CARDIOLOGY
DOCTORS
ORIENTATION
Updated November 2014
Welcome
Welcome to the Cardiology Service at Waikato Hospital.
We are part of the wider Cardiology, Cardiothoracic and Vascular
Surgery (CCTVS) Service and as such work very closely with these
other departments.
As a tertiary unit we cover the Midland Region of the North Island
(including BOP, Lakes, Tairawhiti & Taranaki DHBs) and provide
advanced cardiac intervention and treatment including angiography,
angioplasty, trans-thoracic & trans-oesophageal echocardiography,
electrophysiology and ablation, pacemakers and defibrillators, and
structural heart intervention (including TAVI). We also have a
strong research interest and are committed to teaching and training.
The information presented here is designed to give you background
information and prepare you for working in the Cardiology Service
and to help with the day-to-day administrative aspects of the job.
Further information can be found in the Cardiology RMO Handbook.
We hope you enjoy your run and learn a lot about this exciting field.
What’s not covered
This presentation will not
cover material that is in
the “Waikato RMO
Pocketbook – an
orientation guide” which
is issued by the RMO Unit
(if you have not received a
copy and would like one,
please contact Paul Miller in
the RMO Unit)
Cardiology & CCTVS Wards
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CCU* 1 (Level 1, Menzies Building) – 6 beds
CCU* 2 (Level 1, Menzies Building) – 16 beds
CCU* 3 (Level 1, Menzies Building) – 26 beds
Chest Pain Unit (CPU) – situated within the
Acute Medical Unit (AMU) in the Acute Services
Building (ASB), above Emergency Dept (ED)
M14 & Enhanced Recovery Unit (Level 4,
Menzies) – Cardiothoracic Surgery + Vascular
Surgery (+ Cardiology outliers if required)
* CCU = Coronary Care Unit
Cardiologists
Team A (2 House Surgeons)
Cherian Sebastian (Clin.Dir.)
Janice Swampillai
Pranesh Jogia
Team B (1 House Surgeon)
Raewyn Fisher
Madhav Menon
Chris Nunn (Dir. Training)
Team C (1 House Surgeon)
Spencer Heald
TV Liew
Martin Stiles
Team D (2 House Surgeons)
Mark Davis
Rajesh Nair
Sanjeevan Pasupati
Only one Cardiologist from each team is on ward cover at any one
time – usually 4 weeks on then 8 weeks off (12 weeks off in Team
A as there are four Cardiologists).
Two Cardiologists not in teams:
•  Hamish Charleson
•  Gerry Devlin
The Consultant and Cardiology/CCTVS Administration offices are
located on Level 2 of the Waiora Building.
What’s What & Who’s Who
CCU Charge Nurse Manager (CNM) –
Bridget Killion (x23009)
Associate Charge Nurse Manager (ACNM) –
HayBrenda Tai-Rakena (X96560)
CCU Nurse Educator –
Michelle Galbraith (x96560 or 021497846)
What’s What & Who’s Who
Clinical Nurse Specialists
Acute
Ruth Aspden (x23785 or 021 242 8089)
Elective Cardiac Surgery, Vascular & Thoracic
Alison McAlley (x23786 or 021 242 7134)
Structural Heart and Elective Cardiology
John Durning (x96580 or 021 403 6301)
Electrophysiology (EP)
Irene Gray (x23220 or 021 549 852) (no photo)
What’s What & Who’s Who
Ward Receptionists
CCU 1/2 – Sharon Mullany
CCU 3 – Rina Samy
CCU 1/2/3 – Sue Watkins
What’s What & Who’s Who
Telemetry
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CCU has 48 remote telemetry units and provides
cardiac level monitoring for all of the Menzies block
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NB: the telemetry is not monitored 24/7 – it relies on
a member of nursing staff being present in the office
to see an abnormality or hear an alarm but rhythm
strips are reviewed every 4 hours
AMU/CPU has 10 units and provides medical level
telemetry monitoring within the Acute Services
Building which is equivalent to in-patient Holter
monitoring. Rhythm strips are printed off each
morning for review
What’s What & Who’s Who
Cardiac Catheterisation Suite
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Located on Level 2, Meade Clinical Centre (Reception G)
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Performs the following procedures/interventions:
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Coronary angiography
Percutaneous Coronary
Interventions (PCI)
24-hr Primary Angioplasty for
Acute Myocardial Infarctions
(PAMI)
Electrophysiology studies
Permanent Pacemakers (PPM)
Internal cardiac defibrillators (ICD)
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Temporary pacing
Percutaneous aortic valve
replacement (incl. TAVI)
Valvuloplasty (e.g. BAV)
Ablations (incl. PVI)
Alcohol septal ablation
PFO/VSD repairs
o  Also has a Hybrid Lab for combined Cardiology /
Cardiothoracic Surgery procedures
o  CNM is Hayley Scown
What’s What & Who’s Who
Cardiology/Respiratory Investigations Unit (CRIU)
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Located on Level 2 Meade Clinical Centre (Reception F)
Performs the following investigations:
l  Exercise Tolerance Tests (ETTs)
l  Holter & Event Monitors
l  24 hr Blood Pressure Monitoring
l  PPM & ICD checks
l  Respiratory function testing (e.g. spirometry, diffusion
capacity etc.)
Team Leader – Kellie Timmins
What’s What & Who’s Who
Echocardiology
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Located on Level 2 Meade Clinical Centre (Reception F)
l  Trans-thoracic echocardiograms (TTE)
l  Trans-oesophageal echocardiograms (TOE)
l  Stress echocardiograms
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Team Leader – Bruce Atkins
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Charge Sonographer – Jackie Toy
What’s What & Who’s Who
Pharmacy
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CCU Ward Pharmacist
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Fiona McNabb
(x23095)
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Rotational Pharmacist: Gail Campbell (no photo) (x23668)
Chronic Care Pharmacist
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Linda McCracken
(x23655)
What’s What & Who’s Who
Outpatient Booking clerks
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Offices are on Level 2, Waiora Building
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Clinic (Fisher, Heald, Jogia, Menon, Stiles,
Swampillai) – Karen McCloughen (x95961)
Clinic (Devlin, Davis, Liew, Mustafa, Nair, Nunn,
Pasupati, Sebastian) – Val Rudd (x98566)
Echo – Sandra Nicholson (x98717)
Cardiac Procedures (ETT, Holter, respiratory) –
Tracy Friedlander (x98768)
Weekly Events
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House Surgeon Teaching:
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PGY-1 – Tuesday 1:30pm (BEC)
PGY-2/SHO – Wednesday 1:30pm (BEC)
Grand Round – Thursday lunchtime (BEC)
Friday morning teaching:
Registrar-to-House Surgeon – 8:00am (CCU)
Cath Conference – Friday lunchtime
(Meeting Room 1, Level 1 Meade Clinical Centre)
House Surgeon Daily Responsibilities
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Normal hours are 08:00-16:00 Mon-Fri
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Attending team ward rounds
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Management of day-to-day problems
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Clear documentation of management plans
(including underlying reasoning)
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Requesting further investigations
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Following up and acknowledging results –
includes bloods, radiology & echos
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Timely discharge summaries – completed
pre-discharge whenever possible
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Performing procedures as appropriate
Registrar Daily Responsibilities
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Normal hours are 08:00-16:00 Mon-Fri
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Running the team ward rounds
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Management of day to day problems
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Clear documentation of management plans
(including underlying reasoning)
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Managing acute admissions
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Following up and acknowledging results
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Performing procedures as appropriate
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Supervision of the House Surgeon
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Clinic and Cath Lab as required
Documentation
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Keep documentation:
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Legible
Objective
Accurate
Concise
Clear
Current
Complete
Relevant
Not misleading or
ambiguous
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The following events
should always be
documented in the
clinical notes:
When you review a patient
(including ward rounds)
When you perform any
procedures
When you make any
changes to a patient’s
treatment or management
plan
Documentation
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The following
information must be
included any time you
document in the clinical
notes:
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Date (dd/mm/yy)
Time (24-hr clock)
Your name & signature
Your designation (e.g. HS)
Your contact details
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Always remember to
document the following:
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What treatment was provided
What happened
How was the patient’s
condition managed
Record alterations and
responses
Describe any family
involvement in the care
provided
Describe what education or
information was provided to
the patient or their family
Weekend Plans
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Any patient in hospital for any part of the weekend
should have a weekend plan/summary in their notes
Draft versions of electronic discharge summary are ideal
As a minimum, they should include:
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Presenting complaint/primary problem
Past medical history
Current treatment/management plan
Any changes planned for the weekend
Any results or investigations to be followed up over the weekend
Be sure to rechart any medications or fluids that will run
out over the weekend
Prepare the discharge summary for any patients likely
to be discharged over the weekend
Handover to the weekend House Surgeon on Friday
afternoon re: any patients or investigations to be
reviewed over the weekend
Handover
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Effective clinical handover is essential to ensure
continuity of responsibility and accountability for
patient care from one team/shift to another
Should happen any time there is a shift change
i.e.:
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Night shift to day team
Day team to evening/on-call
Evening/on-call to night shift
Day team to weekend on-call
at 08:00
at 16:00
at 22:00
Friday afternoon
Face-to-face using the standardised “Waikato DHB
Out-of-Hours Handover Sheet” is best
Use SBARR as necessary
Handover
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What should be handed over:
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Any patients in HDU, even if they are stable
Unstable patients, ADDS ≥ 4
Unresolved problems
New and expected admissions still needing to be seen/clerked
Patients expected to die overnight
(with instructions re: coroner & death certification)
Tests to be done
Results awaited and action expected
Outstanding jobs on Out-of-Hours Worklist on the wards
Evening-to-night shift handover occurs in AMU at 10pm
Even if you have nothing to handover, you still
need to handover that you have nothing to
handover!!!
High Dependency Unit &
Intensive Care Unit (Level 4 MCC)
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Most Cardiology patients who are high acuity or critically
unwell will usually be managed in CCU 1
When this is not possible, patients may be in either HDU
or ICU as appropriate
HDU & ICU patients should be reviewed daily by
10:00am (including weekends & public holidays)
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HDU Patients are still owned & managed by Cardiology
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HDU patients are a priority if asked to see (i.e.<15 mins)
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There is a designated HDU SHO on duty at certain times
(14:00-22:30 Mon-Fri; 08:00-16:30 Sat-Sun & Public Holidays)
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Patients in ICU are managed under “shared care”
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ICU patients are handed back on return to the ward
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ICU will see patients before they are discharged
Chest Pain Unit (CPU)
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The CPU is located within the Acute Medical Unit (AMU),
on Level 2 of the Acute Services Building (above the
Emergency Department)
It comprises one 6-bed room with an adjacent
procedure room for exercise tolerance tests (ETTs) and
is equipped with telemetry
It is staffed by one registered nurse on each shift with
HCA support from AMU
The clinical responsibility for CPU patients is a shared
partnership model between Cardiology and General
Medicine – during normal business hours it is run by
General Medicine, but out-of-hours (including
weekends) it is run by Cardiology
Chest Pain Unit (CPU)
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The CPU is dedicated to the care of low risk chest pain
patients (as identified by the accelerated chest pain
pathway as shown on the next slide) with guidelines for
patient selection that have been agreed with clinical staff
Eligible patients will be identified from within the
Emergency Department
The use of highly sensitive troponins now makes it possible
to exclude a myocardial infarct quickly with a high degree
of certainty, however some patients with chest pain and
negative troponins will still have pain that is caused by
critical or undiagnosed coronary artery disease and it is
important not to miss this
Patients with high risk Acute Coronary Syndrome (ACS) –
i.e. raised troponin or dynamic ECG changes – should be
admitted to CCU under Cardiology, not the CPU
Chest Pain Unit (CPU)
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Patients may be admitted to CPU either while awaiting a
Troponin level or after two negative Troponin levels,
both with a normal ECG
If the pain has no cardiac features, it is unlikely to be
due to coronary artery disease, so do not admit to CPU
If at any stage a patient has a positive Troponin or ECG
changes they must be referred to the On-Call
Cardiology Registrar for review
Depending on the outcome of the ETT (or alternative
tests as necessary), the patient may be either
discharged or discussed with Cardiology for further
investigation and/or admission
N.B. New guidelines for the management of acute chest
pain are due to be introduced shortly so the information
on this slide will change in the near future
Daily Ward Rounds
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All Cardiology in-patients should be reviewed daily
Monday-Friday by the responsible clinical team
(House Surgeon at least, usually with a Registrar)
If a Registrar is unable to be present on the daily
ward round, the House Surgeon must discuss all their
patients with their Registrar at the earliest
opportunity after completing the ward round (or
during the round if urgent)
Consultants all have their own schedules, but when
they are on ward duties, most will do a post-acute
and at least one other ward round during the week
If a weekend review is needed it must be handed
over to the House Surgeon or Registrar on-duty over
the weekend
Post-acute Ward Rounds
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Be ready to start post-acute round at 8:00am
Have the notes ready in the trolley for all new
and existing patients on your team
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Have all relevant results immediately to hand
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Make sure the laptop is turned on & logged in
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Have a pile of blood forms, radiology, echo
and yellow referral forms handy
Be prepared to present patients you admitted
Request as many investigations/referrals as
possible while on the round (esp. ETT/echo)
Ward Round Documentation
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All ward round documentation must include:
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Diagnosis (including differentials as appropriate)
Clear management plan (particularly important on the
post-acute ward round)
If you are not sure of something on the ward
round – ASK!!!!! (Consultant, Reg or Nurse)
If the Cardiologist decides that a patient needs
an angiogram but they have a low TIMI score
and/or few risk factors, please clarify the
reasoning behind the decision so that patients
are not sent back from cath lab
N.B. Not all angiograms are for Acute Coronary
Syndrome or Ischaemic Heart Disease
Cardiologist/Team On-call Roster
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On-call split by teams, M-Th allocated to each
team. Fr-Sun shared.
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Except: teams A & D swap days when covering the
weekend to avoid long weekday + weekends on-call
One Cardiologist from a team rostered on-call
for one month at a time
Leave is covered within teams
Can be found on Amion (via intranet), dept or
Cathlab rosters
Mon
Tue
Wed
Thur
Team A
Team B
Team C
Team D
Fri
Sat
Sun
House Surgeon On-call &
Long Day Responsibilities
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Hours are 16:00-22:30 (22:00-22:30 is set
aside for handover to the night shift)
Carry the Cardiac Arrest pager
Out-of-hours – Only cover Cardiology patients
(including CCU 1/2/3, HDU & outlying wards)
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Ward calls – ward job lists must be checked
regularly on all CCU wards
Admission clerking for direct transfers from
Regional Hospitals
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Assist Registrar as required (e.g. in ED/CPU)
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If in doubt – call the Registrar
Registrar On-call &
Long Day Responsibilities
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Carry the Cardiac Arrest pager
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Carry the on-call phone for GP referrals
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Respond to GP requests for advice
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Respond to requests for Cardiology advice and
review from other in-patient specialties
Review acute patients referred either direct
from GP or from ED
Review patients who have been transferred
from other hospitals
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Support the Cardiology House Surgeon on-call
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Escalate to on-call Cardiologist as necessary
Cardiology Admission Criteria
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Patients should be admitted under Cardiology ONLY if
the primary diagnosis or presenting complaint is
cardiac, or where the presenting complaint is the
consequence of a cardiac condition or cardiac treatment
This includes but should not be limited to:
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Chest pain – cardiac pain to be excluded, without other
clear diagnosis (cf. Chest Pain Unit)
Unstable angina
Acute myocardial infarction
Acute arrhythmia
Congestive heart failure
Type B Aortic dissection (distal to Left subclavian artery)
Transfers from other Regional Hospitals must first be
referred directly from Consultant-to-Consultant
Non-Cardiology Admission Criteria
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Patients with a non-cardiac condition which results in
an exacerbation of a cardiac condition (provided this
is not life-threatening or does not require major
intervention) should be admitted under General
Medicine or other relevant medical specialty e.g.:
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Cardiac admission is recommended ONLY if the
cardiac component is life-threatening or requires
major intervention. For example:
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Pneumonia in a patient with chronic atrial fibrillation
resulting in poor rate control à admit under Respiratory
Acute myocardial infarction
Life-threatening arrhythmia
If the patient is undergoing regular cardiac review for
the condition that has resulted in admission
“Collapse ? cause” should be admitted under
General Medicine
Investigations
Laboratory Tests
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Within the CCU wards, many patients will have early
morning blood samples taken by the night nursing staff
so that results are available for the morning ward
round
Otherwise samples are taken during the daily
phlebotomy rounds
If you want a blood test done, you must complete the
green request form and leave it in the appropriate
place on each ward for collection by the nurse/
phlebotomist – best done the afternoon before
Results are available in Clinical Results Viewer (usually
within 2 hours of sample reaching the Laboratory)
Investigations
Radiology
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All requests for radiology (except MRI) are made on the
radiology request form and faxed to the appropriate
department (fax numbers are on the wall above the fax
machine in each ward)
CT coronary angiogram requests must be signed by a
Consultant and are faxed to the usual CT number
Cardiac MRI requests are made on the Midland MRI
request form, must be signed by a Consultant and must
be faxed to 98639 – they will then be reviewed and
triaged by Dr. Davis
All imaging may be viewed on PACS (currently iSite) –
can also be accessed through Clinical Results Viewer
Investigations
Acknowledging Lab & Imaging Results
¡  All laboratory and imaging results must now be
acknowledged electronically as paper copies are no longer
generated
¡  If results are not acknowledged there is uncertainty
whether a result has been seen or required action taken.
For this reason no results should be left unacknowledged
¡  Results should be acknowledged in a timely way. If results
are acknowledged as soon as they have been viewed and
action taken this helps prevent a backlog accumulating. All
results associated with an admission should be
acknowledged when the patient is discharged (including
those requested while the patient was in ED)
¡  House Surgeons & Registrars should discuss with their
Consultants which results they may acknowledge under
delegation and which results should be escalated
Investigations
Echocardiology
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All echos must be requested on the
form shown here and faxed to 96363
or handed to the department directly
Form must be signed by SMO
Relevant sections must be completed
in full or request may be declined
Include as much relevant information
as possible so the request can be
triaged appropriately
Referral protocols for TOEs, stress
echos and accelerated out-patient
echos are described on the reverse
side of the form
If you request an echo before 3pm
Mon-Fri it will be done the same day
Echo reports can be viewed in CRV
when they are ready
Investigations
Exercise Tolerance Tests (ETTs)
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Most are performed in CRIU
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Requested using the yellow A5 referral form
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Fax requests to 98760 A.S.A.P. after decision
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During weekends/out-of-hours some ETTs may also be
performed in CCU procedure room by senior CCU nurses
ETTs for CPU patients are often performed in the AMU
procedure room by the CPU nurse
ETTs must be reviewed by Cardiology Registrar
Monday a.m. & p.m. ETT sessions in CRIU are done by a
Cardiology House Surgeon (usually from Teams A or D)
with support from a Physiologist – ECGs are still
reviewed afterwards by a Cardiology Registrar
Investigations
Cardiac Procedures
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All other Cardiac and Respiratory
investigations are requested using the
Yellow A5 Referral Form
Request is faxed to 98760
ICD and PPM checks may be requested via
telephone – either the patient will be taken
to CRIU or a technician may come to the
ward, depending on how busy they are
How to book Cath Lab procedures
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Referrals for in-patient ACS angiograms and cath lab
procedures must go through Ruth Aspden (CNS –
Acute, x23785)
Referrals for out-patient angiograms and cath lab
procedures must be completed by a Registrar or
Cardiologist and go through Alison McAlley (CNS –
Elective, x23786)
The information required in referrals is shown below:
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(you must also include a pregnancy status for all female patients ≤ 55 years old)
Structural Heart Disease (SHD) &
Electrophysiology (EP) Referrals
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Do not assume that because a referral is made that
a patient has been accepted for a procedure
SHD referrals are Cardiologist to Cardiologist only.
Confirmation of acceptance of the referral must be
documented in clinical notes
Dr. Nair and Dr. Pasupati are the SHD Consultants
and they alternate months on call (odd months Dr P)
If there are SHD post procedure issues 24/7, contact
the Cardiologist who carried out the procedure
SHD referrals processed by Alison McAlley (CNS –
Elective, x23786)
All EP referrals must be discussed with the EP Fellow
EP referrals are processed by Irene Gray (CNS – EP/
Cardioversion, x23220)
Referral for Cardiac Surgery
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Either the interventionalist performing an angiogram or
the responsible Cardiologist may decide that a referral is
required to the Cardiac Surgeons for consideration of
surgical intervention
Do not assume that because a referral is made that a
patient has been accepted for surgery
Straightforward cases may be discussed directly with the
on-call Cardiac Surgeon
More complex cases are presented and discussed at the
weekly Cath Conference held on Friday lunchtimes
Once a patient has been accepted for surgery (either as
in-patient or out-patient), there are a number of tests
that need to be requested A.S.A.P. prior to surgery
Referrals can be discussed with Alison McAlley (CNS –
Elective, x23786)
Cardiology Cath Conference
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Fridays 12:00pm
Meeting Room 1,
MCC Level 1
Cardiologists and Cardiac
Surgeons present
Patients are presented for
discussion with Cardiac
Surgeons re: need for
surgical intervention
Cardiology Inpatient
Summary form must be
completed for all patients
being discussed
Acute Coronary Syndrome (ACS)
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ACS covers:
l  Unstable Angina Pectoris (USA)
l  Non-ST Elevation MI (NSTEMI)
l  ST Elevation MI (STEMI)
There are Midland Region protocols for managing ACS
– see the flow charts on the following slides
All ACS patients need Fasting Lipids and HbA1c tested
Patients prescribed Ticagrelor on discharge require
Special Authority (this can be done electronically for
instant approval)
Patients with a Heavy Vehicle License need to have a
repeat ETT 4 weeks after PCI before they are cleared
to drive again (needs to be organised on discharge)
Midland Region Management of
Non-ST Elevation ACS
Midland Region Management of
ST Elevation MI (STEMI)
Community Thrombolysis
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Aim
Areas:
-Coromandel, Whitianga, Whangamata
(go to Thames if stable)
-Te Kuiti, Matamata, Kawhia
GP contacts CCU nurse co-ordinator
Fax ECGs à Registrar review
Audit Form in folder in CCU
Highlight if Community Thrombolysis
(for audit purposes)
Ticagrelor (Brilinta)
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New antiplatelet drug
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Being used instead of clopidogrel for ACS
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Dose: 180mg loading then start 90mg BD 12 hrs later
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Contraindications – mod-severe hepatic impairment,
active bleeding, history of intracranial haemorrhage
Precautions – renal impairment, increased risk of
bleeding, sick sinus syndrome, 2nd/3rd degree AV
heart block, asthma, COPD
Drug interactions, eg. digoxin, simvastatin, CYP3A4
inhibitors (e.g. ketaconazole, clarithromycin)
Special Authority required after discharge (can be
applied for electronically for instant approval)
ANZ-ACS QI
Information pending from
Clinical Trials Unit
Role of the Cardiac Rehab Nurse
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We support ward and Cath-lab nursing staff to provide
Phase 1 Cardiac Rehabilitation to all patients diagnosed with
an Acute Coronary Syndrome or who have recently had
Coronary Bypass surgery
We Provide Phase 2 Cardiac Rehabilitation in the outpatient
setting through local classes, drop-in clinics, home visits and
telephone consultations
We support patients to attain their optimum quality of life, to
control their illness and take control of their treatment by
providing information, education, psychological support and
exercise classes
We liaise with other health care professionals such as GPs,
District nurses, Cardiologists, Physiotherapists etc to help
patients manage their illness & maximise their quality of life
We put patients in touch with community groups to help
patients maintain their lifestyle changes lifelong
Dr’s Role to help this process
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Ensure discharge summaries are accurate – if
information is not in there then no one will know
e.g. all medications including changes, tests and
results
Accurate diagnosis – ACS is not a diagnosis
Ensure driving guidelines are accurate,
documented clearly & communicated to patient
Do they need a Heavy Vehicle Licence?
Request ETT prior to discharge (no job, no pay)
GTN is prescribed and is correct dosage
Acknowledge referral to Cardiac Rehab team
Waikato DHB Integrated Heart
Failure Service Team
o  Julie Jay, Eileen Gibbons, Karyn Haeata, Debbie
Chappell, Simona Inkrot, Catherine Callagher
o  Cardiologists (not pictured):
•  Mark Davis, Gerry Devlin, Raewyn Fisher
What do we do?
o  Provide nurse-led service in rural areas and
communities with little access to specialists
o  Specialist clinics (CNS and Cardiologists), Home visits,
Telephone care
o  Patient and family/whanau education: heart failure
knowledge and self-care
o  Clinical monitoring
o  Titration of heart failure medications in consultation with
GP and/or cardiologist
o  Professional education/CME for other health
professionals and community teams
Referral criteria
o  Inclusion
•  Patients with possible heart failure and/or at high risk for heart failure in
the community, e.g. previous MI, family history of cardiomyopathy
•  Patients readmitted for heart failure within 3 months
•  Heart failure patients with significant co-morbidities affecting optimisation
of treatment
•  “Shared care” for end stage/palliative care
o  Exclusion
•  Lack of consent from patient
•  Acute coronary syndrome
•  Patients already under the care of a cardiologist, unless referred by this
cardiologist (inclusion criteria must be satisfied)
o  How to refer?
•  Via yellow form, fax to: 98926
•  Online via the following link: XX (to be inserted once uploaded)
Who to contact?
o  South Waikato/ Tirau/ Putaruru/ Tokoroa/ Atiamuri/
Mangakino/ Arapuni region: Eileen Gibbons 021 242 9040
o  Otorohanga/Te Kuiti/Taumarunui region:
Debbie Chappell 021 241 9452
o  Hamilton City - East of the river/ Cambridge/ Morrinsville/ Te
Aroha/ Matamata:
Julie Jay 021 428 795
o  Hamilton City - West of the river (Huntington/Flagstaff,
Rototuna), Te Awamutu & towns west to Raglan:
Catherine Callagher 021 549 846
o  Hamilton City - Northwest of the river/ Ngaruawahia/ Huntly/
Te Kauwhata region: Karyn Haeata 021 226 7358
o  Hauraki & Coromandel Peninsula: Simona Inkrot 021 404 271
Discharge planning
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Discharge planning should begin from the first day of
admission so that patients may be discharged as soon
as they are clinically ready to do so
It is important that the correct follow-up is
documented in the discharge summary i.e. named
consultant and where follow-up should happen (this is
particularly important for patients from around the
Midland Region)
Referrals for outpatient angiograms/PPMs etc
(including CPAC form) must be completed by a
Registrar or Cardiologist and a copy sent to CRIU along
with a completed discharge summary documenting
what is required
ACS follow-up clinic
Referral for out-patient Cardiology investigations
should be made on the A5 yellow referral forms and
faxed to CRIU on 98760
Criteria-Based Discharge (CBD)
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Historically, there have been significant delays
associated with Cardiology patients who are
clinically ready for discharge but waiting to be
cleared by their doctors
CBD is a process which recognises that patients
may become clinically ready for discharge at any
time of day, not just on the daily ward round
CBD clearly sets out the criteria that a patient
must meet to be deemed ready for discharge
CBD process flow and ACS-CBD form are shown
on the next slide
For more information please refer to Protocol 0397 in the
Controlled Documents Centre
CRITERIA-­‐BASED DISCHARGE PROCESS/INSTRUCTIONS -­‐ ACS PATIENTS PATIENT
Patient admitted with suspected/confirmed Acute Coronary Syndrome (ACS)
DOCTORS
Probable ACS Diagnosis confirmed on post-­‐acute ward round
Patient undergoes coronary angiogram +/-­‐ intervention
PATIENT
Patient returns from cath lab
NURSES
Call Registrar to inform them that patient has returned from cath lab
Registrar discusses angiogram findings with Consultant & confirms patient is still for CBD (this & other information to support assessment of criteria must be evident in clinical record)
DOCTORS
Registrar informs nursing shift co-­‐ordinator of confirmed CBD
Registrar / House Surgeon completes discharge summary + prescription (must document “This patient is being discharged by Criteria-­‐Based Discharge”)
Shift Co-­‐ordinator updates whiteboard and informs patient of likely CBD
CNM / ACNM / Shift Co-­‐ordinator reviews patient, assesses criteria and ensures Phase 1 Cardiac Rehab/education provided AND referral completed
CRITERIA MET
CRITERIA MET BUT
NURSE HAS CONCERNS
CRITERIA NOT MET
NURSES
Give discharge summary + prescription to patient
CNM/ACNM/Shift Co-­‐ordinator completes “Reason for Failure” section on CBD form
Complete CBD form & place in the notes
CNM/ACNM/Shift Co-­‐ordinator informs Doctors that patient is not suitable for discharge via CBD
Discharge Patient
Team reviews patient on the ward round and
a revised discharge plan is made
Criteria-Based Discharge (CBD)
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ALL ACS patients are to be managed via CBD
unless otherwise deemed unsuitable, which must
then be clearly documented in the notes
Patients are assessed by senior nursing staff
whether they meet these criteria
Patients may then be discharged at any stage
after they have met all criteria without further
review by the responsible Cardiology team
If nursing staff have any concerns, patient will
remain in hospital for further review
All patients discharged via CBD must have a full
discharge summary & prescription before leaving
Discharge Summaries
CARDIOLOGY DISCHARGE SUMMARY INSTRUCTIONS & TEMPLATE PRIMARY DIAGNOSIS Also include a very brief statement regarding the management (if possible) e.g. NSTEMI – 3-­‐vessel disease, drug-­‐eluting stent to RCA. SECONDARY DIAGNOSES All past medical history (including cardiac history) should be listed here – it does not need to be duplicated in the “Relevant Clinical Information” section. Tick the long-­‐term box to include diagnosis in future discharge summaries. RELEVANT CLINICAL INFORMATION The responsible Ward Cardiologist during this admission was Dr………. PRESENTING COMPLAINT … year old male/female. Presented acutely to ED/referred by GP/referred from [where] with [presenting symptoms] MANAGEMENT Patient admitted acutely under Cardiology service and ….. (e.g. booked for ETT) Include admission and discharge weights for heart failure patients. RELEVANT INVESTIGATIONS Bloods – Hb, WCC, Plts, Na, K, Creat, Urea, Mg, TropT, BNP, INR, BGL ECG, Chest XR, ETT, Echo DIAGNOSIS e.g. Unstable angina PROCEDURES (Procedure information must also be entered in the Procedures/Investigations field) Date & Procedure e.g. Coronary angiogram + angioplasty/insertion of bare metal stent to LAD Findings e.g. Normal RCA & Circumflex with 95% stenosis of mid-­‐LAD, normal diastolic function DISCHARGE MEDICATION & CHANGES List all medications at discharge and indicate those that have been stopped or started since admission (including the reasons why) and any dose adjustments. A full list of medications must also be entered in the appropriate field below to generate a prescription. ONGOING MANAGEMENT PLAN 1. [Ongoing management plan for other healthcare professionals e.g. GPs] 2. Follow-­‐up in Cardiology Out-­‐patient Clinic with [Consultant Name] in [timeframe] 3. [Medication Instructions] 4. [Wound care instructions] 5. A referral has been made for you to be seen by [Community Service e.g. District Nurses] in [how long] for [reason] MISCELLANEOUS "Smoking Advice" & "Medically Fit to Drive" fields must be completed for ALL patients plus Special Authority, ACC, Medical Certificate details as required. FOLLOW UP RECOMMENDATIONS Include instructions for other health professionals (e.g. GPs, DNs) here so it is easy to find. FOLLOW UP RECOMMENDATIONS FOR PATIENT Include all instructions to patient here, including when to see GP, get blood tests, medication instructions, return to work advice etc. USE SIMPLE LANGUAGE THAT THEY CAN UNDERSTAND. •  ALL Cardiology patients must
have a completed discharge
summary prior to discharge
•  Use the template shown here –
yellow section can be cut/pasted
•  Target audience is patient, GP and
out-patient clinician
•  Keep it clear, simple, concise
•  Past medical history belongs
under “Secondary Diagnoses”
•  Only include the results of
relevant investigations –
DO NOT cut-and-paste results
•  Clearly document medication
changes with reasons why
•  Cardiology follow-up – WHERE,
WHEN & WITH WHOM must be
clearly documented
Discharge Summary Review
All House Surgeons will have a sample of five discharge
summaries audited at Weeks 6 & 12 by their Consultant –
content & quality will be scored as per review sheet below:
Adult Deterioration
Detection Score (ADDS)
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Waikato DHB has a medical
early warning score called
ADDS
It is incorporated into the
TPR observation chart as
shown with an easily
identified colour-based
scoring system
ADDS parameters may be
adjusted by Registrars or
Consultants on a case-bycase basis to accommodate
abnormal observations that
may be considered normal
for that patient
Adult Deterioration
Detection Score (ADDS)
Adult Deterioration
Detection Score (ADDS)
Escalation of Clinical Concerns
Deaths
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In the event of an unexpected death you must inform
the responsible Consultant who can advise you
whether the death needs to be reported to the
Coroner or what to certify
Always discuss any possible Coroner’s cases with the
Consultant. Coroner’s cases include deaths without
known cause, suicide, unnatural or violent deaths,
and deaths that occurred during, or as a result of, a
medical or surgical procedure
New Coronial Services were introduced in 2007 with
24/7 access – Switchboard have the contact numbers
An electronic discharge summary must be completed
at the same time as the death certificate