INTEGRATED CARE PATHWAY

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


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


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)


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:


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)


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


7

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: …………………..


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:


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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


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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…..


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DATE …………………………………..

TIME MULTIDISCIPLINARY COMMENTS SIGNATURE


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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


13

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



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


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DAY 2: NURSING DATE:……………………


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


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


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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:


DIETICIANSeen by dietician

Written information givenNotes

DAY 3. DATE _______________


Cardiac rehabilitationSeen by cardiacrehabilitation staff


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Written information givenNotes


DATE …………………………………..



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DAY 4: MEDICAL REVIEW DATE: …………………….

ٱ Discharge advice (with partner/ carer as appropriate eg. Shopping, housework, gardening)


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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)





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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


DAY 5 DATE: …………………….

Patient to be discharged if mobile and condition stable


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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


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TIME NOTES SIGNATURE



Appendix I

SERIAL PATHOLOGY RESULTS


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DATETIME

TROPONIN ICHOLESTEROL

NaKCHLORIDEUREACREATININE

R.GLUCOSEF.GLUCOSE

HbWBCPLT.

INRKCCT

MgESR

OTHERS

INTEGRATED CARE PATHWAY

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