County of Los Angeles
Department of Medicine
HARBOR-UCLA MEDICAL CENTER
Acute Coronary Syndrome Admitting Orders (STEMI)
STEMI Clinical Pathway Order Form
(STEMI = ST Segment Elevation MI)
THE FIVE GOALS OF AMI THERAPY:
1. Door to drug time < 30 minutes or Door to balloon time < 90 minutes
2. Aspirin for all patients (clopidoprel 75mg QD if patient ASA sensitive).
3. Beta blockers in absence of contraindications.
4. ACE inhibitors if LVEF < 40% anterior MI, hypertension or diabetes
5. Lipid lowering therapy for all patients.
INDICATIONS FOR REPERFUSION THERAPY (Thrombolysis or Primary PCI)
1. Chest Pain or equivalent suggesting AMI
2. AGE: 18 or greater. No upper age limit.
3. ECG: ST elevation of > 1 mm consistent with AMI in at least 2 or more contiguous leads or new or presumably
new LBBB.
4. Time to therapy < 12 hours from continuous onset of chest pain
5. If thrombolytic therapy contraindicated or cardiogenic shock present, consider Primary PCI. Call Cardiology.
 Begin STEMI Clinical Pathway in ED ___________________ED- MD//
Admission
ID#_________________________ Date: _____________________
Criteria
Time:_______________________
 Admit:
□ C-Team
 Obtain Bed: □ CCU/ICU
 Diagnosis: □ STEMI
 Obtain old chart on unit ASAP
1. Emergency
NOTE: Call Housestaff for any of the following (see Transfer/Discharge Criteria):
Interactions
 Chest pain > 5 min or recurrent chest pain; repeat ECG
 Any change in ST elevation or depression identified on monitor or with chest pain
 Symptomatic hypertension or B/P > 180/110; or ≥ 120 diastolic
 Heart rate < 35 or > 110 beats per minute or symptomatic bradycardia or ventricular
arrhythmia
 T>38.4C
2. Activity
 Bedrest with bathroom privileges if pain free and VS stable
 Progress to ambulating as tolerated.
3. Nutrition
 Low fat/low carbohydrate (no added salt)
4. Assessment

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
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
5. Teaching
 Teach patient to verbalize chest pain or associated symptoms
 Discuss the pathway with the patient/family
 Other:_______________
 Other___________________
Cardiac assessment upon admission by nurse
Nursing assessment q 8h
Vital signs q 4 L h or CCU/PCU standing orders
Record BP and pulses in both arms on admission
Cardiac monitor- Assess cardiac rhythm q 4 hours and with chest pain
Alarm review per standard protocol
Record Allergies________________________________________________
Physician signature and ID Number:
_____________________________
Date: __________________________Time:
_________________________
Nurse Signature:
_______________________________________________
Date: __________________________
Time:________________________
PATIENT IDENTIFICATION
County of Los Angeles
HARBOR-UCLA MEDICAL CENTER
Department of Medicine
Acute Coronary Syndrome Admitting Orders (STEMI)
STEMI Clinical Pathway Order Form
6. Medication
 Aspirin (enteric coated) 325 mg po and QD
 Metoprolol 5 mg IV over 2-5 min X3. If IV dose tolerated, start 50 mg PO orally.
Goal: HR 60 bpm and no hypotension
 Nitroglycerin 1/150 tab Q 5min X3 if chest pain persists. (SL or spray)
 Morphine: PRN to control chest pain
 Statin: ______________________________________________
 ACE Inhibitor for CHF or LV EF< 40%, hypertension or diabetes
Enoxaparin 1 mg/kg SC Q12h
- Avoid if creat >2.5
- Above 140kg, consider use of UFH
 Heparin Hospital protocol (Bolus 60/kg, max 4,000 units ; infusion 12 u/kg/hr, max 1000/hr)
 Contact Cath Lab Fellow for primary PCI or urgent Cath if pain and/or ischemia occurs on
therapy
 TNK Protocol:
lbs.
kg.
DOSE OF TNK (Reconstituted)
<135 lbs
<60 kg
6 ml (30 mg)
≥135 to <155 lbs.
≥60 to <70 kg
7 ml (35 mg)
≥155 to <175 lbs.
≥70 to <80 kg
8 ml (40 mg)
≥175 to < 200 lbs.
≥80 to < 90 kg
9 ml (45 mg)
≥200 lbs.
≥90 kg
10 ml (50mg)
7. Treatment
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




Insert heplock
O2 @ 2l/ min via nasal cannula X 24 hrs if O2 saturation < 90%
8. Labs/Test
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CBC, Chem. 7, fasting lipid panel, (INR/a PTT)
Troponin at 0, 6 and 12 hours (If abnormal, repeat daily)
CK-MB at 0, 6 and 12 hours (if abnormal, repeat daily)
ECG at 0, 6 and 12 hours
Chest x-ray (portable)
Cardiac Cath Consult
9. Cardiac
Rehab/ Discharge
Planning
10. Other
Orders:
√
√
Coordinate outpatient follow-up
Patient Education – Risk factors
- Smoking cessation
- Nutritional counseling
- Activity levels
- Low level Bruce, 4 mets, before discharge
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PATIENT IDENTIFICATION
Physician Signature and ID Number:
___________________________________________
Date: _______________Time: ____________
Nurse Signature: ___________________________________
Date:_______________Time:_____________
STEMIAdmittform 12/31/2002
County of Los Angeles
HARBOR-UCLA MEDICAL CENTER
Department of Medicine
ACUTE CORONARY SYNDROME DISCHARGE ORDERS
(STEMI)
I. Medications/Other Treatments
Y
N














(ALL Highly Recommended)
C (Check y = yes; n = not indicated; c = contraindicated)







ASA _______________________________________________________
Beta Blocker_________________________________________________
Ace Inhibitor_________________________________________________
Statin ______________________________________________________
Smoking cessation counseling for current smokers
Exercise 5-7 times 1 week; 30-45 minutes each time
Dietary guidelines
II. Outpatient follow-up

Cardiology Clinic appointment in 1 week for Cardiac Rehab follow-up.
Cardiology Fellow’s signature required.
__________________________MD________________________ID#______________________
 Other Clinic appointment__________________________________
 All PCI patients referred to the Cath/Interventional Clinic EXT. 5146
 If on Warfarin, enroll in Anticoagulation Clinic ext. 5146; Beeper #501-5559
III. Discharge Diagnosis/Codes AMI (NSTEMI and STEMI)
Primary ACS Diagnosis
Code
Secondary or Other Co-Morbid Diagnoses
 STEMI - Anterolateral
410.0
 Aortic Stenosis
 STEMI - Anterior
 STEMI - Inferolateral
 STEMI - Inferoposterior
 STEMI - Inferior
 STEMI - Lateral
410.1
410.2
410.3
410.4
410.5
 STEMI -True posterior
410.6
 Unstable angina
411.89
 NSTEMI
410.07
 Old MI
412
 Chest pain –Non Cardiac
 Other
786.59
 Cath - right heart
93501
 Cath - left heart
93510
 Angioplasty
92980
 IABP
33967
 Ventilator
94656
395.0
 Diabetes:
● No insulin
● No insulin-PVD
● Insulin
● Insulin-PVD
 Heart failure
 Hyperlipidemia
 Hypertension
 Hypertension/CHF
 Obesity:
●< 100 kg
● > 100 kg
Procedure Codes
Code
 Pericarditis
 Pulmonary edema
 Pulmonary hypertension
 Renal failure – acute
 Renal failure –chronic
 Shortness of breath
 Smoking
 Warfarin
250.8
250.7
250.8
250.73
428.1
272.0
401.0
402.01
278.00
278.01
420.91
518
416
584.9
585
786.09
989.84
V58.6`
Physician Signature and ID Number:
_________________________________________
Date:_______________Time:__________________
Nurse Signature: _____________ _______________
Date:_______________Time:___________________
PATIENT IDENTIFICATION