© The State of Queensland (Queensland Health) 2012 Contact CIM@health.qld.gov.au
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Facility:
Date of birth:
Sex: M F I
Clinical Pathways 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:...............................
Has patient transferred from another facility?
STEMI date:............................... Time:............................... Initials:....................
If STEMI > two days ago, commence daily care on page 5
Late presentation:
Pathway ceased
Yes
Yes Date:................................ Time:....................................
Date:.......................................... Time:......................... Reason:.................................................................... Initials:..................
Treating consultant (print name):.................................................................................................................
Thrombolysis:
Yes Date:................................ Time:............................... Type:.................................................................................................................
No
Chest x-ray:
Yes Date:................................
Echocardiogram:
Scheduled?
Yes Date:................................
Performed?
Yes Date:................................
Angiogram:
Scheduled?
Yes Date:................................
Performed?
Yes Date:................................
Angioplasty (PCI):
Scheduled?
Yes Date:................................
Performed?
Yes Date:................................
Not for angiogram, Reason:................................................................................................
Not for PCI, Reason:..................................................................................................................
Coronary Artery Bypass Grafts (CABG):
Surgical referral completed?
Yes Date:.................................
Cardiac surgeon review?
Yes Date:.................................
Scheduled for CABG?
Yes Date:.................................
Mat. No.: 10206020
Documentation Instructions:
v6.00 - 02/2012
Not for echocardiogram, Reason:.................................................................................
•
•
•
•
•
•
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.
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:
SW028b
ÌSW028bmÎ
Not for CABG, Reason:..............................................................
Initials
Patient with chest pain
ED Chest
Pain Medical
Assessment Tool
Signature
Print name
Acute Coronary Syndrome suspected/under investigation
Cardiac Chest Pain Risk Stratification Pathway
Intermediate Risk Chest Pain Clinical Pathway
Page 1 of 12
Role
Acute Coronary Syndrome diagnosed
NSTEACS Mgt. Plan
NSTEACS Pathway
OR
STEMI Mgt. Plan
STEMI Pathway
STEMI Pathway Interventional
Do Not Write in this binding margin
Procedures:
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
Sex: M F I
Signature Log (continued):
Initials
Signature
Print name
Role
DO not write in this binding margin
Page 2 of 12
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
All care givers who initial are to sign signature log
Medical
Key
Sex: Nursing
Pharmacy
M Allied Health
Discharge Checklist
• Review with
patient and carer:
Resumption of lifestyle activities (sexual activity, physical activity, return to work)
Driving / pilot / commercial licensing
Current status, diagnostic and therapeutic options and general prognosis
Chest pain home management plan
Education and counselling for all current medications
• Group Healthy Eating education session attended?
Do Not Write in this binding margin
Yes (specify):
No (refer to community health or outpatient group session)
• Given: Written and personalised risk factor control information (smoking, nutrition, diabetes, stress
management, high blood pressure and cholesterol)
Information on disease process (eg. atherosclerosis)
‘My Heart My Life’ book or similar
Written medication information:
Consumer Medicines Information
Discharge Medication Record (DMR)
• Cardiac rehab OPD referral completed?
Yes
No
• Heart Failure Service referral completed?
Yes
N/A
• Stress / Depression identified?
Yes
No (if Yes, refer to psychologist / social worker)
Medications
Discharge medications review for:
• ACE inhibitors:
Indicated?
Yes
No
Given?
Yes
No
Indicated?
Yes
No
Given?
Yes
No
Indicated?
Yes
No
Given?
Yes
No
• Clopidogrel (or alternative): Indicated?
Yes
No
Given?
Yes
No
Yes
No
Given?
Yes
No
If Not Given, specify reason:
• Aspirin:
If Not Given, specify reason:
• Beta Blockers:
Mat. No.: 10206020
SW028b
ÌSW028bmÎ
v6.00 - 02/2012
If Not Given, specify reason:
If Not Given, specify reason:
• Statins:
Indicated?
If Not Given, specify reason:
• Sublingual Glyceryl Trinitrate PRN: Supplied at discharge?
Yes
• Discharge script completed and sent to pharmacy?
No (If No, reason:
Yes
Appointments
Patient to make appointment with General Practitioner within one week
Cardiologist
Other (specify):........................................................
Forms
•
Medical discharge summary
• Travel forms, if required
(
not required)
• Medical certificate, if required
(
not required)
Page 3 of 12
No
)
I
Cardiac Rehab
Initials
Rehabilitation / Education
F Date
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
All care givers who initial are to sign signature log
Category
Investigations
Sex: Medical
Key
Nursing
Emergency (ED) Presentation Date:
Day 1
Pharmacy
M Allied Health
Time:
AM
Admission to CCU
F I
Cardiac Rehab
PM
ND
V
• ECG on arrival to CCU (right sided ECG V4R if inferior mycoardial infarction),
repeat with pain or clinical deterioration and review by MO (observe for signs of
reocclusion post PCI)
• If had Lysis, conduct ECGs
90 mins
6 hrs and
12 hrs post Lysis
N/A
• Continuous cardiac monitoring (ST segments if available)
•
TnI (6–8hrs after presentation)
• Request for next day:
Medications
and Pain
Management
ELFT
TFT
FBC
COAGS
BGL
Fasting glucose / Lipids
• Check the allergy status of the patient by referring to the medication chart
• Record weight and height on medication chart
DO not write in this binding margin
• Confirm Aspirin given
• Confirm Clopidogrel (or alternative) given
• Glyceryl Trinitrate prescribed?
Yes
If Yes,
No
Contraindicated (eg. Aortic stenosis)
Intravenous
Sublingual prn
• Other intravenous infusions:
• Review
need for:
Observations
Treatments
Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs)
IV Heparin (or alternative)
• Follow post PCI / Lysis protocol, then if stable Q4H (or as per MO order*) TPR,
BP, heart sounds (HS) and breath sounds (BS), SaO2, rhythm check, circulation
and pain assessment. Neurological observations post-lysis
*Record alternate frequency:
• Assess, manage and report chest pain
•
Blood glucose level (BGL) monitoring - frequency:
(if newly diagnosed, refer to Diabetic Educator)
N/A
• Daily weight and/or fluid balance chart
N/A
• Check angiogram puncture site
N/A
• Deep breathing, coughing and leg exercises
Nutrition
•
Healthy Heart diet
Other (specify):
• If for fasting lipids / glucose, no food after 8pm (may have H2O)
Mobility /
Elimination /
Hygiene
N/A
• Strict rest in bed for 12 hrs post STEMI (12–24 hours post successful PCI/
Lysis, patient may go to toilet on wheelchair with telemetry [must be supervised],
provided they are pain free, and off ionotropic and oxygen therapy) – Record
alterations in mobility:
• Sponge in bed
• Mouth care after meals and prn
Other Care
(specify)
Education
and
Discharge
Plan
• Basic explanation to be given of:
AMI
Diagnostic procedures
Mobilisation and bed exercises
Risk factors
My Heart My Life book or similar
Expected
Outcomes
Patient demonstrates: A - Achieved
• Complete patient assessments (eg. falls risk and Waterlow assessment)
V - Variance
• Painfree
• ST segment or T wave changes resolving
• Other (specify):
Page 4 of 12
A
V
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
All care givers who initial are to sign signature log
Category
Investigations
Do Not Write in this binding margin
Medications
and Pain
Management
Medical
Key
Day 2 of pathway Days post STEMI:
Sex: Nursing
Pharmacy
Date:
M Allied Health
AM
Ward:
F I
Cardiac Rehab
PM
ND
V
A
V
• ECG performed daily, repeat with pain or clinical deterioration and review by MO
•
Continuous cardiac monitoring
•
FBC
ELFT
Fasting Lipids / glucose
•
Considered for angiography (if Yes, withhold AM subcut anticoagulation,
Metformin and others as indicated)
Preparation and education completed as per angiogram pathway
TnI
TFT
APTT (if on IV anticoagulation as
per protocol/nomogram)
• Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or
alternative) and ACE inhibitors
• Glyceryl Trinitrate
prescribed?
Yes
If Yes,
No
Contraindicated (eg. Aortic stenosis)
Intravenous
Sublingual
• Other intravenous infusions:
• Review
need for:
Observations
Treatments
Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs)
IV Heparin (or alternative)
• 4 hourly (or as per MO order*) temperature, pulse, resps, rhythm check, BP,
breath sounds, heart sounds, SaO2 (on room air) and circulation
*Record alternate frequency:
• Assess, manage and report chest pain
•
Blood glucose level (BGL) monitoring - frequency:
(if newly diagnosed, refer to Diabetic Educator)
N/A
• Daily weight and/or fluid balance chart, if indicated
N/A
• Check angiogram puncture site
N/A
• Patent IVC – change if cubital fossa inserted in DEM/ED (remove if not required)
Insertion date:
Resite date:
• Deep breathing, coughing and leg exercises
Nutrition
•
Healthy Heart diet Other (specify):
Mat. No.: 10206020
SW028b
ÌSW028bmÎ
v6.00 - 02/2012
• If fasting bloods, confirm blood collection before breakfast Mobility /
Elimination /
Hygiene
N/A
• Gentle mobilisation, shower with supervision, toilet privileges permitted (if
pain free and TnI reducing). - Record alterations in mobility:
Other Care
(specify)
Education and
Discharge Plan
• Discuss treatment plan with patient / carer
Expected
Outcomes
Patient demonstrates: A - Achieved
• Commence discharge checklist on p.3
V - Variance
• Painfree
• ST segment or T wave changes resolving
• Other (specify):
Page 5 of 12
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
All care givers who initial are to sign signature log
Category
Investigations
Medical
Key
Day 3 of pathway Days post STEMI:
Sex: Nursing
Date:
Pharmacy
M Allied Health
AM
Ward:
F I
Cardiac Rehab
PM
ND
V
A
V
• ECG performed daily, repeat with pain or clinical deterioration and review by MO
•
Continuous cardiac monitoring
•
Telemetry
•
Monitoring ceased - time:
• Daily Bloods as requested (FBC if on IV or subcut antithrombotic)
Considered for angiography (if Yes, withhold AM subcut anticoagulation,
Metformin and others as indicated)
Preparation and education completed as per angiogram pathway
•
Other test:
• Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or
alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate
• Other intravenous infusions:
• Review
need for:
Observations
Treatments
DO not write in this binding margin
Medications
and Pain
Management
•
Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs)
IV Heparin (or alternative)
• QID or BD as indicated (or as per MO order*) temperature, pulse, resps,
rhythm check, BP, breath sounds, heart sounds, SaO2 (on room air) and
circulation
*Record alternate frequency:
• Assess, manage and report chest pain
•
Blood glucose level (BGL) monitoring - frequency:
• Daily weight and/or fluid balance chart, if indicated
N/A
• Check angiogram puncture site
N/A
• Patent IVC resite date:
Nutrition
•
Healthy Heart diet
OR
IVC removed
Other (specify):
• If fasting bloods, confirm blood collection before breakfast
Mobility /
Elimination /
Hygiene
N/A
N/A
• Increase mobilisation if painfree
•
Self care Other – Record alterations in mobility/hygiene:
Other Care
(specify)
Education and
Discharge Plan
• Discuss treatment plan with patient / carer
Expected
Outcomes
Patient demonstrates: A - Achieved
• Review discharge checklist on p.3
V - Variance
• Painfree
• ST segment or T wave changes resolving
• Other (specify):
Page 6 of 12
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
All care givers who initial are to sign signature log
Category
Investigations
Medical
Key
Day 4 of pathway Days post STEMI:
Sex: Nursing
Date:
Pharmacy
M Allied Health
AM
Ward:
F I
Cardiac Rehab
PM
ND
V
A
V
• ECG performed daily, repeat with pain or clinical deterioration and review by MO
•
Continuous cardiac monitoring
•
Telemetry
•
Monitoring ceased - time:
• Daily Bloods as requested (FBC if on IV or subcut antithrombotic)
Do Not Write in this binding margin
Medications
and Pain
Management
•
Considered for angiography (if Yes, withhold AM subcut anticoagulation,
Metformin and others as indicated)
Preparation and education completed as per angiogram pathway
•
Other test:
• Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or
alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate
• Other intravenous infusions:
• Review
need for:
Observations
Treatments
Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs)
IV Heparin (or alternative)
• QID or BD as indicated (or as per MO order*) temperature, pulse, resps,
rhythm check, BP, breath sounds, heart sounds, SaO2 (on room air) and
circulation
*Record alternate frequency:
• Assess, manage and report chest pain
•
Blood glucose level (BGL) monitoring - frequency:
• Daily weight and/or fluid balance chart, if indicated
N/A
• Check angiogram puncture site
N/A
• Patent IVC resite date:
Nutrition
•
Healthy Heart diet
OR
IVC removed
Other (specify):
Mat. No.: 10206020
SW028b
ÌSW028bmÎ
v6.00 - 02/2012
• If fasting bloods, confirm blood collection before breakfast
Mobility /
Elimination /
Hygiene
N/A
N/A
• Increase mobilisation if painfree
•
Self care Other – Record alterations in mobility/hygiene:
Other Care
(specify)
Education and
Discharge Plan
• Discuss treatment plan with patient / carer
Expected
Outcomes
Patient demonstrates: A - Achieved
• Review discharge checklist on p.3
V - Variance
• Painfree
• ST segment or T wave changes resolving
• Other (specify):
Page 7 of 12
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
All care givers who initial are to sign signature log
Category
Investigations
Medical
Key
Day 5 of pathway Days post STEMI:
Sex: Nursing
Date:
Pharmacy
M Allied Health
AM
Ward:
F I
Cardiac Rehab
PM
ND
V
A
V
• ECG performed daily, repeat with pain or clinical deterioration and review by MO
•
Continuous cardiac monitoring
•
Telemetry
•
Monitoring ceased - time:
• Daily Bloods as requested (FBC if on IV or subcut antithrombotic)
Considered for angiography (if Yes, withhold AM subcut anticoagulation,
Metformin and others as indicated)
Preparation and education completed as per angiogram pathway
•
Other test:
• Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel (or
alternative), ACE inhibitors and Sublingual Glyceryl Trinitrate
• Other intravenous infusions:
• Review
need for:
Observations
Treatments
DO not write in this binding margin
Medications
and Pain
Management
•
Enoxaparin (or alternative) (refer to STEMI Management Plan, p.2, 0-24hrs)
IV Heparin (or alternative)
• QID or BD as indicated (or as per MO order*) temperature, pulse, resps,
rhythm check, BP, breath sounds, heart sounds, SaO2 (on room air) and
circulation
*Record alternate frequency:
• Assess, manage and report chest pain
•
Blood glucose level (BGL) monitoring - frequency:
• Daily weight and/or fluid balance chart, if indicated
N/A
• Check angiogram puncture site
N/A
• Patent IVC resite date:
Nutrition
•
Healthy Heart diet
OR
IVC removed
Other (specify):
• If fasting bloods, confirm blood collection before breakfast
Mobility /
Elimination /
Hygiene
N/A
N/A
• Increase mobilisation if painfree
•
Self care Other – Record alterations in mobility/hygiene:
Other Care
(specify)
Education and
Discharge Plan
• Discuss treatment plan with patient / carer
Expected
Outcomes
Patient demonstrates: A - Achieved
• Review discharge checklist on p.3
V - Variance
• Painfree
• ST segment or T wave changes resolving
• Other (specify):
Page 8 of 12
SW028b
ÌSW028bmÎ
Mat. No.: 10206020
v6.00 - 02/2012
Do Not Write in this binding margin
Insert additional days here if applicable.
Page 9 of 12
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
Sex: M F I
Variance Codes
Actions
A:1
Recurrent chest pain (Differentiate Chest
Pain Type; ischaemic, pericarditis or chest wall
pain)
•
•
•
•
•
•
Administer O2 if indicated – (SaO2 < 93% or evidence of shock)
Administer Sublingual Glyceryl Trinitrate
Perform ECG
MO Review
Repeat TnI
If re-infarction, consider urgent PCI
A:2
Cardiac arrest
•
•
•
•
•
•
•
•
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: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
• Urgent MO review: • Urgent MO review: -
unstable patient (hypotensive): call
Medical Emergency Team;
stable patient within 5 mins
unstable patient: within 5 mins;
stable patient: 15–60 mins
A:11
• Urgent MO review: - unstable patient (hypotensive/syncope):
call Medical Emergency Team;
- stable patient within 5 mins
• Prepare for transthoracic pacing, transvenous pacing
Left ventricular failure (with Pulmonary
• Sit patient upright
Oedema)
• Administer O2, 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
Pericarditis
• MO review
• Consider analgesia
• Consider echocardiogram
Pulmonary embolus (PE) / Deep vein
• Urgent MO review
thrombosis (DVT)
• Anticoagulation
• CTPA or VQ Scan +/- Leg Ultrasound
• O2 if indicated
• Bed rest
Renal failure (Significant worsening of renal
• Assess volume state and urine output
function as defined by rising creatinine or
• Urgent MO review; 1–2hrs
worsening GFR)
• Strict fluid balance chart, consider IDC
• Treat hyperkalaemia
Pulmonary complications (Cough, sputum
• MO review
production, fever and pleuritic chest pain)
• Chest X-ray
• Sputum M/C/S
• Assessment for pneumonia
• Exclusion of pulmonary embolism
Severe nausea
• MO review
• Consider anti-emetic
Adverse drug reactions
• MO review
• Cease and / or withhold drug
ACS medications contraindicated / Withheld • Check with MO
A:99
Other
A:4
A:5
A:6
A:7
A:8
A:9
A:10
Page 10 of 12
DO not write in this binding margin
A. Patient Variances
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
Sex: M F I
Do Not Write in this binding margin
Variance Codes (continued)
A. Patient Variances
Actions
A:12
Cardiogenic shock
(Hypotension with peripheral shutdown and poor urine
output, assess age of patient and comorbidities, seek
senior medical officer / ICU input early)
•
•
•
•
•
A:13
Haemorrhage
A:13.1
Post PCI, access site haematoma / bleed
A:13.2
A:13.3
Retro-peritoneal bleeding (hypotension, abdominal
pain, poor urine output)
Other bleeding
A:13.4
Post Lysis (STEMI), change in neurological status
A:14
Urgent MO review
Consider inotropes
Urgent Echocardiogram
Fluid balance chart and consider urinary catheter
Consider intra-aortic balloon pump
• Follow hospital angiogram protocol
•
•
•
•
•
Urgent MO review
Frequent neurological observations
Cease anti-coagulants
CT Head
Neurosurgical review
Coronary artery bypass surgery
B. Discharge / Treatment Delay Variances
B:1 Treatment delay
B:6 Blood tests delayed
B:11 Transfer to private hospital
B:2 Delay in transfer
B:7 Delay in chest X-ray
B:12 Change of plan / orders
B:3 No bed available
B:8 Delay in stress test
B:13 Self discharge
B:4 No monitored bed available
B:9 Medication not available
B:14 Overnight stay
B:5 Interdepartmental issues involving care
B:10 Patient discharged home off pathway
C. Staff Variances
C:1 Medical
C:2 Nursing
C:3 Allied Health
C:4 Unable to provide patient education
Clinical Events / Variance
Variance
Code
Describe variances to clinical path and any other patient related notes.
Document as Variance / Action / Outcome
Mat. No.: 10206020
SW028b
ÌSW028bmÎ
v6.00 - 02/2012
Date / Time
Page 11 of 12
Initials
(Affix identification label here)
URN:
STEMI Clinical Pathway
Family name:
(ST-Elevation Myocardial Infarction)
Given name(s):
For Interventional Cardiac Facilities
Address:
Date of birth:
Sex: M F I
Clinical Events / Variance (continued)
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 12 of 12