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ISLHD POLICY

COVER SHEET

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NAME OF DOCUMENT

High Risk Cardiology or STEMI Patients - Transfer to Wollongong Hospital

TYPE OF DOCUMENT

Policy

DOCUMENT NUMBER

ISLHD CLIN PD 44

DATE OF PUBLICATION

April 2017

RISK RATING

Medium

REVIEW DATE

April 2020

FORMER REFERENCE(S)

Revision 1

EXECUTIVE SPONSOR or

EXECUTIVE CLINICAL SPONSOR

A/Prof Astin Lee- Director Cardiology ISLHD.

AUTHOR

Tony Tiberio-CNC Cardiac Assessment

[email protected]

Update

Marc Aquilina- Acting CNC Cardiac Assessment

KEY TERMS

STEMI

Cardiology

Transfer

SUMMARY

The purpose of this policy is to facilitate the safe and timely transfer of ST Elevation Myocardial Infarct and High Risk Acute Coronary Syndrome patients across the ISLHD (inclusive of Hospitals with and without emergency Departments) that require further assessment and management within a hospital capable of providing specialised diagnostic and interventional cardiology services

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mailto:[email protected]

INTERNAL ONLY ISLHD POLICY


ISLHD CLIN PD 44

Revision 2 Trim No. DT12/8263 April 2017 Page 1 of 15

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1. PURPOSE & SCOPE

The purpose of this policy is to facilitate the safe and timely transfer of ST Elevation Myocardial Infarct patients and High Risk Acute Coronary Syndrome patients across the ISLHD (inclusive of Hospitals with and without emergency Departments) that require further assessment and management within a hospital capable of providing specialised diagnostic and interventional cardiology services. This includes:

All High Risk Cardiology patients and STEMI patients requiring transfer from

Coledale, Bulli, Port Kembla and Shellharbour Hospitals

Post-lysis STEMI patients requiring transfer from Bulli, Shellharbour and Shoalhaven

or Milton Ulladulla Hospitals.

These patients must be transferred to 2 sequestered Cardiology beds located at Wollongong Hospital that will facilitate timely access to effective and appropriate diagnostic and interventional services.

Patients presenting to BUPCC or Shellharbour ED deemed suitable for urgent transfer for urgent angiogram / primary PCI please refer to ISLHD CLIN PROC 149 STEMI-Management of STEMI at Bulli Urgent Primary Care Centre and Shellharbour Hospital Emergency Department.

Patients presenting to Milton Ulladulla Hospital at times when there is no medical coverage on site please refer CARD CLIN PROC 21-Nurse Administered Thrombolysis (NAT) Protocol for ST Elevation Myocardial Infarction(STEMI)-Milton Ulladulla Hospital.

Patients who are considered inappropriate for coronary intervention after discussion with Physician/Cardiologist on call may be managed on site in accordance with local policies and guidelines, therefore not requiring transfer to TWH.

2. RESPONSIBILITIES

Clinical Director Medicine Nursing Co-Director; Medicine and Emergency Director of Emergency ISLHD Director of Cardiology ISLHD TWH Cardiologists SHH Physicians SDMH Cardiologists SDMH Physicians/ Medical and ICU Registrars TWH Manager and DON



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SHH, SDMH and MUH Manager and DON TWH, SHH, SDMH, BDH, CDH and MUH Bed managers Medical Officers SHH, SDMH and MUH NUM ED All SHH, SDMH and MUH ED staff SDMH Director and NUM ICU

3. REFERENCES

1. Inter-facility Transfer Process for Adults Requiring Specialist Care (2011).NSW Health Policy Directive PD2011_031SOUTHERN HOSPITAL NETWORK BUSINESS RULE. Transport Booking for Inpatients within the Southern Hospital Network (SHN) May 2011

2. NSW HEALTH POLICY PD2011_037 NSW CHEST PAIN PATHWAY JUNE 2011

3. National Heart Foundation of Australia &Cardiac Society of Australia and New Zealand Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung and Circulation Vol.25 No.9 (September 2016)

4. Indications for transfer to higher level care; Southern Hospital Network-Clinical Practice Improvement Unit: June 2009, Version 2

5. Cardiac Monitoring in Adult Cardiac Patients in Public Hospitals in NSW (2016). NSW Health Policy Directive GL2016_019

6. Acute Coronary Syndrome Guidelines Working Group (2006). Guidelines for the management of acute coronary syndromes 2006. Medical Journal of Australia, 184(8), S1-S30.

7. PD2015_044. Nurse Administered Thrombolysis(NAT) Protocol for ST Elevation Myocardial Infarction (STEMI) (2016)

8. ILSLHD CLIN PROC 149. STEMI Non Primary PCI SITE: Management of STEMI at Bulli Urgent Primary Care Centre and Shellharbour Emergency Department. (2016)

4. DEFINITIONS

TWH Wollongong Hospital

SHH Shellharbour Hospital

BDH Bulli District Hospital

BUPCC Bulli Urgent Primary Care Centre

CDH Coledale District Hospital

SDMH Shoalhaven District Memorial Hospital

MUH Milton Ulladulla Hospital

ED Emergency Department

CCU Coronary Care Unit

SACCU Sub Acute Coronary Care Unit



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NUM Nurse Unit Manager

STEMI ST Elevation Myocardial Infarction

NSTEMI Non ST Elevation Myocardial Infarction

ACS Acute Coronary Syndrome

PCI Percutaneous Coronary Intervention

SACQ ISLHD Acute Cardiology Quarantined beds

I/C In Charge

5. PROCEDURE

5.1 STEMI PATIENT TRANSFERS – Applies to all ISLHD Hospitals

All post-lysis STEMI patients must be transferred to TWH irrespective of bed

availability at TWH.

STEMI patients presenting at SDMH or MUH should receive thrombolytic therapy

unless contraindicated.

STEMI patients presenting to BUPCC or SHH may be transferred for urgent

angiography/ primary PCI if patient can be transferred out of the department within 30

mins of diagnostic ECG. If this time frame cannot be achieved the patient should

receive thrombolytic therapy unless contraindicated- refer to ISLHD CLIN PROC 149

STEMI-Management of STEMI at Bulli Urgent Primary Care Centre and Shellharbour

Hospital Emergency Department.

Only the clinical need for surgical facilities should influence the decision to transfer

to alternate site after discussion with the cardiologist accepting care at TWH.

5.1.1 STEMI Criteria



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5.2 STEMI Treatment Protocol Non Primary PCI Site

5.2.1 MEDICATION

All patients who satisfy the STEMI criteria and DO NOT have contraindications or cautions for thrombolysis will receive the following;

Aspirin 300mg

Clopidogrel-age adjusted dose, see 5.2.2 and appendix table 1. (Patients presenting to BUPCC or SHH will receive 300mg of clopidogrel as per ISLHD CLIN PROC 149 STEMI Non Primary PCI Site: Management of STEMI at Bulli Urgent Primary Care Centre and Shellharbour Hospital Emergency Department)

Tenecteplase age and weight adjusted dose See 5.2.2 and appendix Table 2. Enoxaparin age and weight adjusted dose see 5.2.2 and appendix tables 3.

5.2.2 Medication Overview (see appendix table 1-5 for more information and doses)

5.3 Post Thrombolysis Management

Arrange for transfer to WH.

All patients to be monitored as per NSW Health Policy Directive-Cardiac Monitoring in Adult Cardiac Patients in Public Hospitals in NSW (PD 2008_055).

Patient’s vital signs to be attended and documented on the NSW Health Standard Adult General Observations Chart every 15 mins/ prn for at least 60 mins post thrombolysis then every 60 mins/prn till transfer.



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Vital signs include: respiratory rate, SpO2, pulse rate and rhythm, blood pressure, neurological status, pain score and temperature.

Assess for signs and symptoms of adverse events such as: allergic reaction, bleeding, haemorrhage of any kind, stroke and reperfusion arrhythmias.

12 lead ECG to be recorded at 60 (and 90 minutes if transfer to TWH has not occurred) post thrombolysis and reviewed by a medical officer. ECG should be recorded and interpreted prior to transfer.

Documentation, management and escalation of any deterioration as per NSW Health Policy Directive –Recognition and Management of Patients who are Clinically Deteriorating (PD2013_049) and ISLHD CLIN PD 52 Management of Clinical Deterioration : Between the Flags (BTF) –Patient with Acute Condition for Escalation (PACE).

6. HIGH RISK CARDIOLOGY PATIENT TRANSFERS – Applies to all ISLHD Hospitals without dedicated Cardiac monitoring facilities

Only patients meeting the High Risk ACS criteria or those who will likely require cardiac diagnostics and treatment will be transferred to Wollongong Hospital.

6.1 ACS Risk Stratification Criteria

7. CARDIOLOGY PATIENT TRANSFERS – Applies to all ISLHD Hospitals. (See flowchart appendix 6.)

http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_049.pdf



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7.1 STEMI or HIGH RISK ACUTE CORONARY SYNDROME

1. Patient is identified as per NSW Health Chest Pain Pathway as STEMI or HIGH RISK Acute Coronary Syndrome

2. Senior ED doctor / physician or medical registrar delegate at the referring site is to

contact the TWH Cardiologist on-call regarding patient’s condition and suitability for transfer. SDMH high risk ACS patients that are hemodynamically stable/ resolved CP may be admitted to SDMH ICU while awaiting angiogram.

3. It is the responsibility of the Senior ED doctor / physician or medical registrar delegate

at the site to communicate to the referring site Bed manager/Clinical Nurse Manager/in charge Nurse that patient is for transfer.

4. The referring site Bed Manager is responsible for notification of patient for transfer to

TWH Bed Manager. 5. The TWH Bed Manager is responsible for ensuring the patient is accepted within

benchmarked timeframe of no longer than 4 hours.

6. The senior doctor managing the patient will determine the mode of transport required (Hospital transport with Nurse Escort, ambulance service or MRU) based on the patient’s condition and acuity.

7. It is the responsibility of the nursing staff at the referring site to handover to the NUM or

delegate at Wollongong Hospital Cardiology of impending transfer and brief ISBAR handover of the patient given.

NUM 4222 5308

CCU 4222 5250

SACCU 4222 5424

8. All STEMI and High Risk ACS patients to be monitored as per NSW Health cardiac monitoring guidelines.

Minimum Standard Patient Escort Guidelines

i. Require an appropriately trained* escort and defibrillator for all transfers

(*appropriately trained means a Registered Nurse or Ambulance Paramedic who can interpret a 3 Lead ECG and defibrillate if necessary)

9. The TWH Cardiologist on-call should be contacted by the referring senior ED doctor/

Medical Registrar prior to transfer should there be a concern about changes/ deterioration in the patient’s clinical condition.



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10. A copy of all medical records to accompany patients transferred to TWH if not scanned

in the electronic medical record.

11. On arrival to the TWH the patient must be reviewed as per the following

I. During work hours (8am to 5pm)- Cardiology Advanced Trainee at TWH is to be notified by nursing staff of patient arrival and immediate review completed

II. From 5pm to 8am on weekdays and at all hours on weekends, the afterhours medical registrar reviews the patient on arrival.

12. Patient flow managers at all sites are responsible for ensuring patient transfers occur within the specified timeframe (immediate for STEMI and 4 hours for other ACS) after clinical decisions for transfer have been made.

7.2 INTERMEDIATE RISK AND OTHER CARDIOLOGY PATIENTS

1. All Intermediate Risk ACS patients to be admitted at peripheral sites are to follow the

NSW Health Chest Pain Pathway management and treatment plan. 2. Intermediate risk patients, who have gone through the Intermediate risk stratification at

peripheral sites and are, found to have reversible ischemia on Myocardial perfusion scan or exercise stress test, should then be referred to the cardiologist on-call at TWH that day and transferred as a high risk patient for further invasive diagnostic / interventional procedures.

3. Should a VMO/Staff Specialist at a peripheral hospital wish to have a cardiology patient

admitted under a TWH Cardiologist and transferred to TWH at any stage, the cardiologist on-call at TWH should be contacted directly and arrangements made for the transfer of the patient.

8. EXPECTED OUTCOME

Patients presenting for emergency investigation and/or management of cardiac conditions will receive optimal care and access to diagnostics/therapeutics in a timely manner.

9. CONFLICT RESOLUTION PROCESS

The following resolution process will be implemented when a dispute on patient management occurs or access to an appropriate bed at Wollongong is refused. 1. All STEMI patients are accepted and transferred as per policy (there is no negotiation).



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2. If a dispute occurs in relation to a High Risk Acute Coronary Syndrome patient transfer the site registrar/medical officer escalates to the site VMO/Staff Specialist on call to negotiate with the on call Cardiologist at TWH.

3. The on call Cardiologist at TWH will negotiate with the site VMO/Staff Specialist On call regarding the management of the transfer to TWH.

4. The final decision for the patient’s management will be the responsibility of these senior clinicians.

10. KEY PERFORMANCE INDICATORS

Average length of stay of patients in Emergency Department prior to transfer for

cardiology admission at TWH

Time to diagnostics for ISLHD ED patients

ALOS in ISLHD Cardiology Beds

Cardiology access

Utilisation by appropriate patients

11. ADMISSION CRITERIA (refer to NSW HEALTH POLICY PD2011_037 NSW CHEST PAIN PATHWAY).

Patients suitable for transfer to TWH must meet the following criteria:

HIGH RISK ACS or STEMI +/- thrombolysis or urgent angiography/ primary PCI(SHH/ BUPCC), and accepted by Cardiologist on-call at TWH

Or

Cardiology patients requiring high level expert care not routinely available at a peripheral hospital and accepted by Cardiologist on-call

11.1 Exclusions

1. Low to Intermediate Risk chest pain ACS Patients (refer to NSW HEALTH POLICY PD2011_037

NSW CHEST PAIN PATHWAY).

2. Clear evidence of a non-cardiac cause of chest pain.

12. DOCUMENTATION

NSW HEALTH POLICY PD2011_037 NSW CHEST PAIN PATHWAY Electronic Medical Record







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13. REVISION & APPROVAL HISTORY

Date Revision No. Author and Approval

November 2012

0 Tony Tiberio – CNC Cardiology Assessment SHN

Frank Testa NUM ED SHH

Dr Astin Lee Dir Cardiology Wollongong & Shellharbour Hospitals

Dr Thomas Carrigan Director of Emergency SHN

Dr Jones Consultant Physician Wollongong & Shellharbour

Dr Dunn Wollongong & Shellharbour

Dr Harvey Wollongong & Shellharbour

Dr Poulos Wollongong & Shellharbour

Alex Smeaton- A/SHN Patient Flow Manager

Dr Mark Ryan Consultant Cardiologist SDMH

Rob Jarvis Cardiac Assessment Nurse SDMH

Marc Aquilina CNC Coronary Care Unit TWH

Katherine Higgins Clinical Nurse Educator SDMH

Stephanie Barrett – NUM Wollongong Hospital Cardiology

Approved for publication by ISLHD Executive Clinical Management Committee

June 2014

1 Inclusion of Medications

Alastair Riddell Chief Pharmacist Shellharbour Hospital

Eyra Munzner Pharmacist Shellharbour Hospital


A/Prof Astin Lee Director Cardiology Wollongong & Shellharbour Hospitals

Rob Jarvis Cardiac Assessment Nurse SDMH

Tony Tiberio – CNC Cardiology Assessment ISLHD

Approved Drug and Therapeutics Committee

Dr Roman Jaworski , Chairman

April

2017

2 Updated STEMI criteria, age and weight adjusted doses for Tenecteplase and Clopidogrel.

Author: Marc Aquilina ISLHD Cardiac Assessment CNC

Approval

CARDIOLOGY:

A/Prof Astin Lee ISLHD Director Cardiology


Susan Worthy Nursing Lead Cardiology

ED

Thomas Carrigan ISLHD Area Director Division of Emergency Medicine

Peter Smith Director SHH ED

Pharmacy



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Erica Wales Pharmacist

Educators

Kate Ruperto ISLHD ED NE

Cardiac Assessment Nurses

Lisa Chesters SDMH

Lilli Anderson SHH

Committee approval

TWH Cardiology Business Meeting 14/10/2016

SDMH Cardiology Meeting Oct 2016

Drug and Therapeutics Committee 26/10/2016

Draft for comment Nov 2016

Published April 2017.



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14. Appendix 1. ASPIRIN and CLOPIDOGREL

Table 1 Medication: aspirin and clopidogrel

Age adjusted dose. Route: ORAL

PATIENT AGE

18 -74 years 75 years and over

Aspirin 300mg if not already given 300mg if not already given

Clopidogrel 300mg (4 x 75mgs tablets OR 1 x 300mg tablet)

75 mg (1 x 75mg tablet)

15. Appendix 2 TENECTEPLASE

Table 2 Medication:-tenecteplase.

Weight and age adjusted dose. Route: IV

PATIENT AGE

18 -74 years 75 years and over

Weight(kg) Dose (mg) Volume(mL) Dose (mg) Volume (mL)

Less than 60 30 6 15 3

60-69 35 7 17.5 3.5

70-79 40 8 20 4

80-89 45 9 22.5 4.5

90kg and above 50 10 25 5

Directions:

1. Accurately determine patients weight 2. Tightly attach prefilled syringe to the vial adaptor 3. Penetrate vial with vial adapter (prefilled syringe attached) 4. Slowly inject water for injection into vial to avoid foaming 5. Reconstitute contents of vial by swirling gently to reconstitute – do not shake 6. Withdraw required dose 7. Administer dose IV over 10seconds



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16. Appendix 3. ENOXAPARIN

Table 3 Medication: enoxaparin

Route: IV and SC

PATIENT AGE Route Dose

18 - 74 years

IV

Stat 30mg IV BOLUS administered immediately after tenecteplase USE: 60mg graduated prefilled syringe. Expel half dose (30mg) prior to administration. Note: IV line with needless and needle access port (see Appendix 5) to be used. To prepare line; prime prior to use and flush after medication administration with normal saline.

SC 1mg/kg (up to max 100mg) subcutaneously administered within 15 minutes of IV dose see Appendix 4 (column 1)

75 years and over

IV NO IV BOLUS

SC 0.75mg/kg (up to max 100mg) subcutaneously see Appendix 4 (column 2)

Caution: CHECK for allergies and / or contraindications Unfractionated heparin Acute Coronary Syndrome (ACS) protocol may be considered if the patient has allergies and / or contraindications to Enoxaparin / or Enoxaparin unavailable.(see Intravenous Heparin Record for further details)



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17. Appendix 4. ENOXAPARIN subcutaneous doses.

Table 4 Medication: enoxaparin

Age and weight adjusted dose ROUTE: SC

USE: Graduated pre-filled syringes only (60,80 or 100mg)

Calculate dose using table below: 1. Select patient weight in left hand column 2. Select patient’s age 18 - 74 years or 75 years and over

Column 1 Column 2

Patient age 18 - 74 years Patient age 75 years and over

Timing 15mins after IV enoxaparin 15mins after tenecteplase

Weight kg Dose: 1mg/kg

(up to max 100mg)

Dose:0.75mg/kg

(up to max 100mg)

Volume (mL) Volume (mL) (rounded to measureable dose)

≤ 40 kg 0.4 0.3

45 0.45 0.35

50 0.5 0.35

55 0.55 0.4

60 0.6 0.45

65 0.65 0.5

70 0.7 0.5

75 0.75 0.55

80 0.8 0.6

85 0.85 0.65

90 0.9 0.65

95 0.95 0.7

100 1 0.75

105 1 0.8

110 1 0.8

115 1 0.85

120 1 0.9

125 1 0.95

> 130 kg 1 1



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18. Appendix 5. IV LINE

Needless access port

Needle access port



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19. Appendix 6: Cardiology Patient Transfer Flow Chart for Patient Admission to Acute Cardiology Quarantined beds 1ALL ISLHD HOSPITALS:

Peripheral Hospital Site

1. Patient c/o chest Pain 2. ACS pathway initiated

Initial Assessment

Patient meets STEMI/High Risk ACS Criteria

1. Medical officer to contact Cardiologist on call for

admissions at TWH

2. Patient accepted by Cardiologist at TWH

3. Peripheral site Patient Flow Manager to contact TWH

Patient Flow Manager

TWH patient Flow Manager responsible for accepting patient to Wollongong

Hospital cardiology bed within 4 hours

Transfer arranged by

Peripheral site

Patient Transferred to TWH

TWH Patient Flow

Manager to notify NUM

CCU of transfer

(#5308)

OR

RN I/C After Hours

(#5250)

Admit to Cardiology

On arrival to CCU RN on duty to contact Advanced Trainee to review patient Mon-Fri business hours

OR A/H contact Med Reg on call

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