Acute Coronary Syndromes

1
Acute Coronary Syndromes

• Education Workshop (click to go to the desired
  section)
• Introduction to Workshop/Instructions
• Evidence Based Care Program
• Acute Coronary Syndromes Pathway

2
Introduction

• This interactive workshop is designed to go along
  with a workbook. Keep the workbook handy as you
  go through the workshop to engage in the required
  activities.
• This is a web-based workshop, and thus has links
  throughout each page to enable you to move
  throughout the workshop. Whenever you see words
  underlined like this, you can click on that area
  to go to another section or to find more
  information on a topic.
• At the bottom of each page are navigational
  buttons to help you move through the workshop.
• You can go through as much or as little of the
  workshop as you like at a time.
• If you have any questions about how to use this
  workshop or the individual pathways, feel free to
  ask your Site Champion.

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3
Evidence-Based Care Program

• These pathways have been developed as a part of
  the Evidence-Based Care Program, which is
  Schedule 6 in the agreement of the Grey Bruce
  Health Network.
• The intent is to develop regional pathways and
  other evidence-based tools that flow across all
  hospitals and community services in Grey and
  Bruce (including Grey Bruce Health Services,
  Hanover and District Hospital, South Bruce Grey
  Health Centre, Grey Bruce Health Unit and the
  Community Care Access Centre).
• It is hoped that these pathways will improve
• Coordination of care through more communication
  across professions
• Continuity of care, through increased linkages
  among hospitals and the CCAC
• Clinical outcomes, through increased usage of
  best practices and
• Patient satisfaction, through linked expectations
  and increased patient teaching at our agencies.

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4
Acute Coronary Syndromes (ACS)

• This pathway is for all patients with Acute
  Coronary Syndromes, including ST-Elevated
  Myocardial Infarction, Non-ST-Elevated Myocardial
  Infarction, and Unstable Angina.
• The pathway consists of 7 parts
• Clinical Practice Guideline
• Pre-Printed Orders
• Patient Pathway
• Community Resources Sheet and Heart and Stroke
  Education Materials
• Teaching Checklist
• Clinical Pathway
• Community Care Pathway Package

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5
Clinical Practice Guideline

• A guideline was created for this pathway based on
  the available evidence in literature for this
  pathway.
• This guideline summarizes the evidence used in
  the development of this pathway.
• It can be found with the electronic pathway
  materials on your unit.

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6
ACS Pre-Printed Orders

• There are two sets of orders for this pathway
  the general Acute Coronary Syndromes Orders, and
  the Thrombolytic Therapy Orders
• The Acute Coronary Syndromes Orders are used for
  those patients that do not fulfill the criteria
  for thrombolytic therapy, but have ACS.
• The Thrombolytic Therapy Orders are used for
  those patients that do fulfill the criteria for
  thrombolytic therapy.
• In addition, there is a Thrombolytic Therapy
  protocol and a Tirofiban protocol available if
  these therapies are used.

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7
Patient Materials

• This package has a patient pathway, which
  explains to the patient what is happening to them
  while in hospital.
• It should be given to the patient early in the
  hospital stay and used to explain the care to the
  patient.
• Also, there is a teaching checklist, which should
  be put on the chart and used to track what
  education has been done with the patient and what
  is left to cover before the patient is
  discharged. You should be familiar with these
  topics, if not you should look through the
  reference materials listed for each topic. (see
  sample)
• The reference materials for the teaching
  checklist are the Heart and Stroke materials
  Recovery Road, and other booklets as needed.
  There should be ample supply of these booklets in
  your hospital, if not, they can be ordered from
  the Heart and Stroke Foundation.
• There is also a smoking cessation algorithm to
  help you determine where the patient is at with
  regards to quitting smoking. There are two
  booklets available for those patients who are
  ready to quit, and for those who are not.
• A final piece that should be given to the patient
  is a Community Resources Sheet. It includes a
  list of resources available around the counties
  for the patient after hospital discharge. (see
  sample)

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8
ACS Clinical Pathway

• Take a look at the pathway by clicking here.
• The pathway is focused on a five day length of
  stay for MI patients, and a three day length of
  stay for unstable angina patients. It is divided
  into days, other than the first page, which is
  the first two hours in hospital.
• The first page is focused on the first two hours
  because these are the most crucial in the initial
  treatment of the patient.
• In these two hours, there are specific goals we
  are looking for. These are listed in the top two
  rows of the page, Performance Indicators. These
  indicators need to be ticked as met or not
  met.
• The rest of the page lists the tasks to be done
  in the first two hours.
• After the first two hours, the rest of the page
  is divided into days. Each day starts at the
  beginning of the day shift, and ends at the end
  of the night shift.

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9
ACS Clinical Pathway

• The Discharge Criteria should also be checked
  daily. If any of the criteria have been met,
  these should be initialed and dated.
• Once the Discharge Criteria have been met, the
  patient should be ready to go home.

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10
End of ACS Workshop

• This is the end of the general information for
  the ACS pathway.
• To get further information by trying the pathway
  on a sample patient, move to the Simulation
  portion of the ACS workshop.
• Test your knowledge of ACS Pathway by doing the
• ACS quiz.

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11
Simulation

• Try it!
• Nancy arrives in hospital with chest pain. Based
  on initial tests, she has no ST elevation. The
  looking at the results of initial testing, it
  looks like she has had a Non-ST Elevated MI. She
  then fits the criteria to be put on the ACS
  pathway - find the inclusion criteria on the
  first page of the pathway.
• The pathway should be started in Emergency, as
  this is where the care begins. If Nancy was
  directly admitted from the physicians office,
  the pathway can be started on the unit.
• The clinical pathway and teaching checklist goes
  on the chart, and the patient pathway and patient
  education materials are given to Nancy.
• Take a look at the clinical pathway. On the first
  page is a master signature sheet. Sign it, and
  then for the remainder of the pathway you can
  just initial as tasks are complete (if you have a
  Master Signature Sheet for your facility, this
  will not be on your pathway page).

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12
Simulation Contd

• There are also some basic instructions on the
  first page on how to use the pathway.
• Each page will need a patient ID sticker.
• Flip to the first page of the pathway, Admission
  Day First Two Hours
• On the first page of each pathway will be a
  section for comorbid conditions. Please list any
  conditions the patient has other than the MI,
  that may affect the care you are giving. This
  will help health records in coding Nancy
  appropriately.
• This page is used for the first two hours Nancy
  is in hospital. You will see a column on the
  right hand side write in todays date at the top
  (in some sites, this will be filled in for you).
  Below the date, write in the hours you will be
  caring for Nancy. You will then use this column
  to initial as each task on that page is
  completed. (see a sample page completed). You can
  use your corporate progress notes if you require
  further documentation.

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13
Simulation Contd

• The first two sections, on the left, are the
  performance indicators. Monitor these indicators,
  and input whether they were met or not met.
• The rest of the page, and going on to the back of
  the page, lists the tasks that should be
  completed during these two hours. For example,
  under assessments, Vitals should be taken
  frequently, including O2 Sats. Initial in the
  column to the right that corresponds to your
  shift as each task is completed.
• Some tasks are not appropriate for all patients
  or all time frames. In these cases, you can
  indicate an N/A and initial to show this. (see a
  sample page completed)
• Take a look back at the indicators. Lets assume
  that Nancy was not given a chewable ASA until the
  third hour of hospitalization, because the ER
  staff were too busy and couldnt get to it
  immediately. This needs to be inputted as not met
  to the right of the indicator.

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Simulation Contd

• Flip to the next page of the pathway, which is
  used for the remainder of the admission day,
  until the end of the night shift. It works the
  same as the first page, except is in effect
  longer, which is why there are more columns to
  initial in on the right hand side. Be sure to
  indicate the time you are caring for Nancy at the
  top of each column if it has not been entered for
  you.
• The sections are tasks that are to be completed
  for that day. Again, some tasks are not
  applicable to each patient, or to each shift. For
  example, if it is night shift, you will most
  likely not be teaching Nancy, so under
  Psychosocial Support/Education, you can indicate
  N/A and initial Review Patient Pathway and
  Start Teaching Checklist. (see a sample page
  completed)

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15
Simulation Contd

• On each day of all pathways, you will notice a
  referral to a Teaching Checklist and a Patient
  Pathway. Find this on the pathway.
• The Teaching Checklist should be on the chart and
  be filled in as topics are covered with Nancy.
  This way the next nurse on shift will know what
  has been covered and can continue down the list.
  The Patient Pathway should also be given to the
  patient. However, if it is too early and Nancy is
  not ready for education, as she is in too much
  pain and not ready for learning, indicate N/A and
  initial these tasks until she is ready for
  education.
• The Heart and Stroke Materials can be referenced
  to aid you in teaching. Also, the Patient Pathway
  should be referred to on a daily basis to help
  Nancy understand the plan of care. The smoking
  cessation algorithm will help you determine where
  the patient is at with regards to quitting, and
  there are two booklets you can give to the
  patients one for those who want to quit, and
  one for those who arent ready.

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16
Simulation Contd

• At the end of each day, in the Discharge Planning
  section (last section of each page), you will
  notice it says Assess Discharge Criteria Daily.
  This means you will need to flip to the Discharge
  Criteria, on a daily basis, at some point during
  the day, and check if any of these goals have
  been met. If they have, initial and date them.
  Once all of these criteria have been met, Nancy
  is ready to go home.
• Lets assume it is Day 4 of the pathway, and
  Nancy has now achieved all the Discharge
  Criteria. As soon as these criteria have been
  met, she can go home.
• If Nancy is transferred to another hospital or
  into CCAC care, there are instructions for this
  on the first page (or on the back of the
  discharge criteria, for SBGHC users). Make sure
  the proper materials get forwarded to the
  receiving hospital or the CCAC, so they can
  continue using the pathway.

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17
ACS Quiz

1. What are the inclusion/exclusion criteria for
   this pathway?
2. What are 2 different sets of orders for this
   pathway.
3. What are the protocols included in this package?
4. What patient education materials are used for
   this pathway?
5. What do you do with the teaching checklist?
6. What type of a pathway is this A) Day B) Phase ?

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Answers
18
Answers ACS Quiz

• What are the inclusion/exclusion criteria for
  this pathway? This pathway is applicable to those
  patients who have had a myocardial infarction,
  whether it is ST Elevated or Non-ST Elevated, or
  Unstable Angina.
• What are the 2 different sets of orders for this
  pathway? The ACS orders, and the Thrombolytic
  Therapy Orders
• What are the protocols included in this package?
  Thrombolytic Therapy, and Tirofiban for those
  sites that use this drug.
• What patient education materials are used for
  this pathway? There are Heart and Stroke
  Foundation booklets that can be used, the
  Recovery Road binder from the Heart and Stroke
  Foundation, the patient pathway, the smoking
  cessation algorithm and booklets, and the
  community resources sheet. All of these should be
  used in patient teaching.
• What do you do with the teaching checklist? This
  goes on the chart and is used to keep track of
  what education has been done. This sheet should
  be completed before the patient is discharged.
• What type of a pathway is this A) Day B) Phase ?
  This is a Day type pathway, meaning each page is
  one day, except for the first page which is for
  the first 2 hours the patient is in hospital.
• If you have had difficulty with any of these
  questions, go back through the material on this
  pathway and/or the general pathway information in
  this workshop, or ask your Site Champion any
  other questions you have.

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