Í*5k/>Î Mat.

: 10217515
© The State of Queensland (Queensland Health) 2010 Contact: cpic@health.qld.gov.au
(Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

Clinical Pathways Never Replace Clinical Judgement

Care Outlined In This Pathway Must be Altered If It Is Not Clinically Appropriate For The Individual Patient
If contraindication to thrombolysis, thrombolysis failure or cardiogenic shock; arrange immediate transfer.
If thrombolysis successful; arrange transfer to cardiac catheter laboratory within 48 hours.

Pathway commenced Date: Time:......................... Initials:..............................

Pathway ceased Date: Time:......................... Reason:.................................................................... Initials:..................
Treating consultant (print name):.................................................................................................................
Procedures:
Thrombolysis: Yes  Date:................................  Time:...............................  Type:.................................................................................................................
No
Chest x-ray: Yes  Date:................................
Do Not Write in this binding margin

Angiogram:
Scheduled? Yes  Date:................................   Not for angiogram, Reason:................................................................................................
Performed? Yes  Date:................................
Documentation Instructions:
• Initials - Indicates action / care has been ordered / administered.
• N/A - Indicates preceding care / order is not applicable.
• Crossing out - Indicates that there is a change in the care outlined.

STEMI Pathway  Non-Interventional

• V - Indicates a variation from the pathway on that day, in that section. When applicable flag it in the “Variance
column”, then document in the free text area as instructed. If this variance occurs more than once daily,
document the additional times of the variance in the variance free text area and in the patient’s progress
notes as applicable.
• Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab
Symbols guide care to a primary professional stream, it is a visual guide only and its direction is not intended
to be absolute.
• When signing in a split box, first signature should be entered in the left box and the second in the right.
• Every person documenting in this clinical pathway must supply a sample of their initials and signature below.
Signature Log:
Initials Signature Print name Role
ÌSW043bv2.00@Î SW043b - v2.00 - 04/2010

Clinician suspects   Cardiac Chest Pain Management Protocol Acute Coronary Syndrome diagnosed
acute coronary   Chest Pain Assessment Tool
 Intermediate Risk Chest Pain Clinical Pathway   STEMI Management Plan OR   NSTEACS Management Plan
syndrome
  Patient Information. Sheet   STEMI Pathway   NSTEACS Pathway

Page 1 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

Signature Log (continued):

Initials Signature Print name Role

DO not write in this binding margin

Page 2 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

All care givers who initial are to sign signature log Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab

Discharge Checklist Initials Date

Rehabilitation / Education

• Review with patient and carer: Resumption of lifestyle activities (sexual activity, physical activity, return to work)

Driving / pilot / commercial licensing

Current status, diagnostic and therapeutic options and general prognosis

Chest pain home management plan

Education and counselling for all current medications

• Group Healthy Eating education session attended?
  Yes (specify):.........................................................................................................................................................................................................
  No (refer to community health or outpatient group session)
Do Not Write in this binding margin

• Given: Written and personalised risk factor control information (smoking, nutrition, diabetes, stress
management, high blood pressure and cholesterol)

Information on disease process (eg. atherosclerosis)

‘My Heart My Life’ book or similar

Written medication information: Consumer Medicines Information
Discharge Medication Record (DMR)

• Cardiac rehab OPD referral completed? Yes  No

• Heart Failure Service referral completed? Yes  N/A

• Stress / Depression identified? Yes  No (if Yes, refer to psychologist / social worker)
Medications
Discharge medications review for:
• ACE inhibitors: Indicated?  Yes  No     Given?  Yes  No
If Not Given, specify reason:..................................................................................................................................................................................
• Aspirin: Indicated?  Yes  No     Given?  Yes  No

If Not Given, specify reason:.................................................................................................................................................................................

• Beta Blockers: Indicated?  Yes  No     Given?  Yes  No

If Not Given, specify reason:..................................................................................................................................................................................

• Clopidogrel: Indicated?  Yes  No     Given?  Yes  No

If Not Given, specify reason:..................................................................................................................................................................................

• Statins: Indicated?  Yes  No     Given?  Yes  No

If Not Given, specify reason:..................................................................................................................................................................................

• Sublingual Glyceryl Trinitrate PRN:  Supplied at discharge? Yes  No

• Discharge script completed and sent to pharmacy? Yes  No (If No, reason:. ......................................)
Appointments
Patient to make appointment with General Practitioner within one week
SW043b - v2.00 - 04/2010

Cardiologist
Other (specify):........................................................................................
Forms

• Medical discharge summary

• Travel forms, if required ( not required)

• Medical certificate, if required ( not required)

Page 3 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

All care givers who initial are to sign signature log Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab
Hours from ED
First 24 hours  From: hrs  To: hrs presentation
Category
Day 1    Admission to CCU 0–8 9–16 17–24 V
Investigations • ECG on arrival to CCU (right sided ECG V4R if inferior mycoardial infarction), repeat
with pain or clinical deterioration and review by MO
• If had Lysis, conduct ECGs  90 mins  6 hrs and  12 hrs post Lysis  N/A
• If reperfusion unsuccessful at 90 mins, arrange emergency transfer for
PCI (percutaneous coronary intervention)
• Continuous cardiac monitoring (ST segments if available)

• Troponin (TNI)  ELFT  FBC  TFT  COAGS  BGL

Fasting glucose / Lipids request for next day
• If re-occlusion, refer immediately for emergency rescue PCI

• Other test:..........................................................................................................................................................
Medications • Supplemental Oxygen with chest pain

DO not write in this binding margin

and Pain
Management • Check the allergy status of the patient by referring to the medication chart
• Record weight and height on medication chart
• Confirm Aspirin given
• Confirm Clopidogrel given
• Confirm prescription of PRN medication (morphine, metoclopramide)
• Other intravenous infusions:. ...........................................................................................................................
• Review need for: Enoxaparin (refer to STEMI Management Plan, p.2, 0–24 hrs)
IV Heparin
Observations • If successful lysis, refer immediately – angiography recommended within 48 hours
Treatments • Follow post Lysis protocol, then if stable Q4H (or as per MO order*) TPR, BP, heart
sounds (HS) and breath sounds (BS), O2 sats, rhythm check, circulation and pain
assessment. Neurological observations post-lysis

*Record alternate frequency:...........................................................................................................................

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency:.....................................................   N/A

(if newly diagnosed, refer to Diabetic Educator)
• Daily weight and/or fluid balance chart N/A
• Deep breathing, coughing and leg exercises
Nutrition • Healthy Heart diet  Other (specify):.................................................................................................
• If for fasting lipids / glucose, no food after 8pm (may have H2O)  N/A
Mobility / • Strict rest in bed for 12 hrs post STEMI (12–24 hours post successful thrombolysis,
Elimination / patient may go to toilet on wheelchair with telemetry [must be supervised], provided
Hygiene they are pain free, and off inotropic and oxygen therapy) – Record alterations in
mobility:

. ........................................................................................................................................................................................
• Sponge in bed
• Falls risk score:..............................  Waterlow score:............................
• Mouth care after meals and prn
Other Care
.............................................................................................................................................................................................
(specify)
.............................................................................................................................................................................................

Education and • Basic explanation to be given of: AMI Diagnostic procedures

Discharge Plan Mobilisation and bed exercises Risk factors My Heart My Life book or similar
Expected Patient demonstrates:  A - Achieved  V - Variance A V
Outcomes
(complete at • Painfree
end of 24 hour • ST segment or T wave changes resolving
period)
• Other (specify):..........................................................................................................................................................................................

Page 4 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

All care givers who initial are to sign signature log Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab
Category Day 2 of pathway   Date: to  Ward:................. Shift: V
Investigations
• ECG performed daily, repeat with pain or clinical deterioration and review by MO

• Continuous cardiac monitoring

• TNI  FBC  ELFT  APTT (if on heparin as per protocol / nomogram)
Fasting Lipids / glucose (if fasting glucose > 5.9 for glucose tolerance test)

• Refer to interventional cardiac facility for coronary angiography

• Other test:..........................................................................................................................................................
Medications • Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel and sublingual ACE
and Pain inhibitors
Management
• Other intravenous infusions:. ...........................................................................................................................
Do Not Write in this binding margin

• Review need for: Enoxaparin (refer to STEMI Management Plan, Anticoagulation)

IV Heparin
Observations • 4 hourly (or as per MO order*) temperature, pulse, resps, rhythm check, BP, breath
Treatments sounds, heart sounds, O2Sats (on room air) and circulation

*Record alternate frequency:...........................................................................................................................

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency:.....................................................   N/A
(if newly diagnosed, refer to Diabetic Educator)

• Daily weight and/or fluid balance chart, if indicated N/A

• Patent IVC — change if cubital fossa inserted in DEM / ED (remove if not required)
Insertion date: ..........................................  Resite date:..............................................

• Deep breathing, coughing and leg exercises

Nutrition
• Healthy Heart diet  Other (specify):.................................................................................................

• If fasting bloods, confirm blood collection before breakfast  N/A

• If for Glucose Tolerance Test, no food after 8pm (may have H2O)  N/A
Mobility / • Gentle mobilisation, shower with supervision, toilet privileges permitted (if pain free and
Elimination /
TNI reducing). - Record alterations in mobility:.......................................................................................
Hygiene
. .......................................................................................................................................................................................
Other Care
(specify) .............................................................................................................................................................................................

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

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

.............................................................................................................................................................................................
Education and
Discharge Plan • Discuss treatment plan with patient / carer

• Commence discharge checklist on p.3

SW043b - v2.00 - 04/2010

Expected Patient demonstrates:  A - Achieved  V - Variance A V

Outcomes
(complete at
• Painfree
end of 24 hour
period)
• ST segment or T wave changes resolving

• Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography.

• Other (specify):..........................................................................................................................................................................................

Page 5 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

All care givers who initial are to sign signature log Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab
Category Day 3 of pathway   Date: to  Ward:................. Shift: V
Investigations
• ECG performed daily, repeat with pain or clinical deterioration and review by MO

• Continuous cardiac monitoring

• Telemetry

• Monitoring ceased - time:............................

• Daily Bloods as requested (glucose tolerance test if indicated, FBC if IV Heparin,
Enoxaparin)

• Other test:..........................................................................................................................................................
Medications • Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel, ACE inhibitors and
and Pain Sublingual Glyceryl Trinitrate
Management

DO not write in this binding margin

• Other intravenous infusions:. ...........................................................................................................................
• Review need for: Enoxaparin (refer to STEMI Management Plan, Anticoagulation)
IV Heparin
Observations • QID or BD as indicated (or as per MO order*) temperature, pulse, resps, rhythm check,
Treatments BP, breath sounds, heart sounds, O2Sats (on room air) and circulation

*Record alternate frequency:...........................................................................................................................

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency:....................................................  N/A

• Daily weight and/or fluid balance chart, if indicated N/A

• Patent IVC   Resite date:...............................  OR IVC removed

Nutrition
• Healthy Heart diet  Other (specify):.................................................................................................

• If fasting bloods, confirm blood collection before breakfast  N/A

Mobility / • Increase mobilisation if painfree
Elimination /
Hygiene • Self care   Other – Record alterations in mobility/hygiene:

. ......................................................................................................................................................................................
Other Care
(specify) .............................................................................................................................................................................................

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

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

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

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

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

Education and
Discharge Plan • Discuss treatment plan with patient / carer

• Review discharge checklist on p.3

Expected Patient demonstrates:  A - Achieved  V - Variance A V
Outcomes
(complete at • Painfree
end of 24 hour
period) • ST segment or T wave changes resolving

• Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography.

• Other (specify):..........................................................................................................................................................................................

Page 6 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

All care givers who initial are to sign signature log Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab
Category Day 4 of pathway   Date: to  Ward:................. Shift: V
Investigations
• ECG with pain or clinical deterioration and review by MO

• Continuous cardiac monitoring

• Telemetry

• Monitoring ceased - time:............................

• Daily Bloods as requested (FBC if IV Heparin, Enoxaparin or GP IIb/IIIa inhibitors)

• Other test:..........................................................................................................................................................
Medications • Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel, ACE inhibitors and
and Pain Sublingual Glyceryl Trinitrate
Management
• Other intravenous infusions:. ...........................................................................................................................
Do Not Write in this binding margin

• Review need for: Enoxaparin (refer to STEMI Management Plan, Anticoagulation)

IV Heparin
Observations • QID or BD as indicated (or as per MO order*) temperature, pulse, resps, BP, breath
Treatments sounds, heart sounds, O2Sats (on room air) and circulation

*Record alternate frequency:...........................................................................................................................

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency:....................................................  N/A

• Daily weight and/or fluid balance chart, if indicated N/A

• Patent IVC   Resite date:...............................  OR IVC removed

Nutrition
• Healthy Heart diet  Other (specify):.................................................................................................
Mobility / • Increase mobilisation if painfree
Elimination /
Hygiene • Self care   Other – Record alterations in mobility/hygiene:

. ......................................................................................................................................................................................
Other Care
(specify) .............................................................................................................................................................................................

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

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

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

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

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

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

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

Education and
Discharge Plan • Discuss treatment plan with patient / carer

• Review discharge checklist on p.3

SW043b - v2.00 - 04/2010

Expected Patient demonstrates:  A - Achieved  V - Variance A V

Outcomes
(complete at • Painfree
end of 24 hour
period) • ST segment or T wave changes resolving

• Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography.

• Other (specify):..........................................................................................................................................................................................

Page 7 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

All care givers who initial are to sign signature log Key  Medical  Nursing  Pharmacy  Allied Health  Cardiac Rehab
Category Day 5 of pathway   Date: to  Ward:................. Shift: V
Investigations
• ECG with pain or clinical deterioration and review by MO

• Continuous cardiac monitoring

• Telemetry

• Monitoring ceased - time:............................

• Daily Bloods as requested (FBC if IV Heparin, Enoxaparin or GP IIb/IIIa inhibitors)

• Considered for angiography (if Yes, withhold AM Enoxaparin, Metformin and others
as indicated)
Preparation and education completed as per angiogram pathway

• Other test:..........................................................................................................................................................
• Confirm prescription of Aspirin, Statin, Beta blockers, Clopidogrel, ACE inhibitors and

DO not write in this binding margin

Medications
and Pain Sublingual Glyceryl Trinitrate
Management
• Other intravenous infusions:. ...........................................................................................................................
• Review need for: Enoxaparin (refer to STEMI Management Plan, Anticoagulation)
IV Heparin
Observations • QID or BD as indicated (or as per MO order*) temperature, pulse, resps, BP, breath
Treatments sounds, heart sounds, O2Sats (on room air) and circulation

*Record alternate frequency:...........................................................................................................................

• Assess, manage and report chest pain

• Blood glucose level (BGL) monitoring - frequency:....................................................  N/A

• Daily weight and/or fluid balance chart, if indicated N/A

• Check angiogram puncture site N/A

• Patent IVC   Resite date:...............................  OR IVC removed

Nutrition
• Healthy Heart diet  Other (specify):.................................................................................................
Mobility / • Increase mobilisation if painfree
Elimination /
Hygiene • Self care   Other – Record alterations in mobility/hygiene:

. ......................................................................................................................................................................................
Other Care
(specify) .............................................................................................................................................................................................

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

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

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

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

Education and
Discharge Plan • Discuss treatment plan with patient / carer

• Review discharge checklist on p.3

Expected Patient demonstrates:  A - Achieved  V - Variance A V
Outcomes
(complete at • Painfree
end of 24 hour
period) • ST segment or T wave changes resolving

• Referred to interventional cardiac facility for coronary angiography, unless unsuitable for angiography.

• Other (specify):..........................................................................................................................................................................................
Utilise ‘STEMI / NSTEACS Pathways (Additional page)’ for further inpatient stay

Page 8 of 12
 Do Not Write in this binding margin
SW043b - v2.00 - 04/2010

Insert additional days here if applicable.

 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

Variance Codes
A. Patient Variances Actions
A:1 Recurrent chest pain (Differentiate Chest Pain Type; • Administer O2
ischaemic, pericarditis or chest wall pain (post PCI)) • Administer Sublingual Glyceryl Trinitrate
• Perform ECG
• MO Review
• Repeat Troponin
• If re-infarction, consider urgent PCI
A:2  Cardiac arrest
A:2.1 Ventricular Fibrillation (VF) or Pulseless Ventricular • Basic Life Support — CPR
Tachycardia (VT) • Code Blue
• Advanced Life Support — Defibrillation
A:2.2 Unconscious Complete Heart Block / Asystole • Basic Life Support — CPR
• Code Blue
• Emergency transthoracic pacing, transvenous pacing
A:2.3 Pulseless electrical activity • Basic Life Support — CPR

DO not write in this binding margin

• Code Blue
A:3 Other arrhythmias:
A:3.1 Conscious sustained Ventricular Tachycardia • Urgent MO review: - unstable patient (hypotensive): call
Medical Emergency Team;
- stable patient within 5 mins
A:3.2 First episode of Atrial Fibrillation (AF) or other Supra • Urgent MO review: - unstable patient: within 5 mins;
Ventricular Tachycardia (SVT) - stable patient: 15–60 mins
A:3.3 First episode of Heart Block; 2nd or 3rd degree AV Block • Urgent MO review: - unstable patient (hypotensive/syncope):
call Medical Emergency Team;
- stable patient within 5 mins
A:4 Left ventricular failure (with Pulmonary Oedema) • Urgent MO review: with respiratory distress: within 5 mins; or
no respiratory distress but SaO2 < 93%: within 20 mins
• O2, consider CPAP / BiPAP
• Strict FBC, consider IDC
• Morphine PRN
• Nitrates IV
• Diuretics
• Correction of Hypertension
A:5 Pericarditis • MO review
• Consider echocardiogram
• Consider non-steroidal anti-inflammatory drug
A:6 Pulmonary embolus (PE) / Deep vein thrombosis (DVT) • Urgent MO review within 30 minutes
• CTPA or VQ Scan +/- Leg Ultrasound
• Anticoagulation
• Bed rest
A:7 Renal failure (Significant worsening of renal function as • Urgent MO review; 1–2hrs
defined by rising creatinine or worsening GFR) • Assess volume state and urine output
• Report Cardiac Output; assess pre-renal cause
• Contribution of Medications
• Strict FBC, consider IDC
• Treat hyperkalaemia
A:8 Pulmonary complications (Cough, sputum production, • MO review
fever and pleuritic chest pain) • Chest X-ray
• Assessment of pneumonia
• Exclusion of pulmonary embolism
A:9 Severe nausea • MO review
• ECG and General Observations
• Consider anti-emetic
A:10 Adverse drug reactions • MO review
• Anaphylaxis and allergy management
• Cease and / or withhold drug
A:11 ACS medications contraindicated / Withheld • Check with MO
A:99 Other

Page 10 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

Variance Codes (continued)

A. Patient Variances Actions
A:12 Cardiogenic shock • Urgent MO review within 5 minutes
(Hypotension with peripheral shutdown and poor urine • Urgent Echocardiogram (exclude severe Mitral Regurgitation or
output, assess age of patient and comorbidities, seek Ventricular Septal Defect)
senior medical officer / ICU input early) • Fluid balance chart and consider urinary catheter
• Consider Swann-Ganz catheter
• Consider intra-aortic balloon pump
• Consider inotropes
A:13 Haemorrhage

A:13.1 Post PCI, access site haematoma / bleed • Follow hospital angiogram protocol

A:13.2 Retro-peritoneal bleeding (hypotension, abdominal

pain, poor urine output)
A:13.3 Other bleeding
Do Not Write in this binding margin

A:13.4 Post Lysis (STEMI), change in neurological status • Urgent MO review within 5 minutes
• Cease anti-coagulants
• CT Head
• Neurosurgical review
A:14 Coronary artery bypass surgery

B. Discharge / Treatment Delay Variances

B:1 Treatment delay B:6 Blood tests delayed B:11 Transfer to private hospital
B:2  Delay in transfer B:7  Delay in chest X-ray B:12  Change of plan / orders
B:3 No bed available B:8  Delay in stress test B:13 Self discharge
B:4  No monitored bed available B:9 Medication not available B:14  Overnight stay
B:5 Interdepartmental issues involving care B:10  Patient discharged home off pathway
C. Staff Variances
C:1 Medical C:3 Allied Health
C:2 Nursing C:4  Unable to provide patient education

Clinical Events / Variance

Variance Describe variances to clinical path and any other patient related notes.
Date / Time Initials
Code Document as Variance / Action / Outcome
SW043b - v2.00 - 04/2010

Page 11 of 12
 (Affix patient identification label here)

URN:
STEMI pathway
Family name:
ST-Elevation Myocardial Infarction
Given names:
For Non-Interventional Cardiac Facilities
Date of birth: Sex: M F
Facility:

Clinical Events / Variance (continued)

Variance Describe variances to clinical path and any other patient related notes.
Date / Time Initials
Code Document as Variance / Action / Outcome

DO not write in this binding margin

Page 12 of 12