Chest Pain: Primary PCI Integrated Care Pathway PATIENT DETAILS (Addressograph)

NEXT OF KIN

Name: …………………………………

Name…………………………………….

Address: ……………………………….

Relationship ……………………………

…………………………………………..

Address …………………………………

Post Code: …………………………….

……………………………………………

DOB: …………………………………..

Phone No: ………………………….….

Age …………………………………..…

Mobile No: ……………………………..

Hospital No: ……………………………

Other contact No………………………..

Date/ time of admission

GP Address

Ethnic origin Oriental

White

Black

Asian

Consultant

Other

Allergies/Warnings

Admitting nurse

This pathway is intended for guidance only. It is in no way intended to be prescriptive. Clinical decisions remain at the dis cretion of the clinician. Where a clinical decision would result in a variation from treatment and car e set out in the pathway, please document that variation and the reason for it.

Pages are colour coded – see key below

Protocols 1

Doctors

Nurses

Multi disciplinary Next review Dec 2012

2

Clinical assessment for procedure Date/time………………………………………………. Bleep no………………….. Name of Doctor……………………………………………..….. History of presenting complaint Pain time......................... Call time.......................... Hospital arrival................ Cath lab arrival…………..

Please circle Anterior/ Inferior/ Posterior/ Lateral/ LBBB Time………….

Thrombolysis given (if PHT)

Consent signed

Y/N

Cath lab nurse assessment for procedure Drugs given (including medications given by WAST) Aspirin 300mg Clopidogrel 600mg Ticagrelor 180mg Prasugrel 60mg

Yes / No Yes / No Yes / No Yes / No

Other (state drug, dose, administered by and time)

Allergies

3

Given by: Given by: Given by: Given by:

Time: Time: Time: Time:

Procedure/ PPCI (Consultant to Complete)

Grafts (if applicable)

Procedure Angiogram / Angioplasty Start time............ Finish time.................... Stent type: DES / BMS / No stent used Reperfusion time (balloon/ Export)........... Access site: Radial R / L Femoral R/ L Contrast volume mls..........

Comments

Medications given (see next page)

Procedure complication

Management plan: Is patient fit for repatriation to local hospital within 24 hours?

Yes / No

Signed.................................. Print.................................. Date.................. 4

Cath lab Drug Prescription Chart Drug

Usual dose

Abcxicimab bolus (Reopro) Abcxicimab infusion (Reopro) Adenosine (no reflow)

As protocol

IV/ Intracoronary

As protocol

IV infusion

50200mcg 75300mg 600mcg -3mg As protocol

Intra-coronary

As protocol

IV infusion

75mg/ 300mg/ 600mg 200mcg 40mg/ 80mg 1–2 spray 0.5 – 10mg/hr 70 – 100 IU/kg

PO

Aspirin Atropine Bivalirudin bolus (Angiox) Bivalirudin infusion (Angiox) Clopidogrel

Flumazenil Frusemide

GTN spray GTN infusion Heparin “Hooch” Verapamil ISDN Heparin ISDN (isoket) Metoclopr amide Midazolam

Morphine Sulphate Naloxone Ondanset ron Prasugrel Ticagrelor Verapamil (no reflow)

2.5mg 1mg 2500IU 100mcg1000mcg 10mg

Dose prescribed

Dose prescribed (if repeated)

Route

PO IV IV

IV IV S/L IV infusion Intra-arterial IV bolus Intra-arterial

Intra coronary IV

1mg 10mg 2.5 10mg 100mcg200mcg 4mg

IV

60mg 180mg 250mcg

PO PO intracoronary

IV IV IV

IV Fluids Dextrose 5% Gelofusin

IV .........mls IV .........mls

N.Saline 0.9%

5

IV .........mls

Prescriber’s signature

Time

Given by

Clinical assessment post procedure/ PPCI – cath lab

AVPU – alert, voice, pain, unresponsive

6

Post procedure assessment – ward (Tick all boxes that apply) Risk factors None Previous AMI Previous treated angina Hypertension Hyperlipidaemia Peripheral vascular disease Asthma or COPD Chronic renal failure Heart failure

Diabetes Not diabetic Diabetes (Dietary control) Diabetes (Oral meds) Diabetes (Insulin) Diabetes (Insulin & oral) Unknown Previous CABG No Yes Unknown Previous PCI(Angioplasty/Stent) No

Yes

Unknown

Cerebrovascular disease No Yes Unknown Smoking Status Never smoked Ex smoker Current smoker Unknown Non smoker history unknown

Known Past Medical history

Family history of CHD? (Premature CHD, father/mother before age 55yrs, Brother/sister before 65yrs) No Yes Unknown Social history

Systems Review

Current medication Yes Beta Blocker use ACE I or ARB use Statin Use Clopidogrel use Asprin use Other

Allergies / warnings

7

Type/dose

No

Unknown

Clinical examination Height............

Weight...............

CARDIOVASCULAR BP / Heart sounds JVP Bruits present

Pulse I II

I

Yes / No

Site................

RESPIRATORY SaO2: RA.......... O2....................L/min

GASTROINTESTINAL

OTHER RELEVANT CLINICAL FINDINGS

Investigations requested FBC



ARTERIAL GASES



ESR U&E LFT/Ca COAG

   

BLOOD CULTURE URINE MICRO,C&S CRP TFT

   

X-RAYS - CHEST ABDO SKELETAL ECG  8

  

ECHO



OTHER

TROPONIN T@ 0hrs  12 hrs  CK AMYLASE LIPIDS GLUCOSE

     

Date

Date

Date

Date

Date

Hb

Na

T. Prot

Ca

Coag Screen

WCC

K+

Albumin

Corr. Ca

Neu

Chlor

Bilirubin

Gluco

T. Chol

Plt

Bic

Alk Ph

AST

LDL

MCV

Urea

ALT

Amylase

HDL

ESR

Creat

GGT

CRP

Trig

1st Trop T

2nd Trop T

Echo findings: LV systolic impairment (please circle): Mild

Moderate

Severe

EF% Valvular pathology (please specify): Aortic

Mitral

Tricuspid

Pulmonary

Other test results

Blood glucose >11 mmols - Sliding Scale insulin  

Whenever blood glucose >11mmols/L on admission commence sliding scale. Add 50 units of Actrapid Insulin to 50 mls Normal saline in a 50-ml syringe, infuse intravenously via a syringe driver. Measure blood glucose 1-2 hourly depending on the patients’ diabetic stability.  The infusion continues for at least 24hours, titrate dose according to regimen below.  Stop Metformin. Refer to diabetic specialist nurse

Blood glucose 0 - 2 mmol/l 2 - 4 mmol/l 4 - 10 mmol/l

9

Infusion rate 0.5mls/hr 1.0mls/hr 2.0mls/hr

Blood glucose 10 - 15mmol/l 15 – 20mmol/l >20mmol/l

Infusion rate 4.0mls/hr 6.0mls/hr Contact doctor

10

Day 0. First 24 hours Post Admission: Medical review Management

Circle Y / N / NA Y / N / NA Y / N / NA Y/N Y/N

Initial

Prescribe Circle Morphine IV prn, anti-emetic IV prn, GTN SL prn Y / N / NA Standard secondary prevention medications in place (tick) Aspirin Clopidogrel/ Ticagrelor/ Prasugrel ACE Beta blocker

Initial

Pain free Check observations stable Access site reviewed Patient and next of kin aware of diagnosis and treatment plan Order day 1 bloods

if not state why

Comments and variances

11

Statin

Day 0 – first 24 hours Post admission: Nursing Review

If

no further comments needed. Please

or N/A and initial

Patient pain free / no discomfort in chest/ back/ neck/ arms/ jaw Connected to cardiac monitor and record rhythm on observation chart. Continue cardiac monitoring for up to 24 hours if uncomplicated 12 lead ECG’s: On admission to CCU and if pain experienced Perform cardiovascular, including temp, respirations and saturations and peripheral vascular observations every 30 minutes for 4 hours. Check for ooze or haematoma at femoral / radial site Bed rest: at max 300 until 2 hours after sheath removal ACT check before sheath removal Arterial sheaths removed when ACT < 150 Venous sheaths removed 1 hour post PCI TR band gradually release air from 3 hours post PCI until no pressure then remove Sit up to 450 ( 2 hours post arterial sheath removal/ 1 hour after venous sheath removal/ immediately if radial approach) Bed rest for 12 hours and fully assisted with hygiene needs Fluid balance charted MRSA screen performed Cannula flushed and site checked Refer patient to cardiac rehab team Discussion with patient re: current condition and treatment plan If eligible for repatriation contact bed manager of relevant hospital and inform them of possible repatriation Check admission blood results. Monitor blood glucose Ensure patient and relatives informed of diagnosis and treatment plan Additional notes and variances

12

am

pm

Night

CCU Nursing staff to complete following pages PATIENTS ADMISSION DETAILS Marital status

Single



Married



Widowed



Divorced



Other



Lives with: Type of accommodation: Social circumstances: Occupation: Religion: Presenting symptoms / patient condition on arrival:

Patient Wishes. Are there any issues that may influence decision making? Advanced Decision □ Court Appointed Deputy □ Power of Attorney Patient Signature…………………………...Date………….

□

None

□

These may not be relevant in all situations but collecting information on the existence of any of these may be useful if a decision needs to be made at a later stage and the individual lacks capacity to make the decision at the time. It is in keeping with t he principles of the MCA to support individuals to make decisions at the time, in advance of incapacity, or by nominating a proxy decision-maker.

Agreement to sharing information (please tick as appropriate) I agree that relevant health and social care professionals and service providers may be consulted, and that assessment information is shared with them, in order to understand and respond to my needs.

I wish to restrict sharing of information (details below) Person unable to give consent (details below) Details re consent issues:

Signature of assessed person………………………………………………..Date………………..

Name…………………………………Signature………………………………Date………………..

13

Day 0 – first 24 hours post admission. Nursing notes

Additional notes and variances Date/ Time

14

Day 1 : Medical review

Medications Standard secondary prevention medications in place (tick) Aspirin Clopidogrel/ Ticagrelor/ Prasugrel ACE Beta blocker if not state why

Statin

Patients with symptoms and/ or signs of heart failure and left ventricular dysfunction consider eplerenone Management Order day 1 bloods Glycaemic control Organise echo Give all patients copy of ECG Comments and variances

15

Circle Y/N Y/N Y/N Y/N

Initial

Day 1: Nursing Review

If

no further comments needed. Please

or N/A and initial

Patient pain free / no discomfort in chest/ back/ neck/ arms/ jaw Connected to cardiac monitor and record rhythm on observation chart. Continue cardiac monitoring for up to 24 hours if uncomplicated 12 lead ECG’s: routine and if pain experienced BP, pulse, respiration, saturations, temp within normal limits for patient? Document fluid balance and record bowel movements Assess access site clean and dry and peripheral vascular observations satisfactory Report any changes to medical staff Gently mobilise if no pain. May sit out of bed Assist with hygiene needs Venous cannula flushed and site checked MRSA results checked Repatriate eligible patients to relevant CCU Inform patient and relatives of progress and any changes to treatment plan If discharge planning for today or tomorrow see appendix 1 Additional notes and variances

16

am

pm

night

Day 2: Medical Review

Management Discontinue cardiac monitoring as appropriate If discharge planning for today complete appendix 1 Cholesterol checked recently or during admission. If familial hypercholesterolaemia suspected refer to lipid clinic Additional notes and variances

17

Circle Initial Y/N Y/N Y/N

Day 2: Nursing Review

If

no further comments needed. Please

or N/A and initial

am

pm

night

Patient pain free / no discomfort in chest/ back/ neck/ arms/ jaw 12 lead ECG’s: routine and if pain experienced BP, pulse, respiration, saturations, temp within normal limits for patient? Fluid balance maintained and record bowel movements Report any changes to medical staff Sit out and freely mobilise around the bed May wash in bathroom or shower if pain free Inform patient and relatives of progress and any changes to treatment plan If discharge planning for today or tomorrow see appendix 1 Additional notes and variances

Cardiac Rehabilitation review Rehab location: Smoking cessation discussed Healthy eating Alcohol intake Physical activity Surgical advice Stair assessment completed Clopidogrel card given Stress and relaxation Comments and variances

18

Date: Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Referral to smoking cessation Medication management Chest pain management Driving Returning to work Post PCI advice Sexual activity advice

Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Day 3: Medical Review

Management Complete discharge planning – appendix 1 Additional notes and variances

19

Circle Initial Y/N

Day 3: Nursing Review

If

no further comments needed. Please

or N/A and initial

Patient pain free / no discomfort in chest/ back/ neck/ arms/ jaw 12 lead ECG’s: routine and if pain experienced BP, pulse, respiration, saturations, temp within normal limits for patient? Mobilise to bathroom and around ward Wash in bathroom Record bowel movements Inform patient and relatives of progress and any changes to treatment plan Additional notes and variances

20

am

pm

Night

Reperfusion and ECG ECG determining treatment (one option) ST Segment elevation LBBB

Thrombolytic drug used (if applicable) Tenecteplase (TNK) Alteplase (TPA)

Place first 12 lead ECG performed Ambulance In hospital Other healthcare facility

Successful re-perfusion post lysis yes no

Who made the initial decision to attempt reperfusion? No reperfusion attempted Specialist nurse A&E Clinician Member of on-call medical team Member of on-call cardiology team GP Paramedic Unknown Reason pre-hospital thrombolytic (reperfusion treatment) treatment not given Too late Risk of haemorrhage Uncontrolled hypertension Administrative failure Elective decision Patient refused treatment Ineligible ECG Other please specify……………………… Unknown Date and Time of First Arrest

Was there a justified delay before reperfusion? No Initial ECG ineligible Sustained hypertension Concern re recent cerebrovascular event or surgery Delay obtaining consent Cardiac Arrest Obtaining consent for therapeutic trial Hospital administration failure Ambulance procedural delay Consideration of primary PCI Ambulance administrative delay Ambulance 12 lead ECG not diagnostic of STEMI Delay in activating cath lab team Cath lab access delayed Pre-PCI complication Equipment failure Other* Please specify______________________________ ____________________________________

__/__/____ __:__ Where did it occur? No arrest Before ambulance arrived After ambulance arrived A&E department CCU Medical ward Elsewhere in hospital Catheter lab Method of admission? Called GP/other health professional who saw patient then called emergency service Called GP who called emergency services then saw patient Called 999 Called NHS Direct Made own way to hospital (did not call anyone) Called local helpline Called GP told to make own way to hospital Patient already in hospital Transferred from local A&E for PPCI Other please specify………………………… Unknown Ambulance job number…………………….

21

What was cardiac rhythm? Asystole VF/pulseless VT PEA Not known Outcome No return of circulation Return of circulation, died in hospital Discharged with neurological deficit Discharged, with NO neurological deficit Resuscitation not attempted Not Known Transferred to another hospital

Multidisciplinary continuation Sheet

22

Date/ Name/ Signature

Appendix 1: Transfer / Discharge Checklist Medical preparation for discharge Have the following been done? Has medical therapy been optimised Prescribe TTO’s Cholesterol checked recently or during admission – if familial hypercholesterolaemia suspected refer to lipid clinic Do U+E’s need checking by GP? Discharge summary completed Is OPD echo needed

Circle Y/N Y/N Y/N

Initial

Y/N Y/N Y/N

Nursing preparation for discharge Have the following been done? Plan for discharge on TTO’s obtained Discharge arrangements discussed with patient, relatives, nursing/ rest home Does the patient require transport home? Has transport been booked Does the patient need OPD follow-up at Morriston Cardiac rehabilitation referral Does patient require transport for OPD appointment Has OPD transport been booked Will carer/ relative be waiting at discharge destination Does the patient have keys Patient given a copy of their ECG

Circle

Initial

Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Nursing discharge checklist Have the following been done? Valuables returned Medications given and explained. Ensure patient has 28 days supply of medication. Return patients own medication Appropriate discharge information given and discussed. Patient information re: wound, driving and returning to work discussed Copy of discharge ECG given to patient Transport organised if appropriate Ward clerk to arrange OPD appointment Patient next of kin informed of discharge

23

Circle Y/N Y/N Y/N Y/N Y/N Y/N Y/N

Initial