ACUTE CORONARY SYNDROME - wdhb.org.nz · ACUTE CORONARY SYNDROME PATHWAY. Page 2 of 40 STAT 0033CAT...

WhanganuiDistrict Health Board

STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page 1 of 40

Clinical Pathway

ACUTE CORONARY SYNDROME

Whanganui District Health Board

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

STEMIST Elevation Myocardial

Infarction

NSTEACSNon ST Elevation Acute Coronary

Syndrome

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Page 2 of 40STAT 0033 CAT 0063 Review Date 02/2013

Reviewed 02/2011 CNE Vigenser; Dr Ghamiri.

ACUTE CORONARY SYNDROME ALGORITHM

(A) DIAGNOSTIC CRITERIA History of angina or

equivalent Assess Risk Factors New or presumed ST elevation at J point in 2 or more contiguous leads ST elevation > 0.2 mv in leads V1 V2 V3 or > 0.1 mv in other leads New LBBB with presence of one of the following ST elevation > 1mv in

leads with +ve QRS ST depression > 0.5

mv in V1 – V3 ST elevation > 0.5mv

in leads with -ve QRS Inferior infarcts must

have V3R & V4R leads recorded to detect RV infarct

Posterior V7 V8 V9 should be performed if Posterior MI suspected

Posterior wall infarct ST depression V1 V2 with upright T waves or presence ST elevation in posterior chest leads

(V7 V8 V9) (STEMI/NSTEMI 2005 NZ management

(B) REQUIREMENTS for THROMBOLYSIS Resuscitation status Eligibility sheet

completed (see page 3) Assess need for URGENT

PCI (p11)

(C) TROPONIN >0.04 elevation also noticed in - Significant renal failure - PE (usually < 0.2 and

associated with significant PE - Severe COPD - Muscle disease - CKMB preferred for

diagnosis of reinfarction

- Sepsis - Myocarditis

(D) DECISION to MONITOR Ongoing pain

requiring GTN Arrhythmia Co – morbidities Quality of life Location of monitored beds CCU 6 beds Telemetry 6 units AAU 6 beds

(E) RISK STRATIFICATION

Add TIMI score points Age >65 years 1 3 risk factors for 1 IHD Prior coronary 1 stenosis >50% >0.5mm ST 1 deviation on ECG >angina 1 episodes past 24 hours Aspirin use past 1 7 days Elevated serum 1

cardiac markers 0 – 2 low risk 3 – 4 intermediate risk 5 – 7 high risk NB Admission is at

the discretion of the Consultant

PATIENT ARRIVES IN EMERGENCY WITH SUSPECTED ISCHAEMIC CHESTPAIN

Obtain ECG on arrival, document time and assess for changes

Review by doctor within 10 minutes

Monitor lead 11 O2 @ 2-6L/min via nasal prongs OR 6-8 L/min via Hudson mask

to keep SpO2 94-96% in COPD 88-94% (pending ABG) Insert 18g IV cannula x2 Aspirin 300mgs to chew stat Bloods – Creatinine, Electrolytes, FBC, Troponin T, Coagulation profile, INR if on Warfarin, C Reactive Protein BP both arms Glyceryl Trinitrate/Morphine/anti emetic

ECG shows ST elevation

or new LBBB see (A) STEMI

ECG shows New

ST depression Or

New T wave inversion

NSTEMI

ECG -ve

Troponin +ve

see ( C )

ECG -ve

Troponin -ve

see ( C )

Discuss with consultant

Reperfusion Therapy

Follow STEMI NZ guidelines

see ( B )

Monitor

see ( D )

Monitor 6 hours ED / AAU

Repeat ECG /

Trop 6-8 hours

NSTEMI / ongoing chest pain

Low risk see ( E )

(D/W consultant)

YES NO YES NO

Admit CCU Admit ward on telemetry

Discharge with

Referrals for OPD

investigations

+ve -ve

Oral Metoprolol unless contraindicated

Chest X-ray

Thrombolysis criteria met (see page 3) STK 1.5mu

over 30 mins OR

Tenectaplase As per protocol

See p 10



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ELIGIB

ILITY

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IS

Absolute Contraindications YES √ NO √ • AnypriorIntracranialHaemorrhage • Knownstructuralcerebralvascularlesion(e.g.ateriovenousmalformation) • Knownmalignantintracranialneoplasm(primaryormetastatic) • Ischemicstrokewithin6monthsEXCEPTacuteischemicstrokewithin3hours • Suspectedaorticdissection • Activebleedingorbleedingdiathesis(excludingmenses) • Significantclosed-headorfacialtraumawithin3weeksRelative contraindications • Historyofchronic,severe,poorlycontrolledhypertension • Severeuncontrolledhypertensiononpresentation (SystolicBP>180mmHgofdiastolicBP>110mmHg) • Historyofpriorischemicstrokegreaterthan3months,dementia,orknownintracranialpathology

not covered in contraindications or TIA within 6 months • Traumaticorprolonged(>10min)CPRormajorsurgery(<3weeks) • Recent(within2-4weeks)internalbleeding • Noncompressiblevascularpunctures • Forstreptokinase:priorexposure(morethan5daysago)orpriorallergicreactiontotheseagents • Pregnancyor1weekpostpartum • Activepepticulcer • Currentuseofanticoagulants:thehighertheINR,thehighertheriskofbleeding/Advancedliver

disease Source: American College of Cardiology

n Patients with ongoing chest pain > 12 hours may be eligible for streptokinase – discuss with Consultant

n Informed Consent obtained VERBALLY n STREPTOKINASE charted on medication form Date __________________

Medical Signature ___________________________________ Name _______________________________________ & Time ________________ (Printed)

ASSESSMENT OF ELIGIBILITY FOR THROMBOLYSIS

YES NO Has the patient experienced chest discomfort for greater than 15 minutes from onset?

Has pain persisted for less than 12 hours?

Time of onset of pain ___________________________

Discuss with consultant assoon as possibleYES NO

Are there contraindications to fibrinolysis? If ANY of the following are checked “YES” fibrinolysis MAY be CONTRAINDICATED

Thrombolysis Audit Tool Door to Needle Time √ Avoidable Delays √ Unavoidable delays √ 0-20 minutes Delayto1stECG Language

21-30 minutes InterpretingECG Contraindications

31-40 minutes Contactingkeyperson Other…(specify)

41-60 minutes Other

≥60 minutes




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DO NOT RESUSCITATE ORDER

If _______________________________________________________________________________________________________________

(Patientname)

becomesunresponsiveandiswithoutapulseornotbreathing:

1. DO NOT INITIATE CARDIOPULMONARY RESUSCITATION

(chestcompressionsand/ormechanicalventilation)

2. DO NOT CALL A CARDIAC OR PULMONARY ARREST

Indication(s)forDoNotResuscitateorder:

At the request of __________________________________________________________________________________________________________ (Patient’sname)

_________________________________________________________________________________________________________________________________

(Patientsignatureorparents/guardianifminor)

Witnessed By ________________________________________________________________________________________________________________

(Doctor’snameandsignature)OR

Medically Contraindicated Yes / No

Doctor’sname: _________________________________________________________________________________________________________________

(Print)

Doctor’ssignature: ___________________________________________ Date: _______ / ________ / ________ Time: _________________

Designation:(circleone) Physician Consultant MOSS Registrar

If this is a telephone order, 2 Registered Nurse and/or Medical Practitioner Confirmation:

_______________________________________________________________ ______________________________________________________________

(Nameanddesignation) (Nameanddesignation)

Date of decision: _____________________________________________ Date reviewed: ______________________________________________

Decisiondiscussedwithpatientand/ornominatednextofkin Yes / No

If not discussed, reason:

_________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:


STAT 0033 CAT 0063 Review Date 02/2013Reviewed 02/2011 CNE Vigenser; Dr Ghamiri. Page5of40

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Consultant:

Dateandtimeofdiscomfort/pain/tightnessonset:

Site:

Precipitatingeventandduration:

Character:

Radiation:

Course of Pain:

Relievingorexacerbatingfactors:

Similarepisodesinthepast:

Associatedsymptoms:

Frequency of anigina/use of GTN:

Past Cardiac History:

Previous Cardiac Events: includedatesofangio,CABG,Stentsandwhichhospitalhasprovidedmanagement

Ongoing Cardiac Medical Conditions:

Medical History and Examination: To be completed following administration of thrombolysis

Presentation: History of this episode of chest pain




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BLOOD PRESSURE:

CHOLESTEROL: Never tested Other:

HISTORY OF DIABETES: No

TypeI/II:Duration:CurrentTreatment:

FAMILY HISTORY premature IHD and other conditions:

SMOKER: Current Ex-Smoker Never Pack/Years ___________________

STRESS:

Other Medical History

Social History

EMPLOYMENT: VOCATIONAL DRIVERS LICENSE:

Medications Drug Drug

ALLERGIES/ADVERSE DRUG REACTIONS

General ExaminationBP: Pulse: Rhythm: RR: SpO2:

Colour: Pain: SOB: Skinconditioni.e.cold,clammy

Risk Factors:



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CNS:

CVS:

JVP: Carotid Bruits:

CardiacExam: Peripheraloedema:

HeartSounds PeripheralPulses:

Respiratory:

Effortofbreathing:

ChestExam:

Abdominal

Diagnostic Tests

X-Ray

RESULTS:

Na Hb Other:

K Hct

Cr Plat

Urea WCC

Ca INR

Phos Troponin

Mg CRP

RESUSCITATION STATUS DISCUSSED

YES NO

DO NOT RESUSCITATE FORM COMPLETE

YES NO


Page8of40STAT 0033 CAT 0063 Review Date 02/2013


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DIAGNOSIS / IMPRESSION

PLAN OF CARE

Prescribe on Admission - If not prescribing, state reason for contraindication –

Aspirin Metoclopromide

ACEinhibitor GTN

BetaBlocker Statin(e.g.Simvastatin)

MorphineIVprn Clopidogrel

Diabetics–considerIVinsulininfusionaccordingtoslidingscale

Admitting Consultant Contacted: Time: ________________

CCU informed: Nurse: ____________________________________________________________________ Time: ________________________

Admitting Doctor: ________________________________________________________________________________________________________

Signed: ___________________________________ Designation: ____________________________________ Date: ________________________



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CORONARY SYNDROME PREFERRED TREATMENT GUIDELINES • PatientswithuncomplicatedMI/NSTEACSmaybedischargedafter4-6daysinhospital. • PatientswithUNSTABLEANGINAmaybedischargedafter3daysinhospital. • AnExerciseToleranceTest(ETT)maybedonebeforedischargeorarrangedforasanOutpatient. • Cardiologyreview/follow-upforpatientsidentifiedasHighorIntermediateRiskpostMI.

• ConsideredforpatientswithevidenceofLeftVentriculardysfunction,oratdiscretionofPhysician• Startwithin48hoursofMI;Cilazapril0.5mg,Quinapril2.5mg,Enalapril2.5mgorCaptopril6.25mgdaily,

increase daily as tolerated

• GlycerylTrinitratespray2puffs/tablets0.3–0.6mgat5minuteintervalsdependingonassessmentofseverityofpainandBP(systolic>90mmHg)

Morphine2.5–5mgIV incrementsprntoachievepainrelief,monitoringrespiratorystatus(RR>8)andBP(systolic>90mmHg) (administrationaccordingtoCCUProtocolguidelines)

• IVMetoclopramide10mgq6h• Temazepam10-20mgorZopiclone3.75mg–7.5mgorpatientsusualmedication

• Aspirin150to300mgshouldbegivenonday1ofSTEMIandintheabsenceofcontra-indicationsshouldbecontinuedindefinitelyonadailybasisatadoseof100mg,entericcoated.(LevelofEvidence:A)

• Clopidogrelshouldbeadministeredtopatientswhoareunabletotakeaspirinbecauseofhypersensitivityormajorgastrointestinalintolerance.(LevelofEvidence:C)

• Angiogram+/-PCI<48hoursClopidogrel600mgoralloading,then150mgpood• NoAngiogramwithin48hours–Clopidogrel300mgoralloading,andthen75mgpood• (assessbleedingriskinallpatients;NOCLOPIDOGRELLOADINGINPATIENTSOVER75yo)• ClopidogrelmaybegiventoSTEMI(Clarity-Timi28)postfibrinolytictherapy

• Anxiolytics can play an important role in patient management in this setting. Treatment withbenzodiazepinesshouldbelimitedtotheminimaldoseforalimitedperiodoftime.

• Patientsexperiencingnicotinewithdrawalcanbenefit fromAnxiolytics.Useofbupropionandnicotinereplacementtherapyintheacutesettingshouldalsobeconsideredasoptions

• Alwayscheckelectrolytes(K+,Na+,Ca++,Mg+)andoxygensaturations• IdentifyarrhythmiaandfollowGHWResuscitationguidelines

• Checknocontra-indicationspresent(i.e.Asthma,LVF,HR<60/m,BP<100mmHgSystolic;CardiogenicShock;>1°HeartBlock)

• Carvidolol(dosedecidedbyphysician)ORMetoprololCR23.75mg–47.5mgorallystatandthencharteddaily(Normallygivenimmediatelypost-thrombolysis)

• FBC,Electrolytes,Creatinine,Glucose,LFT,Troponin,TFTs(ifindicated),coagprofile• Electrolytes,Creatinine,Glucose,CK,Troponin(POSTSTKandNSTEAC)• FBC,Electrolytes,Creatinine,Glucose,Troponin,FastingLipids• Electrolytes,Creatinine• NOTE: REPORT ACUTE DROP OF HB of 20% &/OR < 90g/L to RMO

• LBBB:FullthicknessMIdiagnosedonclinicalgroundsÕThrombolysis RBBB:doesnotmaskfullthicknessMI.ThedevelopmentofRBBB+LAHBmayindicateneedforpacing

• DefinedasBP<100mmHgsystolic,LVF,coolperipheries,lowurineoutput• Thrombolysismaynotbeeffective,discusswithConsultantreearlyangiography• SupportivetreatmentwithIVinotropes NB: In presence of inferior MI, low CO may reflect RV infarction. Rx IV fluid challenge/IV

inotropes

• Presenceofsymptoms:chestpain,SOB,palpitations• Presenceofsigns:newmurmur(MR,VSD),evidenceofCardiacFailure,pericardialrub• Presenceofarrhythmias:ECG,telemetry

• Considerinsulininfusionasperseparateprotocolifglucoselevel ≥ 11mmol / L (only if NBM otherwise regular medication with sub cut. If insulin treated and

NBM insulin infusion as per iv insulin protocol. If eating as per sub cut protocol.

ACEInhibitor

Analgesia (ischaemia)

Anti-emeticNight Sedation

Antiplatelets

Anxiolytics

Arrhythmia

Beta-blocker

Bloods0-24hrs(onadmission) 6–8hrs Day 1 Day 2

Bundle Branch Blocks

Cardiogenic Shock(CGS)

Clinical Review

Diabetes&MI&/orhyperglycaemia

Guidelines continue next page 10




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PREFERRED TREATMENT GUIDELINES (CONTINUED)

Enoxaparin

LVF

OxygenTherapy

Post MI / NSTEAC chestpainmanagement in wards

Post MI / NSTEACbradycardia

Post MI / NSTEAhypotension

Thrombolysis

Patientunstablepost-thrombolysis

Statins

• LMWH(enoxaparin)usedafterSTK 1mg/kgscBDisoptionalandifpatient<75withfailedthrombolysis• Innon-STEMILMWH1mg/kgscBDuntil24–48hrspainfree

• Definedasclinicalorradiologicalevidenceofpulmonaryoedema;SOB,LowSpO2• TreatmentoptionsincludeO2,IVFrusemide,IVMorphine,IV/SLGlycerylTrinitrate,IVinotropes• BIPAP(SpO2<92%)/mechanicalventilation

• SupplementaloxygenshouldbeadministeredifSpO2<90%,respiratorydistressorhigh-riskfeaturesforhypoxaemiaviaHudsonmask6–8L/minorNasalprongs4-6l/min(LevelofEvidenceB)

• ItisreasonabletoAdministeroxygentoallACSpatientsduringfirst6hoursafterpresentation(LevelofEvidenceC)

• Monitortherapywithoxygensaturationmeasurements

• Stopactivities,rest,useGTNspray/tab,MorphineandOxygenasperpainreliefprotocolabove.• Ifpainpersists,orisseverefromthestart,take12leadECG,BP,callDoctor• Differentialdiagnosis:Re-infarction/unstableangina;pericarditis,non-cardiacpainetc• Treataccordingtodiagnosis:• Re-infarction/unstableanginatransfertoCCU• Pericarditis:paracetamolQ4h/considerNSAIDfor2days:ConsiderEchocardiography

• HR<45bpmshouldbereportedtoDoctorformedicationreview.Betablockers,calciumchannelblock-ers,digoxinmaybecontributing.Withholdifpatientsymptomatic,take12leadECGtoascertainrhythm

• SystolicBP<95mmHgshouldbereportedtoDoctorformedicationreview.Individualparametersmaythenbeset;Betablockers,Calciumchannelblockers,ACE,nitratesmayrequirereview,especiallywhenpatientsymptomatic.

• Tenecteplase use in large anterior acute STEMI OR NEW LBBBinpatients<75yo• Enoxaparin 30mg IV pre Tenecteplase patients <75yo (omit if >75yo or known creatinine

clearance <30ml/min)• Tenecteplase weight based dose over 5-10secs

Patient Weight

Dose of tenecteplase

Volume of reconstituted solution

<60kg 30mg 6ml

60-69kg 35mg 7ml

70-79kg 40mg 8ml

80-89kg 45mg 9ml

>90kg 50mg 10ml

• Clopidogrel 300mg loading dose post Tenecteplase and then 75mg per day• Enoxaparin 1mg/kg bd (0.75mg/kg in patients over 75yo maximum dose 75mg bd)• UseStreptokinase(STK)in other instances and if patient over 75yo.Give1.5MuofSTK,IVover

30 minutes• Any reaction to STK other than hypotension→ STOP infusion. Evaluate need for other thrombolytic

agent

(Refer to intranet pharmacy page for more detailed information)

• DiscusswithConsultant.Maybecandidateforinvasivetherapy

• CommenceStatin.DiscusswithConsultant• Lipid profile should be performed, preferably after fasting and within 24 hours of symptom onset (LevelofEvidence:C)

Guidelines continue next page 11



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Disclaimer: This tool is intended as a guideline and should not replace clinical judgement

PREFERRED TREATMENT GUIDELINES (CONTINUED)

• RelievepainwithGTNandIVMorphine(perprotocolabove)• treatLVFifpresent• UseIVBetablockerspriortothrombolysis(IVMetoprolol5mgx3,eachover5minutesand5minutesbetweendosesifBP>100mmHgSystolicandHR>60/min)

• Indicatedforpatientswith largeAnteriorMI(CK>3000), inpresenceofdocumentedmural thrombus,TIA/AFpostMI

• Continuedfor3–6monthsorasclinicallyindicated

Primary PCA• Patientsineligibleforthrombolysisandwithanticipatedarrivaltimeincathlabof<12hoursafteronsetofsymptoms

• OtherpatientsinWellingtonorHuttifdoortoneedletime<90minutesRescue PCA• Patientswhohavenot re-perfused at 90minuteswithmoderate to large territory involved andwithsymptomonset<6hoursbeforereferralismade

STEMI complicated by shock• Patients<75years;onsetofshock<12hoursago;<36hourspostSTEMIFollowingSTEMItreatedwithThrombolysis• Patientswhohavere-perfusedandstillhavemoderate-to-largeareaofmyocardiumatrisk• Patientswhohavepost–infarctanginaorapositivepre-dischargestresstest

Troponin positive ACS• GoodstoryforACS• ST depression, widespread T wave inversion, diabetes, haemodynamic changes or known coronary

artery disease• PatientswithlowprobabilityofcoronaryheartdiseaseandnoECGchangesmayundergoanin-hospitalstresstestbeforeconsideringangiography.Anechocardiogrammayalsobeappropriate.Proceedwithangiographyifstresstestpositive.

• Note;Angiogramshouldbedonewithin72hoursofadmissionandrisksversusinterventionshouldbeconsideredinpatients>75yearsandco-morbiditiese.g.Renalfailure

Troponin – negative ACS • Otherhighriskfeaturese.g.STdepression,haemodynamicchanges• PositiveStresstest,especiallyifverypositive

SystolicBP≥180mmHg

Warfarin

Wellington Regional Transfer Guidelines forSTEMI

Wellington Regional Transfer Guidelines for angiographyNSTEACS




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Guidelines for multidisciplinary team: 0 – 24 HOURS (tick where appropriate)

STEMI NSTEACS

DIAGNOSISTick in appropriate box

STEMI NSTEMI UNSTABLE ANGINA

DATE:

Thrombolysistreatmentwithin30minofadmission BloodstakenperACSalgorithm Stat/regular medications administered and charted includingGTN,analgesia,antiemeticandClopidogrel

IVCannulax2(18gauge) ChestX-ray Medicalhistory/examinationcomplete painandassociatedsymptomsassessed rhythm monitoring lead II baselinevitalsigns5minwiththrombolysis (15minutelyinED)thenQ1-2hourly&prn

MRSAriskidentified ECG2hourspostSTK Electrolytes,creatinine,Glucose,CK,Trop4-6hourspostSTK

Fluid Balance Chart commenced Bedrest MDT referrals Explanationcondition/pathwaybookletgiventopatient/family/whanau

Bowelsopened SmokingABCassessedanddocumented

BloodstakenperACSalgorithm Stat / regular medications administered and charted includingGTN,analgesia,antiemeticClexaneandClopidogrel

IVCannulax2(18gauge) ChestX-ray Medicalhistory/examinationcomplete painandassociatedsymptomsassessed rhythm monitoring lead II baselinevitalsignsthenQ1-2hourly&prn MRSAriskidentified Electrolytes,creatinine,Glucose,FBC,TropandECG12hourspostonsetofchestpain(nottakenafter2200hoursbutnextmorning)

Bedrest MDT referrals Assessment for early Angiogram explanationcondition/pathwaybookletgiventopatient/family/whanau

Bowelsopened SmokingABCassessedanddocumented



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Consultant:MULTIDISCIPLINARY NOTES:




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CORONARY SYNDROME PREFERRED GUIDELINES

Summary of Clinical Pathwayn TostandardisethePracticeofNursingandMedicalCareforpatientswithAcuteCoronarySyndrome.

Criteria for Placement on Clinical Pathway n Accordingtoriskstratification

Exclusion Criterian VF Arrest and Ventilatedn DifferentialDiagnosise.g.Pericarditis,PulmonaryEmbolusn Stroke

Education includesUnderstandingbypatientof:n Patientpathwayn SmokefreeABCassessedandacteduponn Expectedlengthofstayn CardiacEducationmayincludeCardiacRehabilitation

Discharge planning n Educationcompleten Multidisciplinaryteaminvolvementn ReferraltoCardiologistWellingtonforangiographyifrequired,completedbyconsultantphysician (checklistforpatientstransferringtoCardiacCareUnitcompleted)n CardiacRehabilitationNursereferralactionedn Wardtransfersheetcompletedpriortotransfertowardn Patient/significantothersawarethatdischargecriteriahasbeenmetn Expectedlengthofstayis3daysNSTEAC,5daysSTEMI

Discharge Criteria n Painfreeaftermobilisationn Definitivediagnosis

Key Performance Indicators Target

1 Aspirinonarrival 100%

2 ECGtakenandsightedwithin10minutes 100%

3 Doortoneedletimelessthan90minutes 100%

4 LipidloweringtherapyondischargewithelevatedLDL-c 100%

5 ACEInhibitorifhypertensiveordiabetic 100%

6 Clopidogrelorotherantiplatelet 100%

7 Metoprololorotherbetablocker 100%

8 SmokingassessmentABCcomplete 100%

9 TargetLengthofStay(LOS)5daysSTEMI,3daysNSTEACachieved 100%

10 Patientreceivespathwaybookletonadmission 100%

11 Patienteducationcomplete 100%



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Guidelines for multidisciplinary team: Day One (tick where appropriate)STEMI NSTEAC



DATE:

NIGHT STAFF START NOTE ENTRY HERE:

BetaBlocker/Aspirin/regularmedscharted Clopidogrel Statin AceInhibitor APPT/INR Echobooked ChestX-rayreview IVCannulasitecheck,secure,flushed Painandassociatedsymptomsassessed Rhythm monitoring lead II VitalsignsthenQ2-4hourlyprn Elect,creatinine,Glucose,CK,Trop,FBC,fastinglipids,(TFT’sifrequired)

ECG FluidBalanceChart(weighifindicated) Monitorbloodglucose Bedrest/upinchair/walktotoiletifpainfree Seenbycardiacrehabilitationnurse explanationcondition/pathwaybookletgiventopatient/family/whanau

Takeheartbookletgiventopatient Takeheartvideoviewed Bowelsopened SmokingcessationABCdocumented

BetaBlocker/Aspirin/Clexane/regularmedscharted Clopidogrel Statin AceInhibitor APPT/INR Echobooked ChestX-rayreview Angiogramreferral/checklistcommenced IVCannulasitecheck,secure,flushed Painandassociatedsymptomsassessed Rhythm monitoring lead II VitalsignsthenQ2-4hourlyprn Elect,creatinine,Glucose,CK,Trop,FBC,fastinglipids,(TFT’sifrequired)

ECG Bowelsopened Monitorbloodglucose Bedrest/upinchair/walktotoiletifpainfree Seenbycardiacrehabilitationnurse explanationcondition/pathwaybookletgiventopatient/family/whanau

Takeheart/angiogrambookletgiventopatientandexplained

Assessmentofsuitabilityforwardtransfer SmokingcessationABCdocumented




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AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

TW

O

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

Guidelines for multidisciplinary team: Day Two (tick where appropriate)

STEMI NSTEAC



DATE:


Electrolytes,creatininetaken/reviewed

Medication review

Angiographyconsidered

Transfer to ward on telemetry

ETTbooked

IVCannulasitecheck,secure,flushed

Painandassociatedsymptomsassessed

Rhythm monitoring lead II

VitalsignsQ-4hourlyprn

ECG

FluidBalanceChart(weighifindicated)

Monitorbloodglucose

Upinchair/walktotoilet/showerifpainifpainfree

explanationcondition/pathwaybookletreviewedwithpatient/family/whanau

Takeheartvideoviewedbypatient

Cardiacrehabilitationnursereview

Bowelsopened

SmokingcessationABCdocumented

Electrolytes,creatininetaken/reviewed

Medication review

Angiographyreferral/checklistcommenced

Transfer to ward on telemetry

ETTbooked





ECG

Monitorbloodglucose

Upinchair/walktotoilet/showerifpainifpainfree

explanationcondition/pathwaybookletreviewedwithpatient/family/whanau

Takeheartvideoviewedbypatient


Bowelsopened




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

TW

OSurname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:





Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

TW

O




Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

TW

O





Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

TW

O




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

THR

EESurname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

Guidelines for multidisciplinary team: Day Three (tick where appropriate)

STEMI NSTEAC



DATE:


Warfarin considered

INR if on warfarin

ACEInhibitorpriortodischarge

Medication chart reviewed

Eligiblefortransfertoward/Telemetry





ECG

FluidBalanceChart(weighifindicated)

Monitorbloodglucose

Upinchair/walktotoilet/shower/walkingincorridorifpainfree

pathwaybookletreviewedwithpatient/family/whanau


Bowelsopened








ECG

Monitorbloodglucose

Upinchair/walktotoilet/shower/walkincorridor



Discharge home / Wellington for angiogram

Dischargesummary/prescription/OPDappointment

Bowelsopened





AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

THR

EE

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

THR

EESurname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:





AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

THR

EE

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

THR

EESurname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:





AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FOU

R

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

Guidelines for multidisciplinary team: Day Four (tick where appropriate)

STEMI NSTEAC



DATE:


ETT arranged

Warfarin considered

INR if on warfarin



Eligiblefortransfertoward/Telemetry

IV Cannula removed / resited




ECG Bowelsopened

FluidBalanceChart(weigh)

Monitorbloodglucose

Upinchair/walktotoilet/shower/walkingincorridor/stairsifpainfree



ETT done

INR if on Warfarin



IV Cannula removed / resited




ECG Bowelsopened

Monitorbloodglucose

Upinchair/walktotoilet/shower/walkincorridor



Discharge home / Wellington for angiogram

Dischargesummary/prescription/OPD& Cardiologyappointment/smokefreefollow-up



AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FOU

RSurname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:





AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FOU

R

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FOU

RSurname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:





AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FOU

R

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FIVE

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:

Consultant:

Guidelines for multidisciplinary team: Day Five (tick where appropriate)

STEMI NSTEAC



DATE:


ETT arranged

INR if on Warfarin

IV Cannula removed




ECG

Fluid Balance Chart Bowelsopened

Monitorbloodglucose




Dischargesummary/prescription/medicalcertificate/OPDandCardiologyappointment

Smokingcessationfollow-up

ETT arranged

INR if on Warfarin

IV Cannula removed




ECG

Fluid Balance Chart Bowelsopened

Monitorbloodglucose




Dischargesummary/prescription/medicalcertificate/OPDandCardiologyappointment

Smokingcessationfollow-up




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FIVE

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:




AC

UTE

CO

RO

NA

RY

SY

ND

RO

ME

DAY

FIVE

Surname: NHI:

First Names: Ward:

Address: DOB:

ACC No:

GP:




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