stable patient within 5 mins Prepare for transthoracic pacing, transvenous pacing Sit patient upright Administer O 2, 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 antihypertensive agent Strict Fluid Balance Chart, consider IDC Urgent MO review Anticoagulation CTPA or VQ Scan +/- Leg Ultrasound O 2 if indicated Bed rest Assess volume state and urine output Urgent MO review; 1 2hrs Strict Fluid Balance Chart, consider IDC Treat hyperkalaemia 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 Page 5 of 6

6 Variance Codes (continued) B. Discharge / Treatment Delay Variances B:1 Treatment delay B:5 Interdepartmental issues involving care B:1.1 Exercise stress test delay B:6 Blood tests delayed B:2 Delay in transfer B:7 Delay in chest X-ray B:3 No bed available B:8 Delay in stress test B:4 No monitored bed available B:9 Medication not available C. Staff Variances C:1 Medical C:3 Allied Health C:2 Nursing C:4 Unable to provide patient education Clinical Events / Variance B:10 Patient discharged home off pathway B:11 Transfer to private hospital B:12 Change of plan / orders B:13 Self discharge B:14 Overnight stay Date / Time Variance Code Describe variances to clinical path and any other patient related notes. Document as Variance / Action / Outcome Initials DO not write in this binding margin Page 6 of 6