1. © 2004-2007 Grey Bruce Health Network 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. © 2004-2007 Grey Bruce Health Network 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.underlined like this 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. Back to Start of Workshop NextBack

3. © 2004-2007 Grey Bruce Health Network 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. Back to Start of Workshop NextBack

4. © 2004-2007 Grey Bruce Health Network 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 Back to Start of Workshop Back to beginning of section NextBack

5. © 2004-2007 Grey Bruce Health Network 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. Back to Start of Workshop Back to beginning of section NextBack

6. © 2004-2007 Grey Bruce Health Network There are two sets of orders for this pathway – the general Acute Coronary Syndromes Orders, and the Thrombolytic Therapy OrdersAcute Coronary Syndromes OrdersThrombolytic 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. ACS Pre-Printed Orders Back to Start of Workshop Back to beginning of section NextBack

7. © 2004-2007 Grey Bruce Health Network Patient Materials This package has a patient pathway, which explains to the patient what is happening to them while in hospital.patient pathway 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)teaching checklist(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.smoking cessation algorithm 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)(see sample) Back to Start of Workshop Back to beginning of section NextBack

8. © 2004-2007 Grey Bruce Health Network ACS Clinical Pathway Take a look at the pathway by clicking here.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. Back to Start of Workshop Back to beginning of section NextBack

9. © 2004-2007 Grey Bruce Health Network 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.Discharge Criteria Once the Discharge Criteria have been met, the patient should be ready to go home. Back to Start of Workshop Back to beginning of section NextBack

10. © 2004-2007 Grey Bruce Health Network 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.Simulation Test your knowledge of ACS Pathway by doing the ACS quiz. Back to Start of Workshop NextBack Back to beginning of section

11. © 2004-2007 Grey Bruce Health Network 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.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 physician’s 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.teaching checklist 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). Back to Start of Workshop Back to beginning of section NextBack

12. © 2004-2007 Grey Bruce Health Network Simulation Cont’d 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 today’s 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.(see a sample page completed). Back to Start of Workshop NextBack Back to beginning of section

13. © 2004-2007 Grey Bruce Health Network Simulation Cont’d 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)(see a sample page completed) Take a look back at the indicators. Let’s assume that Nancy was not given a chewable ASA until the third hour of hospitalization, because the ER staff were too busy and couldn’t get to it immediately. This needs to be inputted as not met to the right of the indicator. Back to Start of Workshop NextBack Back to beginning of section

14. © 2004-2007 Grey Bruce Health Network Simulation Cont’d 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)(see a sample page completed) Back to Start of Workshop NextBack Back to beginning of section

15. © 2004-2007 Grey Bruce Health Network Simulation Cont’d 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.Teaching Checklist Patient Pathway 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 aren’t ready. Back to Start of Workshop NextBack Back to beginning of section

16. © 2004-2007 Grey Bruce Health Network Simulation Cont’d 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. Let’s 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. Back to Start of Workshop NextBack Back to beginning of section

17. © 2004-2007 Grey Bruce Health Network 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 ? Back to Start of Workshop Back Answers

18. © 2004-2007 Grey Bruce Health Network Answers: ACS Quiz 1. 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. 2. What are the 2 different sets of orders for this pathway? The ACS orders, and the Thrombolytic Therapy Orders 3. What are the protocols included in this package? Thrombolytic Therapy, and Tirofiban for those sites that use this drug. 4. 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. 5. 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. 6. 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. Back to Start of Workshop Back