Cardiac Multidisciplinary Integrated Care Pathway (ICP) For patients having Outpatient Coronary Angiogram as Day Stay

Transcription

1 Southend University Hospital NHS Foundation Trust Cardiac Multidisciplinary Integrated Care Pathway (ICP) For patients having Outpatient Coronary Angiogram as Day Stay Patient s preferred name: Consultant: Date ICP started: Ward: Print name please Designation Signature Initials Acceptable abbreviations guidelines ACE Angiotensin Converting Enzyme IA Intra Arterial Cath Catheter K Potassium CVA Cerebrovascular Accident LHC Left Heart Catheter COPD Chronic Obstructive Pulmonary Disease PCI Percutaneous Coronary Intervention DASE Dobutamine Assisted Stress Echo MIBI A Myocardial Perfusion Scan ECG Electrocardiogram Na Sodium egfr Estimated Glomerular Filtration Rate SL Sublingual ETT Exercise Treadmill Test SOB Shortness Of Breath FBC Full Blood Count TIA Transient Ischaemic Attack IV Intravenous U&E Urea and Electrolytes IHD Ischaemic Heart Disease MRSA Methicillin Resistant Staphylococcus Aureus Guidelines for the use of this ICP This ICP should be used for all patients undergoing Coronary Angiography as an outpatient. It should be commenced when the patient attends pre-assessment. If at any stage the patient is no longer to have the procedure this ICP should be discontinued. The Operator is the member of the Cardiology team performing the procedure. When making their first entry in the pathway all members of staff must identify themselves on the front page. All sections/stages must be completed; no sections should be left blank in accordance with guidelines and recommendations for record keeping. If a goal is not met or is inappropriate then this should be documented as a variance with an explanation of reasons and alternative actions undertaken. This ICP should be used in conjunction with Policy for Coronary Angiography. This ICP is intended as a guide to care and does not replace clinical judgement. Version 3 - April Next review and update due 1st March Form 1557

2 Procedure Date Referred for Angiogram:... Name of Referrer:... Referral letter attached: No Indication for Angiogram:... Intended date for Angiogram: Outcome: 1. Date:... Went ahead as planned Cancelled If Cancelled Reason:... AM PM... Intended date for Angiogram: Outcome: 2. Date:... Went ahead as planned Cancelled If Cancelled Reason:... AM PM... Type of Angiogram planned: LHC Right and left Grafts Other... Pre-assessment: Clinical and Past Medical History relevant to procedure Date:... Signature of pre-assessment nurse:... Previous Cardiac Investigations / Interventions: Date: Details / Complications Angiogram Previous PCI Cardiac Surgery Has patient had Angioseal in last 90 days: No On dual antiplatelet therapy: No If - reason: Investigations in the last year: Details: ETT No ECHO No MIBI No DASE No CXR No 2

3 Pre-assessment: Clinical and Past Medical History continued Known Diabetic: No Control: Diet Tablets Insulin (If yes, cath lab staff and operator aware: Informed) Peripheral Vascular Disease: No Hypertension: No Abdominal Aortic Aneurysm: No Asthma or COPD: No Previous Syncope/Blackouts: No Epilepsy: No Previous Renal Impairment: No CVA or TIA: No Clotting Disorder: No If yes, clotting screen requested Previous Anaemia: No If yes, Hb requested If yes to any of the above, doctor aware and suitably checked: No More details: Pre-assessment: Patient details and social information Current medications: Record drug, dose and frequency If patient taking Warfarin / Dabigatran or Diuretics, refer to Angiogram Policy for omissions prior to procedure Known allergies: Any previous reaction to contrast: No Smoking history: Family history of CHD: Alcohol intake - units per week: Breathing: MRSA screen taken: No Patient high risk i.e: from nursing home, had recent inpatient admission or previous MRSA No Social circumstances/self care ability: Mobility: Equipment used: Nutrition score: Special dietary requirements: Any possiblity of pregnancy or patient breast feeding? No LMP: Transport arrangements: Communicating: Equipment used: Waterlow score: Elimination 3

4 Pre-assessment: Continued Goal BP Recorded: Result = / mmhg Pulse Recorded: Result = bpm Pulse: Regular No (if no record details in variance) Patients current height and weight measured: Height:... Weight:... kg Confirmed patient can lay flat for 1 hour or more: (If patient unable to - inform operator) Initial Variance Confirmed patient suitable for 2 hourly recovery. Procedure discussed with patient and pre consent documentation completed. If not record as variance and patient for 3 hourly recovery Patient advised to shave appropriate area. Patient will require sedation No Patient advised to take no diet for 6 hours prior to admission and from then clear fluids only up to 2 hours prior to admission. Patient takes Warfarin/Dabigatran: No If yes, reason for Warfarin/Dabigatran: Patient advised re: omitting medication: No INR to be checked on day of procedure. Alternative anticoagulation arranged: No For those with mechanical valve/recent or recurrent DVT. For patients taking diuretics: Patient advised re: omitting medication on day of angiogram (if on AM list) For diabetic patient: Patient advised as per angiogram policy. 4

5 Pre Angiogram preparation Investigations All patients should have egfr checked at pre-assessment. If patient taking Warfarin - INR should be checked prior to procedure. Blood tests requested for: FBC: No NA Na Date of test: Results: Others: please specify U&E: No NA k egfr: No Urea Glucose: INR: No NA Creatinine Cholesterol: No egfr Hb MRSA Results/Status: Cholesterol Total... HDL... Ratio... Positive Negative INR Pending Flow Chart for patients with egfr < 60 undergoing In Patient Angiography. egfr < 60 Dr to consider discontinuing following drugs on day prior to procedure: ACE inhibitor, ARB, Loop diuretic, NSAID, Dipyridamole. egfr Visipaque egfr Visipaque IV Fluids Repeat egfr 72 hours post procedure Nurses responsibility: Ensure blood form printed to recheck bloods 3 days post procedure. If patient discharged within 72 hours post angio, ensure has blood form and knows to have blood test 3 days post procedure d/w consultant if Creatinine increased by 20% or egfr reduced by 15% Consultant of week responsibility: Review pathway and result Contact Renal Physicians Protocol for patients with Renal Dysfunction undergoing cardiac investigation requiring intravenous contrast. (Intranet Ref: ) 5

6 Pre Angiogram preparation/checklist: Goal Blood results reviewed and managed according to guidelines. If patient takes warfarin: INR Result:... Initial Variance egfr result:... If <60 complete the following: Patient requires Visipaque No Patients drugs on day prior to procedure reviewed by doctor No Patient requires IV fluids No Observations recorded: Blood pressure: Resps: Reported to operator if: BP>200/100mmHg Pulse <60 bpm or > 120 bpm MRSA result checked and action taken according to policy IC009 Pulse: Temperature: Consent completed and discussed with patient No diet and clear fluids only taken for 6 hours prior to procedure Time from..... No Fluids taken for 2 hours prior to procedure Time from Glucose level recorded: Result: mmols Left & Right Pedal pulses present and Marked (if femoral approach) or Left & Right Radial pulses present (if radial/brachial approach) Patent IV cannula insitu (Preferably in left antecubital fossa) Invasive devices tool on page 5 completed. Name band insitu and correct. Operation site prepared and shaved if required. Allergies identified + red allergy wristband insitu. Patient has passed urine prior to leaving ward. Document if patient has dentures insitu. All makeup / nail varnish removed. All jewellery (including body piercings) removed. Patient wearing theatre gown and all underwear removed. Property disclaimer. 6

7 Sodium Chloride 0.9% flush Dose 10ml Date Time Signature Dose Give Invasive Device Tool Please indicate insertion site Numbered Insertion Deatils Date:... Time:... Date:... Time:... Size:... Size:... Numbered Removal Deatils Date:... Time:... Date:... Time:... Right Left Size:... Size:... Insertion Performed with full aseptic non touch technique and appropriate personal protective equipment used. Informed consent - if applicable. Procedure explained to patient - if possible. Staff trained in procedure and aware of EPIC 2 and relevant clinical guidelines. Hand hygiene pre- and post-procedure. Skin prepared with 2% Chlorhexidine solution and allowed to dry. (Use Povidone Iodine if allergic to Chlorhexidine). Appropriate site chosen and indicated on diagram above. Dressed with 3M semi-permeable dressing. Educate patient on care of the site. Clean catheter ports with 2% Chlorhexidine swabs (Clinell Wipe) when accessing ports or administering medication/fluid. Transfer to Catheter Lab Insertion 1 Insertion 2 Handover Check Date:... Time:... Name band insitu and correct Angio Nurse Sign Variance Correct patient notes with patient on transfer Pages 2, 3 and 4 checked for any complicating factors that the operator needs to be informed of. Consent form completed and signed. Patent cannula insitu. egfr < 60 - Visipaque to be used. Risk of pregnancy excluded (p.3) if applicable. 7

8 In Catheter Lab Sign in: To be read out loud, before giving anaesthetic (local or general). (WHO Surgical Safety Checklist: for Radiological Interventions ONLY) Have all team members introduced themselves by name and role? All team members verbally confirm: What procedure, site and position are planned? No All team members verbally confirm: What is the patient s name? No Has the patient confirmed his/her identity, site, procedure and consent? Has essential imaging been reviewed? No Are all IRMER requirements met? Essential imaging available and reviewed? Is the procedural site and side marked and procedure checked with cardiologist? If >500ml blood loss expected is the patient cross-matched? Have risk factors for bleeding and renal failure been checked? N/A Is the anaesthesia machine/monitoring equipment and medication check complete? No N/A If risk of blood loss, adequate IV access/fluids planned N/A N/A N/A N/A No N/A No Does the patient have a known allergy? No Has VTE prophylaxis been undertaken? N/A Are there any critical or unexpected steps you want the team to know about? Is the required equipment available No and in date N0 Signature:... Date:... Are you or might you be pregnant? No N/A Date:... Patients signature:... Radiographers signature:... This box must be filled in and signed on the day of procedure by the patient and the radiographer for all women under 55 years. Record of once only drugs given Date Drug Dose Chloraprep 2% Route Topical Signature and bleep no. Given Date Time Initals Lidocaine 1% Omnipaque 300 SC IA/IV Visipaque GTN spray Verapamil Isosorbide dinitrate (Isoket) Heparin IA/IV SL IA IA IA 8

9 In Catheter Lab Sign out: Questions in bold to be read out loud, before any member of the team leaves the room. Procedure:... Start time (knife to skin): Left heart catheter Left coronary Right coronary Left ventricular Right heart catheter Aortogram Grafts Angioseal insitu: No If yes: Time:.. hrs Size:.. Dr: (Sticker) Access used Pulse Skin Temp. Right femoral Sheath removed by:... Warm Left femoral At:.... No Cool Haemostasis Time:. Right radial TR Band: Warm Left radial Time applied: Mls Air used: No Cool All invasive equipment accounted for? Procedure Complications: No Cannula required to be sited in Cath Lab: No If yes, details: Wound status: Have the instructions for post procedural care for this patient been agreed? Special instructions: Signature:... Date:... Time patient left Cath Lab:... 9

10 Post Angio - On return to ward Goal Time Initial Variance Observations Goal: B/P & Pulse recorded ½ hourly for 1 hour then, 1 hourly for 2 hours. Sats and respiratory rate recorded also if patient had sedation Pedal / radial pulses recorded ½ hourly for 1 hour, then 1 hourly for 2 hours checking for change in depth of pulse, assessing limb for colour & warmth Wound observed for signs of bleeding or haematoma as on going assessment Occlusive dressing applied to wound site. Level of pain / discomfort assessed Urine passed post procedure Nutrition Goal Diet tolerated. Any difficulties with providing diet? At least 1 litre of oral fluids tolerated. Drs advice to be sought for patients with significantly impaired LV Function. Mobility Goal Femoral: - Bed rest lying flat for 1 hour - Gradually sit up over 1 hour (2hrs if previous angio) - Mobilise. If Angioseal insitu: - sit at 45 following haemostasis for ½ hour - sit up fully for ½ hour, then fully mobilise according to plan. Radial: - Sit or mobile on ward, keep arm straight raised on pillow. - Manage TR Band according to local policy Brachial: - Bed rest Sitting up for 1 hour-keep arm straight - Mobilise for 1 hour keeping arm straight. Teaching and Psychological Support Goal Wound Management advice given to patient Care & progress discussed with patient. Relatives updated as appropriate. If more space required for variance details use page 12 or add continuation sheet 10

11 Post Angiogram Ward Round Goal Time Initial Variance Results and management plan discussed with patient. Medications/Investigations to be reviewed if applicable Metformin to be restarted 48 hours after procedure, if pre assessment U&E normal. If pre assessment U&E abnormal patient given blood form for U&E to be rechecked 48hrs after procedure and a letter for GP re: Metformin. Warfarin to be restarted next evening after procedure: anticoagulation clinic contacted and appointment made. Clexane required/or restarted: No N/A Dabigatran to be restarted 48 hours after procedure: anticoagulation clinic contacted and appointment made. Clexane required/or restarted: No N/A If pre angiogram egfr was <60: Blood form given to patient to recheck egfr 3 days post procedure. Name documented in patients results log. On receiving results, letter sent to GP, patient and copy to Consultant if results abnormal. Date Time Notes / Variances Signature 11

12 Angiogram Result and Management Management plan: Pre Discharge and Follow Up Care Goal Tick Variance Wound checked before discharge and is clean and dry. Comments on wound: Patient advised to remove Occlusive dressing after 48 hours. Datacam completed. TTA s prescribed and ordered. Transport arrangements checked. Own Hospital Details: If patient confirmed as IHD, Cardiac Rehab Team details given to patient. If patient to be referred or is query for outpatient PCI/CABG or valve surgery: Patient given choice booklet Choice form for database information completed Dental letter given to patients having valve surgery Health Information Discharge advice given on the following: Managing pain and use of GTN No N/A Smoking/ smoking cessation No N/A Medication No N/A Driving No N/A Wound care No N/A Exercise No N/A Work No N/A Discharge Nurse Signature... 12