chest pain: primary pci integrated care pathway 3 - ppci integrated... · 1 chest pain: primary pci...

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Chest Pain: Primary PCI

Integrated Care Pathway

PATIENT DETAILS (Addressograph) NEXT OF KIN Name: ………………………………… Address: ………………………………. …………………………………………..

Post Code: …………………………….

DOB: ………………………………….. Age …………………………………..… Hospital No: ……………………………

Name……………………………………. Relationship …………………………… Address …………………………………

…………………………………………… Phone No: ………………………….….

Mobile No: …………………………….. Other contact No………………………..

GP Address

Date/ time of admission

Ethnic origin White Black Asian

Oriental Other

Consultant

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 discretion of the clinician. Where a clinical decision would result in a variation from treatment and care set out in the pathway, please

document that variation and the reason for it.

Pages are colour coded – see key below

Protocols Doctors Nurses Multi disciplinary

Next review Dec 2012

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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 Thrombolysis given (if PHT) Time…………. Consent signed Y/N

Drugs given (including medications given by WAST)

Aspirin 300mg Yes / No Given by: Time: Clopidogrel 600mg Yes / No Given by: Time: Ticagrelor 180mg Yes / No Given by: Time: Prasugrel 60mg Yes / No Given by: Time:

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

Allergies

Cath lab nurse assessment for procedure

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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..................

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Cath lab Drug Prescription Chart Drug Usual

dose Dose prescribed

Dose prescribed (if repeated)

Route Prescriber’s signature

Time Given by

Abcxicimab bolus

(Reopro)

As protocol

IV/ Intra-coronary

Abcxicimab infusion

(Reopro)

As protocol

IV infusion

Adenosine (no reflow)

50-200mcg

Intra-coronary

Aspirin 75-300mg

PO

Atropine 600mcg -3mg

IV

Bivalirudin bolus (Angiox)

As protocol

IV

Bivalirudin infusion (Angiox)

As protocol

IV infusion

Clopidogrel 75mg/ 300mg/ 600mg

PO

Flumazenil 200mcg IV Frusemide 40mg/

80mg IV

GTN spray

1 – 2 spray

S/L

GTN infusion

0.5 – 10mg/hr

IV infusion

Heparin 70 – 100 IU/kg

Intra-arterial IV bolus

“Hooch” Verapamil ISDN Heparin

2.5mg 1mg 2500IU

Intra-arterial

ISDN (isoket)

100mcg-1000mcg

Intra coronary

Metoclopramide

10mg IV

Midazolam 1mg -10mg

IV

Morphine Sulphate

2.5 -10mg

IV

Naloxone 100mcg-200mcg

IV

Ondansetron

4mg IV

Prasugrel 60mg PO Ticagrelor 180mg PO Verapamil (no reflow)

250mcg intracoronary

IV Fluids Dextrose 5%

.........mls

IV

Gelofusin .........mls

IV

N.Saline 0.9%

.........mls

IV

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Clinical assessment post procedure/ PPCI – cath lab

AVPU – alert, voice, pain, unresponsive

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Post procedure assessment – ward (Tick all boxes that apply)

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 Type/dose No Unknown

Beta Blocker use

ACE I or ARB use

Statin Use

Clopidogrel use

Asprin use

Other

Allergies / warnings

Risk factors Diabetes Cerebrovascular disease

None Not diabetic No

Previous AMI Diabetes (Dietary control) Yes

Previous treated angina Diabetes (Oral meds) Unknown

Hypertension Diabetes (Insulin) Smoking Status

Hyperlipidaemia Diabetes (Insulin & oral) Never smoked

Peripheral vascular disease Unknown Ex smoker

Asthma or COPD Previous CABG Current smoker

Chronic renal failure No Yes Unknown Unknown

Heart failure Previous PCI(Angioplasty/Stent)

No Yes Unknown

Non smoker history unknown

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Clinical examination

Height............ Weight............... CARDIOVASCULAR BP / Pulse Heart sounds I II I JVP Bruits present Yes / No Site................ RESPIRATORY SaO2: RA.......... O2....................L/min GASTROINTESTINAL OTHER RELEVANT CLINICAL FINDINGS

Investigations requested

FBC ARTERIAL GASES TROPONIN T@ 0hrs

12 hrs

ESR BLOOD CULTURE CK

U&E URINE MICRO,C&S AMYLASE

LFT/Ca CRP LIPIDS

COAG TFT GLUCOSE

X-RAYS - CHEST

ABDO

SKELETAL

ECG ECHO OTHER

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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 Infusion rate Blood glucose Infusion rate

0 - 2 mmol/l 0.5mls/hr 10 - 15mmol/l 4.0mls/hr

2 - 4 mmol/l 1.0mls/hr 15 – 20mmol/l 6.0mls/hr

4 - 10 mmol/l 2.0mls/hr >20mmol/l Contact doctor

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Day 0. First 24 hours Post Admission: Medical review

Management Circle Initial Pain free Y / N / NA Check observations stable Y / N / NA Access site reviewed Y / N / NA Patient and next of kin aware of diagnosis and treatment plan Y / N Order day 1 bloods Y / N

Prescribe Circle Initial

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 Statin if not state why

Comments and variances

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Day 0 – first 24 hours Post admission: 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

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

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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 □ None □

Patient Signature…………………………...Date………….

These may not be relevant in all situations but collecting information on the existence of any of these may be useful i f 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 the 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………………..

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Day 0 – first 24 hours post admission. Nursing notes


Date/ Time

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Day 1 : Medical review

Medications

Standard secondary prevention medications in place (tick) Aspirin Clopidogrel/ Ticagrelor/ Prasugrel ACE Beta blocker Statin if not state why Patients with symptoms and/ or signs of heart failure and left ventricular dysfunction consider eplerenone

Management Circle Initial

Order day 1 bloods Y / N

Glycaemic control Y / N

Organise echo Y / N

Give all patients copy of ECG Y / N


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Day 1: Nursing Review

If no further comments needed. Please or N/A and initial am pm night


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


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Day 2: Medical Review


Discontinue cardiac monitoring as appropriate Y / N

If discharge planning for today complete appendix 1 Y / N

Cholesterol checked recently or during admission. If familial hypercholesterolaemia suspected refer to lipid clinic

Y / N


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If no further comments needed. Please or N/A and initial am pm night




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


If discharge planning for today or tomorrow see appendix 1


Cardiac Rehabilitation review Date:

Rehab location:

Smoking cessation discussed Y / N Referral to smoking cessation Y / N

Healthy eating Y / N Medication management Y / N

Alcohol intake Y / N Chest pain management Y / N

Physical activity Y / N Driving Y / N

Surgical advice Y / N Returning to work Y / N

Stair assessment completed Y / N Post PCI advice Y / N

Clopidogrel card given Y / N Sexual activity advice Y / N

Stress and relaxation Y / N


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Day 3: Medical Review


Complete discharge planning – appendix 1 Y / N


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If no further comments needed. Please or N/A and initial am pm Night




Mobilise to bathroom and around ward

Wash in bathroom

Record bowel movements



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Reperfusion and ECG

ECG determining treatment (one option)

ST Segment elevation LBBB

Place first 12 lead ECG performed

Ambulance In hospital Other healthcare facility

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

_ _ / _ _ / _ _ _ _ _ _ : _ _

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…………………….

Thrombolytic drug used (if applicable)

Tenecteplase (TNK) Alteplase (TPA)

Successful re-perfusion post lysis

yes no 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______________________________ ____________________________________

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

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Multidisciplinary continuation Sheet Date/ Name/ Signature

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Appendix 1: Transfer / Discharge Checklist

Medical preparation for discharge

Have the following been done? Circle Initial

Has medical therapy been optimised Y / N

Prescribe TTO’s Y / N

Cholesterol checked recently or during admission – if familial hypercholesterolaemia suspected refer to lipid clinic

Y / N

Do U+E’s need checking by GP? Y / N

Discharge summary completed Y / N

Is OPD echo needed Y / N

Nursing preparation for discharge

Have the following been done? Circle Initial

Plan for discharge on

TTO’s obtained Y / N

Discharge arrangements discussed with patient, relatives, nursing/ rest home

Y / N

Does the patient require transport home? Y / N

Has transport been booked Y / N

Does the patient need OPD follow-up at Morriston Y / N

Cardiac rehabilitation referral Y / N

Does patient require transport for OPD appointment Y / N

Has OPD transport been booked Y / N

Will carer/ relative be waiting at discharge destination Y / N

Does the patient have keys Y / N

Patient given a copy of their ECG Y / N

Nursing discharge checklist Have the following been done? Circle Initial

Valuables returned Y / N

Medications given and explained. Ensure patient has 28 days supply of medication. Return patients own medication

Y / N

Appropriate discharge information given and discussed. Patient information re: wound, driving and returning to work discussed

Y / N

Copy of discharge ECG given to patient Y / N

Transport organised if appropriate Y / N

Ward clerk to arrange OPD appointment Y / N

Patient next of kin informed of discharge Y / N

chest pain: primary pci integrated care pathway 3 - ppci integrated... · 1 chest pain: primary pci...

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