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Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
Gwent Healthcare NHS Trust
INTEGRATED CARE PATHWAY
SUSPECTED MYOCARDIAL INFARCTION/ACUTE CORONARYSYNDROME
Date of Admission ( if admitted): ……………………
Admitting Consultant(s): ……………………
Anticipated length of stay :
♦Myocardial Infarction -OR♦Troponin + acute coronary syndrome -
♦Stable angina/non-cardiac chest pain -
Summary of Guidelines for Use1. This is a multiprofessional record and replaces all oth2. It is evidence based but it is not a rigid document and
judgement as appropriate.3. Any deviation from the expected plan of treatment sh
of the document.
Patient Name:
Address:(Patient sticker)
Hospital Number:
Date of birth:
General practitioner:
Next of kin:
Relationship:
Contact number:
1
…………………………………………………………….…
……………………………………………………………….
4 - 5 nights
≤ 24 hours
er documentation relating to this episode of care. clinicians are free to use their own professional
ould be recorded as a variance on the appropriate page
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
2
SOURCE OF PATIENT Self-referral
(walk in) Saw GP (surgery)
Self-referral(999)
GP house visit
NHS Direct - 999 Phoned GP – 999
NHS Direct - GP Co-Op/DDS
NURSE TIME
Immediate ECG …………
INFORM A&E DOCTOR …………
Pulse ………. BP ……….
RR ………. 02 SATS ……….
TEMP ………. BM ……….
Symptom onset Date Time
Call for Ambulance Date Time
Ambulance arrival Date Time
Hospital arrival Date Time
Pain to needle time
Call to door time
Door to needle time
A&E Doctor: Time:
HOPC: Allergies:
Drugs:
PMH:
A & E DEPARTMENT/MEDICAL ASSESSMENT UNITDATE: ……..…………………….. TIME……………….…………
TRIAGE NURSE…………………..TRIAGE CATEGORY………
PATIENT ID LABEL
RESUSCITATION ROOM
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
Examination
ECG Findings:
Drug Dose Date Time Signed SignedAspirinOpiateAntiemeticNitrate
TickOne
ST
ST
Ne
Trulea
ECG CRITERIA OF ACUTE MYOCARDIAL INFARCTIONANY of the following:-
elevation ≥2mm in two or more adjacent chest leads
elevation ≥1mm in two or more limb leads (I,II,III,AVL,AVF)
w LBBB
e posterior MI (ST depression in V1-V3 with ST elevation ≥ 1mm in posterior
3
FINDINGS ACTIONChest pain suggestive of MI for <12 hrs AND ECG criteria for MI met
Proceed to THROMBOLYSIS
Chest pain suggestive of MI for >12 hrs with continuing pain and ECG evidence of evolving infarct
Proceed to THROMBOLYSIS
ECG criteria met BUT history atypical
Obtain senior opinion within 5 mins
ECG criteria metBUT contraindication exists
Obtain senior opinion within 5 mins (In selected cases transfer for PTCA may be
appropriate)Pain suggestive of MI BUT ECG criteria not met? ACUTE CORONARY SYNDROME
Repeat ECG at 15mins, 1 hour and inpain
REFER to flow chart on Page 6Atypical chest pain and normal ECG Investigate for non-cardiac causes of
chest painREFER to flow chart on Page 6
dsV7-V9)
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
t
N
N
T
CONTRAINDICATIONS TO THROMBOLYSISNB. CONSIDER ALL contraindications as RELATIVE and discuss with senior
doctor (A&E or Medicine) IMMEDIATELY
Absolute contraindications Relative contraindications
Suspected Aortic Dissection or Internal organ biopsy/large artery
Reason forNOT
hrombolysingimmediately:Time(s) senior
doctorcontacted:
ame of seniordoctor(s):
Decision tothrombolyse: YES / NO
Time decisionmade:
otes:
Thrombolytic Dose / Time Signed
Heparin
ransfer to: Time left Departm
pericarditis Active Internal Bleeding Haemorrhagic CVA/SAH/ intracranial
lesion Embolic CVA <3/12 Major Trauma / Head injury 3 weeks Major Surgery 14 days GI Bleed < 14 days
puncture within last 2 weeks Known bleeding disorder Oral anti-coagulant therapy INR >2-3 Prolonged or Traumatic CPR Acute pancreatitis/active peptic ulcer Diabetic proliferative retinopathy Pregnancy or within 1 week post
partum BP >180/110
IF NO CONTRAINDICATION EXISTSPROCEED TO THROMBOLYSIS IMMEDIATELY
Obtain informed VERBAL consent
CHOICE OF T
Give TENECTEPLASover (page 5) for pro
If perceived higher risk Advanced age Significant hyperte
Consider Streptokinaseor Consultant
HROMBOLYTIC
E as first choice (seetocol)
of stroke eg. :
nsion
and discuss with SpR
4
Given By
ent:
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
5
STEP 1: Give intravenous unfractionated heparin bolus:
Patient’s body weight Heparin IV bolus dose< 67 kg (10st 7lbs) 4,000 IU bolus>67 kg (>10st 7lbs) 5,000 IU bolus
Heparin should be administered as soon as possible after the diagnosis of AMI has been confirmed.
STEP 2: Administer tenecteplase as intravenous bolus over approximately 10 seconds:
Patients’ body weight category
Dose and reconstitutedvolume
Tenecteplasevial size
< 60 kg (<9st 6lbs) 6,000 units (30mg) in 6 mL 8,000 unit pack60 to 69 kg (9st 6lbs-10st 12lbs) 7,000 units (35mg) in 7 mL 8,000 unit pack70 to 79 kg (11st-12st 6lbs) 8,000 units (40mg) in 8 mL 8,000 unit pack80 to 89 kg (12st 8lbs – 14 st) 9,000 units (45mg) in 9 mL 10,000 unit pack> 90 kg (>14st 2lbs) 10,000 units (50mg) in 10 mL 10,000 unit pack
NB. Tenecteplase is incompatible with glucose solutions.
STEP 3: Continue weight adjusted intravenous unfractionated heparin:
1. The heparin infusion is prepared by utilising 20,000 IU in 20 ml. (PUMP HEP). The finalconcentration is 1000 IU heparin in 1mL.
Patient’s body weight Initial Heparin IV infusion rate< 67 kg (10st 7lbs) 800 IU per hour>67 kg (>10st 7lbs) 1000 IU per hour
2. Ensure infusion commenced within 30 minutes of Tenecteplase administration.3. APTT monitoring essential to maintain a ratio of 1.7 -– 2.5 4. APTT ratio should be determined 6 hours after commencing heparin treatment, 6 hours after each
dose adjustment and subsequently on a daily basis. 5. The results should be used to adjust the heparin dose according to the following table:
APTT ratio Heparin infusion rate4.1 – 5.0 STOP infusion for 1 hour then
reduce by 0.6 mL/hour3.1 – 4.0 Reduce by 0.2 mL/hour2.6 – 3.0 Reduce by 0.1 mL/hour1.7 – 2.5 No change1.2 – 1.6 Increase by 0.4 mL/hour
< 1.2 Increase by 0.8 mL/hour
References1 European Heart Journal 2003; 24: 28-662 ASSENT 3 Lancet 2001; 358:605-61
Protocol for administration of single bolus thrombolytic - Tenecteplase (TNK)
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
e
Normal ECG, Tropoon admission
Suspected acutecoronary syndrome
ECG/ troponin at 12 hnormal consider disc
Stress test
Discharge
Level Low>3 mins + no ST∆ ≤3
Suspected NSTEMI/Acute coronary syndrom
ECG & troponin on admission
No ECG ST↑
nin ECG ischaemic orraised Troponin on
admission or 12 hours
Confirmed acute coronarysyndrome
ours: ifharge
Stable for 48 h with nohigh risk features
If any are abnormal
* Level of risk dTropomin statusHIGH RISK FEAa) Dynamic STb) Raised Tropc) Ongoing syd) Pulmonary e) Post MI angf) Diabetes
of risk* (Bruce)Intermediate high
mins or ST ∆ ≤3 mins + ST ∆
REFER TO CARDIOLOGY (NSF)Admit CCU/cardiac ward
ECG monitor aspirin/LMWH/beta blocker/consider clopidogrel 300mg PO loading
75 mg maintenance
Recurrent symptoms or ECGchanges or other indication
of high risk*
Coronary angiography
(consider GP llb/llla blocker withConsultant Cardiologist approval)
Cardiology OP review
Revascularisation or medical treatment (asappropriate)
OR
+/-6
etermined after Cardiology review using:/ECG changes/TIMI score ± ETT resultsTURES INCLUDE: changes I
mptomsoedema and ischaemic ECGina
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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ADMISSION TO CORONARY CARE/MEDICAL ASSESSMENT UNITMEDICAL / NURSING ASSESSMENT
Date……………………………….…….. Time of admission to CCU ……………………………………
Admitted from - transfer A&E Clinic Routine GP
MRSA status - positive Allergies - negative NO contact YES Please list: unknown
_____________________________________________________________________________HOPCAge of patient: …………………..
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
8
RISK FACTORS FOR IHD YES NO NOTESSmoking current ex
neverHyperlipidaemiaHypertensionDiabetes Type I Type IIFamily history of CHD(<65 yrs)
PMH/PSH
________________________________________________________________________________DRUGS & DOSAGE
__________________________________________________________________________________SH
Occupation: Alcohol units per week:
Marital status:
Home situation:
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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Additional information:
OBSERVATIONS
Temperature Heart rate
Blood pressure O2 saturation
Height Weight BMI
__________________________________________________________________________________CVS
JVP Peripheral pulses (check for carotid/femoral bruit)RIGHT LEFT BRUIT
BP R ARM CarotidBrachial
BP L ARM FemoralPosterior TibialDorsalis Pedis
Auscultation Oedema
RESP
ABDOMEN
CNS
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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_________________________________________________________________________________IMPRESSION/DIAGNOSIS
__________________________________________________________________________________MEDICAL OFFICER PLAN/TASKS (only tick if plan/task has been completed or initiated)
FBC ECG U&Es CXR COAG ECHO GLUCOSE EXERCISE TEST LIPID PROFILE LFTs Troponin
SpR OR SENIOR REVIEW
__________________________________________________________________________________ELECTROCARDIOGRAM FINDINGS RADIOLOGICAL FINDINGS
INITIAL BLOOD RESULTS
________________________________________________________________________________
Name of admitting nurse (PRINT): ………………………………….. Signature: ………………………..
Name of admitting doctor (PRINT): ): ………………………… Signature: ……………………BLEEP…..
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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DATE …………………………………..
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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DAY 1/POST TAKE WARD ROUND DATE …………….………..
SELECT APROPRIATE DIAGNOSIS
ST Elevation MI / new LBBB ٱ Non ST Elevation MI / Unstable angina ٱ
Check 12 hour troponin ٱ Aspirin ٱminutes ECG post-thrombolysis 90 ٱ Beta blocker ٱRegular aspirin 75 mg od ٱ Clopidogrel ٱConsider Atenolol (target heart rate ≤ 55) ٱ Consider GTN infusion ٱConsider Ramipril (1.25 mg bd start, target 5 mg bd) ٱ IIb/IIIa (regime approved by Consultant ٱ(Sliding scale insulin if BM ≥ 10 ٱ Cardiologist)
Stable angina or non-cardiac chest pain ٱ
Early Discharge ٱConsider OPD exercise test if CHD possible ٱFollow up arrangements if required ٱ
TIME NOTES SIGNATUREAND BLEEP
TIME VARIANCE & REASON FOR VARIANCE SIGNATURE
OTHER DIAGNOSIS
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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DAY 1: NURSING DATE: …………………….
Activity Time Sign Reason for variance and action taken
Patient on bed rest (out tocommode only)Observe cardiac monitor -record rhythm 4 times dailyAssess pain levels andadminister analgesia asrequired (documentprogress in multi-disciplinary notes)Request ECGMonitor BP and saturationsQDS (within patientsbaseline parameters)Monitor temperature BD
Full assistance with hygieneneedsMonitor fluid balance Ensure patient assessmentcompleted fullyRefer to social worker ifappropriateAny additional activities
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
14
DAY 2: MEDICAL REVIEW DATE: …………………………….
DIAGNOSIS:
ST elevation MI ٱ Non ST elevation MI or unstable angina ٱ
Repeat U&E’s ٱSimvastatin 40mg nocté ٱReconsider Atenolol and Ramipril ٱDiscuss diagnosis & management plan with patient ٱWritten information provided ٱ
Stable angina or non cardiac chest pain ٱ
Discharge ٱReview medication ٱConsider OPD exercise test if CHD possible ٱFollow up arrangements if required ٱ
OTHER DIAGNOSIS
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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TIME NOTES SIGNATUREAND BLEEP
TIME VARIANCE & REASON FOR VARIANCE SIGNATURE
DAY 2: NURSING DATE:……………………
Activity Time Sign Reason for variance and action taken
Request ECG
Patient mobile around bedarea
Provision of hygiene facilities
Observe cardiac monitor -record rhythm 4 times dailyAssess pain level andadminister analgesia asrequired (document progressin multi-disciplinary notes)Monitor BP QDS (within
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
16
patient’s baselineparameters)Monitor temperature (signs ofpyrexia or hypothermia)Monitor O2 sats (signs ofhypoxia)Assess fluid balance Assess cannula site (signs ofinflammation) Refer to cardiac rehabilitation
Consider referral to dieticianGive written health promotionand other informationGive Streptokinase cardGive Cardiac Rehabilitationinformation
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
17
DAY 3: MEDICAL REVIEW DATE: …………………….
DIAGNOSIS:
ST ELEVATION MI ٱ NON-ST ELEVATION MI ٱ UNSTABLE ANGINA ٱ
If on sliding scale for diabetes review need for insulin for 12months (Digami)
If uncomplicated unstable angina, non-ST elevation MI andsymptoms settled consider ETT on Day 5 and consultguidance on page 4. MOST acute coronary syndromesshould be under care of cardiologist but if not seek advice
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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TIME NOTES SIGNATUREAND BLEEP
TIME VARIANCE & REASON FOR VARIANCE SIGNATURE
DAY 3: NURSING DATE: …………………….
Activity Time Sign Reason for variance and action taken
Request ECG
Assess pain
Monitor BP QDS (withinpatient’s baseline) Monitor temperature BD
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
19
(signs of pyrexia orhypothermia)Patient self caring withhygiene needs Patient mobile one way tobathroomCardiac monitor isdiscontinuedCannula removed
Assess bowel habits(deviation from normalbowel habits)Activities carried over:
Activity Time Sign Reason for variance and action taken
DIETICIANSeen by dietician
Written information givenNotes
DAY 3. DATE _______________
Activity Time Sign Reason for variance and action taken
Cardiac rehabilitationSeen by cardiacrehabilitation staff
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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Written information givenNotes
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
DATE …………………………………..
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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DAY 4: MEDICAL REVIEW DATE: …………………….
ٱ Discharge advice (with partner/ carer as appropriate eg. Shopping, housework, gardening)
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
22
Daily tasks: progressive increase over 4-6 weeksWalking: gradually increase each daySex: resume within 2-4 weeks, but may be longerDriving: at least 4 weeks off. Inform insurance company but not DVLAWork : return after 6 weeks, or 8-12 weeks for heavy manual workHeavy lifting : avoid for at least 6 weeks Use of GTN
ٱ Exercise test pre or post discharge
ٱ Written information provided (BHF leaflets etc)
TIME NOTES SIGNATUREAND BLEEP
TIME VARIANCE & REASON FOR VARIANCE SIGNATURE
DAY 4: NURSING DATE: …………………….
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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Activity Time Sign Reason for variance and action taken
Patient freely mobile aroundthe ward
Patient self caring with hygiene needs
Patient is pain free
Discuss discharge with relatives and patient
Reactive support services
Arrange transport fordischarge
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
DAY 5 DATE: …………………….
Patient to be discharged if mobile and condition stable
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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Medical check list:
Discharge Medication
Aspirin ٱ Clopidogrel ٱBeta Blocker ٱStatin ٱACE inhibitor ٱGTN ٱ
Follow up
TTA’s ٱDischarge summary ٱ Exercise test 4 weeks post discharge ٱ (unless contraindicated or done prior to discharge)Patients to continue all drugs, only omit beta blockers 24 hours pre exercise test if diagnosis CHD ٱ in doubt (eg chest pain ? cause).OPA 6 weeks after discharge ٱRefer cardiology ٱ
Nurse checklistDiscuss TTA’s ٱEnsure patient is pain free ٱEnsure patient can maintain own hygiene ٱValuables returned ٱCannula removed ٱPre discharge ECG ٱLifestyle advice ٱWritten information provided ٱCheck cardiac rehab referral made ٱ
DAY 5 DATE: …………………….
Reason for not prescribing
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
25
TIME NOTES SIGNATURE
TIME VARIANCE & REASON FOR VARIANCE SIGNATURE
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
Appendix I
SERIAL PATHOLOGY RESULTS
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
26
DATETIME
TROPONIN ICHOLESTEROL
NaKCHLORIDEUREACREATININE
R.GLUCOSEF.GLUCOSE
HbWBCPLT.
INRKCCT
MgESR
OTHERS