Version 1.0 PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:…………………………….. 1 Gwent Healthcare NHS Trust INTEGRATED CARE PATHWAY SUSPECTED MYOCARDIAL INFARCTION/ACUTE CORONARY SYNDROME Date of Admission ( if admitted): ………………………………………………………………………………….… Admitting Consultant(s): ……………………………………………………………………………………. Anticipated length of stay : ♦Myocardial Infarction - OR 4 - 5 nights ♦Troponin + acute coronary syndrome - ♦Stable angina/non-cardiac chest pain - ≤ 24 hours Summary of Guidelines for Use 1. This is a multiprofessional record and replaces all other documentation relating to this episode of care. 2. It is evidence based but it is not a rigid document and clinicians are free to use their own professional judgement as appropriate. 3. Any deviation from the expected plan of treatment should be recorded as a variance on the appropriate page of the document. Patient Name: Address: (Patient sticker) Hospital Number: Date of birth: General practitioner: Next of kin: Relationship: Contact number:
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INTEGRATED CARE PATHWAY - NHS Wales · Version 1.0 PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:…………………………….. 6 Suspected
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Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..
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:
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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.
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
__________________________________________________________________________________MEDICAL OFFICER PLAN/TASKS (only tick if plan/task has been completed or initiated)
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
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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
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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
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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
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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
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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
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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
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(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
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Written information givenNotes
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
DATE …………………………………..
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
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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: …………………….
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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:……………………………..
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
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TIME NOTES SIGNATURE
TIME VARIANCE & REASON FOR VARIANCE SIGNATURE
TIME MULTIDISCIPLINARY COMMENTS SIGNATURE
Appendix I
SERIAL PATHOLOGY RESULTS
Version 1.0PATIENT NAME: …………………………………………………. HOSPITAL NUMBER:……………………………..