UR NUMBER SURNAME GIVEN NAME(S) Fast Track Cardiac Surgical Repair Clinical Path DATE OF BIRTH AFFIX PATIENT LABEL HERE Ξ NOTE: This Clinical Pathway is intended for those patients who are approved both surgically and by the ward to be fast tracked. Please ensure Fast Track policy is adhered to for the care of these patients. Pre - Admission Requirements Eligibility criteria identified and approved ICU notified of fast track Recovery notified of fast track 7West/ pre-admission notified of Fast track Anaesthetist notified of fast track Patients will have 4 hrs total recovery time or a minimum 2 hours total recovery time if they are reviewed by the consultant anaesthetist or Cardiac Surgeon and the authorization for transfer to the ward is documented on the MR56 Pump blood to be returned over a maximum time of 4 hours in recovery. No pump blood to be given on 7 west Theatre time to be scheduled prior to 1100 Mon - Thurs Doctor Additional notes written in UR Recovery Bloods- Lactate, FBE, U+E, blood gas, BSL should taken prior to transfer from recovery Doctor Additional notes written in UR Post Surgical Review Review by: Surgical Fellow Within 2 hours of return to 7west Review by Cardiac surgical fellow between 2100 and 2300 hrs on the evening of surgery. Doctor Additional notes written in UR The path has been developed with input from Consultants, Registrars, Residents, Nursing staff and all Allied Health personnel involved in patient s care. We have attempted to base this path on best available evidence. Any queries please speak to Clinical Quality & Safety ext 6956. PLEASE NOTE All orders are to be documented on the MR56 -Treatment Order Sheets All additional / relevant information to be documented in the Patient History. The Path is designed to assist clinicians by providing a framework of expected care. It is not intended to replace clinician judgement. If an individual patient does not fit the clinical care outlined, then the patient should be removed from the path. Last updated April 06 Page 1 tracking record last page of path
MEDICAL ADMISSION NOTES Name: Signature: Last updated April 06 Page 2 tracking record last page of path
UR NUMBER Nursing Admission SURNAME GIVEN NAME(S) DATE OF BIRTH Ξ AFFIX PATIENT LABEL HERE RISK SCREENING Yes No Family lives in a rural or isolated area The parent / carer has significant concerns about taking their child home (please ask) PERSONAL / CONTACT DETAILS Yes No Interpreter required? If Yes: Language: Interpreter name and pager: Additional phone numbers: Are the details on ID label correct? Is a medical certificate required? Who are the legal guardians? Will there be any problems arranging transport home? HOME HEALTH Yes No Does anyone at home smoke? If yes, who: Are they interested in help to stop? If yes what resources were given? written materials nurse advice doctor advice other Special care needs / disabilities: Disability profile completed (MR 112 ) HISTORY / PROCEDURE DETAILS Yes No Relevant Past History: eg. gestational age, past surgery/admissions Type of surgery: (please circle) ASD repair Other: Is the patient currently using any medications at home? Please list over the counter and complementary and alternative medicines Diet: Breast fed: milk / type of formula Teat Type: Elimination: Toilet trained: Day Number & size of nappies Volume: Times /day History of problems: Other dietary/elimination requirements: NURSING PHYSICAL ASSESSMENT: Eg. Palpable pulses, capillary return, peripheral warmth, colour i.e. cyanosed, patient behaviour i.e. flat or irritable Nurse Additional notes written in UR Last updated April 06 Page 3 tracking record last page of path
Cardiac Surgical Repair Clinical Pathway Operative Day PRE -OP Ensure patient fasted and record fasting time on MR17d (Anaesthetic sheet) Take TPR & BP and record on Observation sheet & MR 17d Administer pre medication as per MR52 Ensure the Pre op check sheet is fully completed Nurse Additional notes written in UR Recovery Room Record Pulse, Respirations, Blood Pressure & Sa0 2 on arrival then as per recovery protocol Continuous ECG monitoring Pressure monitoring, as required Observe wound with observations Record on anaesthesia record MR17B & inform Anaesthetist if losses excessive Record amount of oxygen therapy delivered Measure & record urine output hourly Measure redivac/chest drain losses 1 hourly & record on Fluid Balance Chart inform Surgical Fellow if losses excessive i.e. exceeding 2ml/kg/hr, or if they become heavily blood stained Complete Pain assessment and PCA observation chart Blood gases and full clotting collected Chest X-ray performed Remove arterial line prior to discharge to 7 West Discharge to 7 West once Recovery Clinical Path is completed and total recovery time of 4 hours. May be transferred to ward after 2 hours total recovery time if reviewed by the consultant anaesthetist or Cardiac Surgeon and documented on treatment order sheet MR56 Nurse Additional notes written in UR Last updated April 06 Page 4 tracking record last page of path
UR NUMBER Cardiac Surgical Repair Clinical Pathway Operative Day SURNAME GIVEN NAME(S) Assessment Investigation & Treatments Medications Nutrition Activity Hygiene Teaching OUTCOMES DATE OF BIRTH Ξ AFFIX PATIENT LABEL HERE Return To Ward Record Pulse, Respirations, Blood Pressure & Sa0 2 on arrival then hourly Record Temp hourly then 3 hourly temperature if patient not febrile Conduct and document full nursing assessment including central & peripheral perfusion Continuous ECG monitoring Report to Registrar immediately if arrhythmia observed Auscultate chest once per shift, or more frequently if required Record & measure pupil size on arrival to the unit & once per shift PCA observation chart completed hourly if applicable Assess wound, wire & exit sites with obs &record on MR77 inform Fellow if losses excessive Record amount of oxygen therapy delivered hourly as per treatment orders Check I.V./ C.V.C. site regularly and record on MR114 as applicable Measure & record urine output hourly Check redivac/chest drain patency, measure losses hourly & record on MR 55 inform Surgical Fellow if losses excessive or if they become heavily blood stained & exceed 2ml/kg/hr Urinalysis once per shift & record on Fluid Balance Chart On arrival assist with connection of I.V fluids & monitoring lines Suction patient prn Milk chest drains 1 hourly only if requested and charted by surgeon 6 hourly Catheter care for IDC if present Ensure all lines, catheters & wires are securely strapped Administer I.V / CVC line fluids as per MR 55 ensure I.V fluids changed every 24 hours Ensure oxygen and suction supplies are available and accessible Opioid infusions as per treatment charts Record all input & output hourly on the Fluid Balance Chart Sips of clear fluids only as tolerated when awake & alert according to restrictions on treatment orders Strict rest in bed 4 hourly mouth & eye care - PRN & maintain general hygiene Reinforce expected plan of care & expected length of stay including fluid restrictions Orientate parents / caregivers to unit Observations within normal limits & patient in sinus rhythm Urine output greater than 1ml/kg/hr and no abnormalities detected on urinalysis No significant losses from wound / redivac / chest drain / wire exit sites if applicable All lines & catheters patent & strapped securely Wires strapped securely as per unit protocol Pain appears controlled with prescribed analgesia Patients/ family/ caregivers state they understand the expected plan of care Nurse Additional notes written in UR Nurse Additional notes written in UR Nurse Additional notes written in UR Ward Medical Staff CXR organised & request card completed on patients arrival to the unit Operative Review CXR Day Order appropriate oxygen therapy on treatment sheet I.V. Maintenance fluid & Filling requirements ordered on treatment sheet No oral opioids/ sedatives ordered while I.V. opioid infusing BSL & K taken 3-4 hrly & PRN & request cards completed U&Es and FBE taken daily & as required, blood results checked & recorded appropriately All I.V./ oral medications charted Medical Additional notes written in UR Medical Additional notes written in UR Medical Additional notes written in UR Last updated April 06 Page 5 tracking record last page of path
Cardiac Surgical Repair Clinical Pathway Post Operative- Day1 Post-Op Day 1 1 hourly P, R &SaO2 2hrly Temperature & BP for 6hrs- if stable move to 4 hrly Temperature & BP 1 hourly PCA observation chart completed including pain assessment if applicable Assessment Continuous ECG monitoring Report to Registrar immediately if arrhythmia observed Observe wound, pacing wire & exit sites with observations record on observation chart MR77 & inform RMO if losses excessive or sites appear inflamed/ infected Record amount of oxygen therapy delivered hourly Measure & record urine output hourly while IDC insitu Measure redivac / chest drain losses 1 hourly & record on Fluid Balance Chart Ensure patency of drains when measuring losses and report excessive losses of >2ml/kg/hr Check IV & CVC site regularly as applicable and record on MR114 Daily weight and record on weight chart Administer appropriate Oxygen therapy as per treatment sheet Investigations Wean oxygen therapy as patient tolerates under medical supervision Ensure all IV / CVC lines and wires are securely strapped as per unit protocol & Administer I.V / CVC / arterial line fluids as per MR 54/55 Ensure all I.V replacement fluids are changed as per CVC protocol Milk chest drains 1 hourly if requested and charted by surgeon If requested by Cardiac Surgeon/Fellow remove redivac / chest drains / CVC Treatments Pacing wire exit site care attended as per protocol. 6 hourly Catheter care for IDC If requested by Registrar, remove IDC Ensure deep breathing & coughing attended to as per Physio orders Medications Opioid infusions as per treatment charts & wean as patient tolerates Ensure I.V drug infusion solutions in syringes / bags are changed every 24hrs Record all input & output hourly on the Fluid Balance Chart Nutrition Fluids as tolerated & according to restriction documented on treatment orders When fluids tolerated commence light diet Activity Encourage patient to sit out of bed for short periods (utilise Cardi Cuddles to assist) Hygiene 4 hourly mouth care - PRN & maintain general hygiene Teaching Reinforce expected plan of care & expected length of stay Observations within normal limits & patient in sinus rhythm Oxygen therapy weaned Opioids weaned OUTCOMES No significant reduction in urine output All Wires, lines & catheters patent & strapped securely IDC removed Wound, drain & wire exit sites clean & dry Redivac / chest drain removed, if applicable Pain appears controlled with prescribed analgesia Patient / family / caregivers state they understand the expected plan of care Nurse Additional notes written in UR Nurse Additional notes written in UR Nurse Additional notes written in UR Parents & nursing staff aware of treatment regime Physio Additional notes written in UR Ward Medical Staff Treatment orders reviewed after liaison with cardiac surgeon / fellow IV / oral medication orders reviewed after liaison with cardiac surgeon / fellow Review oxygen therapy if applicable and commence weaning No oral opioids/ sedatives ordered while I.V. opioids infusing All blood results checked Medical Additional notes written in UR Medical Additional notes written in UR Medical Additional notes written in UR Last updated April 06 Page 6 tracking record last page of path
UR NUMBER Cardiac Surgical Repair Clinical Pathway Post Operative- Day 2 SURNAME GIVEN NAME(S) Assessment Post Operative- Day 2 2 hrly P, R & SaO2 for 6 hours, if observations stable: 4 hourly 4 hourly Temperature & Blood Pressure Continuous ECG monitoring Report to Resident immediately if arrhythmia observed Pain assessment hourly if still on I.V opioids or 4 hourly if on oral analgesia Observe wound & drain, pacing wire & exit sites with obs record on observation chart MR77 & inform RMO if losses excessive or sites appear inflamed/ infected Check IV& CVC site regularly as applicable and record on MR114 Daily weight and record on weight chart Investigations Ensure I.V fluids continue as per orders on MR 55 & Ensure IV / CVC lines are securely strapped & positioned Ensure wires strapped as per unit protocol If requested by Cardiac Surgeon / Fellow remove IV / CVC lines Perform wound, wire &exit site care as per ward protocol Ensure deep breathing & coughing attended to as per Physio orders Give Medications as per MR52 (Medication chart) Record all input & output on the Fluid Balance Chart Nutrition Fluids as tolerated & according to restriction documented on treatment orders Encourage diet Activity Encourage patient to ambulate with assistance Hygiene Maintain general hygiene Teaching Reinforce expected plan of care & expected length of stay Observations within normal limits & patient in sinus rhythm No significant reduction in urine output All Lines patent & strapped securely Wires strapped securely as per unit protocol CVC / IV removed if applicable Wound dressing intact & drain, wire exit sites clean & dry Pain appears controlled with prescribed analgesia Weight stable Patient / family / caregivers state they understand the expected plan of care Nurse Additional notes written in UR Nurse Additional notes written in UR Nurse Additional notes written in UR Treatments Medications OUTCOMES Parents & nursing staff aware of treatment regime Physio Ward Medical Staff DATE OF BIRTH AFFIX PATIENT LABEL HERE Ξ U&E s & FBE performed & results reviewed Chest Xray ordered & request card completed Chest Xray reviewed Weight reviewed The following reviewed after liaison with Cardiac Surgeon / Fellow in cardiac round: oral medication orders current treatment orders Medical Additional notes written in UR Medical Additional notes written in UR Medical Additional notes written in UR Cardiac Surgical Repair Clinical Pathway Last Post updated Operative- April 06 Day 3 Page 7 tracking record last page of path
Assessment Investigations Treatments Medications Post Operative- Day 3 4 hrly P, R & Temp & Blood Pressure Pain assessment 2-4 hourly If patient in sinus rhythm & has had no arrhythmias cease ECG monitoring (Report to Resident immediately if arrhythmia observed) Observe wound & drain, pacing wire & exit sites with obs record on observation chart MR77 & inform RMO if losses excessive or sites appear inflamed/ infected Daily weight and record on weight chart Ensure wires strapped as per unit protocol & Perform wound care & wire exit site care as per ward protocol Ensure deep breathing & coughing attended to as per Physio orders Give Medications as per MR52 (Medication chart) Nutrition Record all input & output on the Fluid Balance Chart Fluids as tolerated & according to restriction documented on treatment orders Encourage diet Activity Encourage patient to ambulate with assistance Hygiene Maintain general hygiene Teaching Reinforce expected plan of care & expected length of stay Ensure parents / caregivers understand; Medication ( When, What, Why & How ) The need to continue pain medication until the child feels comfortable Wound care at home Signs of wound infection & report these back to the GP/Cardiac Surgeon When to resume activities & Pre school / School That they should contact their Cardiologist / GP with other problems Observations within normal limits & patient in sinus rhythm No significant reduction in urine output Wound, drain & wire exit sites clean & dry Wires strapped securely as per unit protocol Pain appears controlled with prescribed analgesia Weight stable Patient / family / caregivers state they understand the expected plan of care and home management plan Nurse Additional notes written in UR Nurse Additional notes written in UR Nurse Additional notes written in UR OUTCOMES Parents & nursing staff aware of treatment regime Physio Additional notes written in UR Ward Medical Staff Weight reviewed Oral medication and current treatment orders reviewed after liaison with Cardiac Surgeon / Fellow in cardiac round Medical Additional notes written in UR Medical Additional notes written in UR Medical Additional notes written in UR Last updated April 06 Page 8 tracking record last page of path
UR NUMBER Cardiac Surgical Repair Clinical Pathway Post Operative- Day 4 SURNAME GIVEN NAME(S) Ξ AFFIX PATIENT LABEL HERE Post Operative- Day 4 Discharge Day 4 hrly P, R &Temp Pain assessment 4 hourly Observe wound, drain & pacing wire exit sites with obs record on observation chart MR77 & inform RMO if losses excessive or sites appear inflamed/ infected Daily weight and record on weight chart Ensure wires & LA line strapped as per unit protocol if applicable & Perform wound care & wire exit site care as per ward protocol If requested by Cardiac Surgeon remove wires Ensure deep breathing & coughing attended to as per Physio orders Remove dressing & redress portions that have not healed Swab site if infection evident Give Medications as per Medication chart MR52 Nutrition Record all input & output on the Fluid Balance Chart Activity Encourage ambulation and diet & fluids Hygiene Maintain general hygiene Teaching Ensure chest X ray & Echo completed & reviewed before patient is discharged Reinforce expected plan of care & expected length of stay Ensure parents / caregivers understand; Medication ( When, What, Why & How ) The need to continue pain medication until the child feels comfortable Wound care at home The signs of wound infection & report these back to the GP / Cardiac Surgeon When to resume activities & Pre school / School That they should contact their Cardiologist / GP with other problems Ensure discharge sheet completed & copy faxed to G.P. / Paediatrician Ensure out patient appointment is made with the Cardiologist Observations within normal limits No significant reduction in urine output Wound, drain & wire exit sites clean & dry Wires removed Pain appears controlled with prescribed analgesia Weight stable Parent/caregivers state they understand the plan of care & home management plan Nurse Signature: Nurse Signature: Assessment Investigations Treatments Medications OUTCOMES DATE OF BIRTH Parents & nursing staff aware of treatment regime Physio Additional notes written in UR Ward Medical Staff The following reviewed after liaison with Cardiac Surgeon / Fellow in cardiac round: oral medication orders current treatment orders Weight reviewed CXR & ECHO results followed up with Cardiology Fellow & patient is able to be discharged All discharge scripts and discharge summary completed Medical Additional notes written in UR Medical Additional notes written in UR Medical Additional notes written in UR Last updated April 06 Page 9 tracking record last page of path
Variance Tracking Record DATE TIME 24 hr clock WHAT OCCURRED? eg: Orientation not given to parents WHY? eg: Parents not in attendance WHAT DID YOU DO ABOUT IT? eg: Handed over to next shift OUTCOME eg: Parents still require orientation SIGNED INSTRUCTIONS for USE Record date and time as appropriate at the top of each column Each shift the nurse should complete the column & sign below in the space provided. TICK = item of care given as per path; n/a = care is not applicable to this patient at this time OR VAR = patient care or condition has varied from the path. The details are written on the Variance Tracking Record above If you have any queries please contact the Clinical Path Coordinator Manager in Clinical Quality & Safety Unit ext / pager 6956 Last updated April 06 Page 10 tracking record last page of path
ICP1 ACS Page 1 of 1 Version 46 Amendment date 05/05/2003 15:26 Acute Coronary Syndrome Pathway Eligibility Patients presenting with chest pain at rest for greater than 15 minutes or suspected acute MI First name Last name DOB CHI No Date Time of admission Time of onset of symptoms Attach Patient Label Immediate Actions Before admission Withheld or not done (reason) Aspirin 300mg chewed Time Oxygen 8l/min Pulse oximetry 12 lead ECG ECG monitor Blood pressure Value IV cannula Diamorphine 2.5 to 5mg IV Cyclizine 50mg IV Estimated weight (kg) Value ST Elevation> 1 mm in two or more limb leads? Yes to any ST Elevation > 2 mm in two or more adjacent chest leads? New left bundle branch block? No to all Pre-existing LBBB or LBBB of uncertain duration associated with convincing symptoms ECG signs of posterior myocardial infarction? Sign Off Pathway completed Date Content authorised by Branch to ACS ST Elevation Pathway Name Signature Branch to ACS Non ST Elevation Pathway
Patient Chart No. No du dossier Patient Chart No. No du dossier Date (YY/MM/DD) C R I T I C A L P A T H Day of Admission (ER HI) Day 1 Day 2 Day 3 Day 4 Additional Days (Repeat Day 4) Discharge Day Intervention Day Consults Tests Assessments / Treatments Mobility / Safety Nutrition Psycho-social Support Patient Education Discharge Planning Cardiology Nsg Coordinator PRN (HI) _ Smoking Cessation: Yes N/A ECG Chest x-ray CBC, platelets, Na, K, Cl, Cr, glucose, INR, PTT Troponin q 8 h 2 CK q 8 h 3 If patient a known diabetic OR fasting glucose results >7.0 mmol/l OR random glucose results >11.0 mmol/l then do capillary glucose monitoring (CBG) QID _ MRSA / VRE swabs sent: Yes No NA Cardiac Monitor O 2 by Titration Protocol VS q4h while awake Chest pain protocol Fluid balance as required Ensure saline lock in place Activity as tolerated when symptom free _ Universal fall precautions HI Diet (HI), AHA Diet (Gen) Patient Specific Diet Identify & address psycho-social concerns Identify contact person Assess patient behaviour re anxiety _ Physical Environment Pain Assess/management Explain medications given Discuss visiting policies with patient & family Review expectations for next 24 hrs _ Advise patient to quit smoking: Yes No Identify discharge concerns as per patient history Identify/document family physician name on admission sheet Unmet care needs should be highlighted for next day Social work consult PRN Patient Revascularization Registry Form Completed: Yes No ECG Consider Echo (AWMI) for day 3 4 _ Fasting cholesterol, HDL, LDL, triglycerides, fasting glucose & Hba1c a.m. of Day 1 _ Cardiac Monitor O 2 by Titration Protocol VS QID Chest pain protocol Fluid balance as required Assess activity ability Activity as tolerated Shower as tolerated Universal fall precautions HI Diet (HI), AHA Diet (Gen) Patient Specific Diet Ongoing assessment/community support needs Communicate with contact PRN Identify & support individual s cultural values & spiritual concerns Assess patient/family perception of condition Provide Cardiology book Review activity tolerance Procedural Teaching PRN Advise patient to quit smoking: Yes No Initiate Patient Discharge Information Tool _ Discuss pending discharge concerns _ Assess financial concerns re drug costs _ Patient has drug plan: Yes No Review discharge plan Unmet care needs should be highlighted for next day Cardiac Rehabilitation Patient Revascularization Registry Form Completed: Yes No ECG Confirm PA & Lateral Chest x-ray done _ Ask Physician re Monitor O 2 by Titration Protocol VS BID & PRN Chest pain protocol Activity as tolerated Shower as tolerated Universal fall precautions HI Diet (HI), AHA Diet (Gen) Patient Specific Diet Ongoing assessment/community support needs Communicate with contact PRN Review patient/family perceptions Review Cardiology book Review Cardiac Risk Factors Review Procedural Teaching PRN Review pain assess/management Reinforce activity tolerance Book Discharge Class (HI) Eat For Your Heart s Content handout given: Yes No Review Patient Discharge Information Tool _ Discuss pending discharge concerns _ Unmet care needs should be highlighted for next day Dietitian for Lipids & PRN Physiotherapy PRN Occupational Therapy PRN Patient Revascularization Registry Form Completed: Yes No VS BID & PRN O 2 by Titration Protocol Chest pain protocol Activity as tolerated Shower as tolerated Assess re stairs Universal fall precautions HI Diet (HI), AHA Diet (Gen) Patient Specific Diet Ongoing Communicate with contact PRN _ Reinforce Cardiology book info Teach use of Nitroglycerine Nutrition class PRN Review patient medications Eat For Your Heart s Content handout given: Yes No Review Patient Discharge Information Tool _ Review discharge plans Discuss & plan transportation arrangements Unmet care needs should be highlighted for next day Patient Revascularization Registry Form Completed: Yes No Echocardiogram Yes No N/A VS BID & PRN O 2 by Titration Protocol Chest pain protocol Activity as tolerated Shower as tolerated Stairs accompanied as required Universal fall precautions HI Diet (HI), AHA Diet (Gen) Patient Specific Diet Ongoing Communicate with contact re discharge _ Reinforce Cardiology book info Review use of Nitroglycerine Discuss 24/7 telephone call line (HI) _ Review patient medications Discuss follow-up possibilities _ Review Eat For Your Heart s Content handout Review Patient Discharge Information Tool _ Review medication Reassess financial concerns re drug costs Unmet care needs should be highlighted for next day INR if on coumadin Patient discharge assessment Continue Day 4 Shower as tolerated Universal fall precautions HI Diet (HI), AHA Diet (Gen) Patient Specific Diet Ongoing Ensure patient has prescriptions Ensure patient has discharge letter _ Has attended D/C class: (HI) Yes No Plans to return for class: (HI) Yes No Complete the Patient Discharge Information form Review Patient Discharge Information Tool Review discharge plans D/C expected by 0900 Post Cath Care Follow Post cath orders: Vital signs q 1h 4 then QID Vascular Assessment q 1h 4 & PRN Blood work according to Heparin/ Integrelin protocol PRN CBC PRN Post PCI 0Care ECG Post Procedure CK (stat) 4 6 hrs post procedure & in a.m. Blood work according to Heparin/ Integrelin protocol PRN CBC PRN Cardiac monitor VS q1h 4 hrs then QID Vascular assessment q1h while sheaths in place then q1h 4 PRN Femoral Sheath Removal Sheath removal hrs post procedure Clamp on @ Clamp off @ Vital signs/vascular assessment as per protocol Dressing change While on bed-rest, turn to affected side, HOB 30, reposition q 1 2 hr Ambulate 4 hrs post sheath removal Diet as tolerated Radial Artery Removal Procedure Clamp release start Clamp release finish Vital signs/vascular assessment on arrival to unit then q 15 min 4 or until 2nd clamp release then q 30 min until clamp removed AAT Diet as tolerated Patient Education Ambulation expectations Sheath removal PCI results reviewed Discharge Planning Review discharge plans Problem List RN Signature Initiate Problem List Review/update Review/update Review/update Review/update RN Signature: D N RN Signature: D N RN Signature: D N Review/update Review/update UOHI 21A (2 2) CHART DOSSIER 2004 UNIVERSITY OF OTTAWA HEART INSTITUTE
CLINICAL PATHWAY PLAN CLINIQUE Acute Coronary Syndrome Syndrome coronairien aigu Patient VARIANCES 104 Recurrent Chest Pain 110 Heart Failure 109 Arrhythmia requiring intervention 102 Vital Signs 800 Awaiting Placement/Transfer 101 Post procedure Vascular Complications Pathway Discontinued dd mm yy Chart No. No du dossier Waiting for procedure: Diagnostic test Cath Surgery Reason(s):, P A T I E N T O U T C O M E S P A T I E N T O U T C O M E S Heart Institute Day of Admission (ER HI) Day 1 Day 2 Day 3 Day 4 Additional Days (Repeat Day 4) Discharge Day Intervention Day General CLINICAL PATHWAY PLAN CLINIQUE Acute Coronary Syndrome Syndrome coronairien aigu Date (YY/MM/DD) Management of Chest Pain & Ischemia Patient notifies staff of chest pain No ECG ST segment shifts or conduction defects Patient is pain free Patient notifies staff of chest pain No ECG ST segment shifts or conduction defects Patient is pain free Patient notifies staff of chest pain No ECG ST segment shifts or conduction defects Patient is pain free Patient notifies staff of chest pain No ECG ST segment shifts or conduction defects Patient is pain free Patient notifies staff of chest pain Patient is pain free Patient notifies staff of chest pain Patient is pain free Potential for Bleeding Complications No evidence of bleeding or neurological change Hgb within 20 gm of baseline No evidence of bleeding or neurological change Hgb within 20 gm of baseline No evidence of bleeding or neurological change Hgb within 20 gm of baseline No evidence of bleeding or neurological change Hgb within 20 gm of baseline Hematoma <4 cm No evidence of excess bleeding or pseudoaneurysm Hemodynamic Stability No arrhythmia requiring intervention VS within normal limits No CHF Symptoms No arrhythmia requiring intervention VS within normal limits No CHF Symptoms No arrhythmia requiring intervention VS within normal limits No CHF Symptoms No arrhythmia requiring intervention VS within normal limits No CHF Symptoms Patient maintains pre-procedure vascular status No arrhythmia No CHF Symptoms Activity Tolerance Tolerates activity (pain free, no SOB) Tolerates activity (pain free, no SOB) No limitations to activity Tolerates activity (pain free, no SOB) No limitations to activity Tolerates activity (pain free, no SOB) No limitations to activity Pain free Anxiety Education Patient verbalizes feelings re admission Patient/family able to discuss/understand: Importance of close observation during early stage of hospitalization Rationale for progressive activity Usual visiting hours Probable length of stay Need to report chest pain/discomfort Appropriate pain management & use of nitroglycerin IV/SL Need for treatment & monitoring Other Unmet teaching needs should be highlighted next day. Patient acknowledges absence of anxiety Patient identifies no need for social &/or financial support Patient/family able to discuss/understand: Perception of condition Basic elements of CAD, (MI vs UA) Need to report chest pain/discomfort Appropriate pain management & use of nitroglycerin IV/SL Need for treatment & monitoring Appropriate diagnostic tests Other Unmet teaching needs should be highlighted next day. Patient acknowledges absence of anxiety Patient identifies no need for social &/or financial support Patient/family able to discuss/understand: Aware of lipid profile Understands risk factors in general Understands personal risk factors Appropriate diagnostic tests Appointment made for discharge & nutrition classes Need to report chest pain Need for treatment & monitoring Other Unmet teaching needs should be highlighted next day. Patient acknowledges absence of anxiety Patient identifies no need for social &/or financial support Patient/family able to discuss/understand: Appropriate pain management & use of nitriglycerin SL Lipid profile awareness Controllable risk factors Necessary lifestyle changes Activity guidelines Rehabilitation referral Financial concerns regarding discharge medications The value of cardiology booklet for further information Other Unmet teaching needs should be highlighted next day. Patient acknowledges absence of anxiety Patient identifies no need for social &/or financial support Patient/family able to discuss/understand: Medication & its use on discharge Availability of community resources including: family physician and community pharmacist Reinforce previous information Other Unmet teaching needs should be highlighted next day. Patient/family able to discuss/ understand: When its appropriate to seek medical advice The value of cardiology booklet for further information Appropriate response to episodes of chest pain Reasons for taking medications and need to fill prescriptions the day of discharge Other Reassess unmet teaching needs. Verbalizes understanding of: Activity restrictions Procedure results Management of puncture site Need to seek medical advice RN Signature RN Signature: D N RN Signature: D N RN Signature: D N UOHI 21A (REV 06-2006) ID CHART DOSSIER 2004 UNIVERSITY OF OTTAWA HEART INSTITUTE