open heart surgery clinical pathway - saswh instructor semi secure area/rqhr... · open heart...

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RQHR 746 (04/11)

Open Heart Surgery Clinical Pathway Inclusion Criteria: Any patient having open heart surgery whereby the attending surgeon has indicated the initiation of this

pathway.

Exclusion Criteria: Complicated medical condition(s), the development of post-op complications where the components of care listed on the pathway no longer suit the needs of care for the patient.

Patient History: LVEF% (circle): <20, 30, 40, 50, 60, 70+ Unknown

HTN Dyslipidemia PVD Cerebrovascular disease Obesity COPD Family History CAD Diabetes (circle one) Type I Type II Chronic Renal Failure CHF AF/Arrhythmia Previous MI Permanent Pacemaker Rheumatic Fever Previous CABG Previous Valve Surgery Internal Cardiac Defibrillator Stent Percutaneous Coronary Intervention (PCI) Other __________________________________ Smoker: Previous Current

Pneumococcal Vaccine previously given: Yes No Unknown

Target discharge date: (5 days after surgery) ________________ LPN/RN Initial_________

Clinical Pathways use the current best evidence gained from systemic reviews, as well as input from multidisciplinary teams, to outline the optimal course of care for all patients who have a specific condition or who are undergoing a specific procedure.

How to use the Clinical Pathway:

Place the Pathway on the front of the chart.

Document on the flow sheets, vital signs sheet and fluid balance sheet as per hospital protocol.

Document variances, comments for components of care not met, and abnormal assessment findings on the Health Care Team Progress Notes/Variance Tracking Record sheet.

Key outcomes/indicators for Pathway evaluation are in bold text.

Each discipline is responsible for initiating components of care that they are responsible for.

When a patient is transferred to local hospital or community service, send required documentation and indicate on the interagencyreferral where the patient is on the Pathway.

Reason Off Pathway - The pathway may be discontinued when the patient’s condition changes to the extent that the pathway can no longer be followed. Attending physician must be notified. Reason off pathway and action taken must be documented.

Open Heart Surgery Discharge Outcomes

▪ Weight at or progressing to pre-op weight.▪ Hemodynamic stability▪ All wounds are clean and dry▪ Respirations easy at rest and O₂ saturation on room air are normal for patient ▪ Patient initiates deep breathing/coughing exercises▪ Patient's activity is returning to normal▪ Patient verbalizes confidence with medications▪ Patient/family verbalize understanding of discharge education, follow-up care & appointments▪ Community supports in place to allow patient/family to manage safely at home

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Documentation Legend

NA = not applicable Initial = done or completed X = not done, not completed, requires further documentation ** = key outcomes

Open Heart Surgery Clinical Pathway Pre-SurgeryPreparation (Inpatient or Outpatient)

Component of Care

PAC Date:_______________ (for PAC) Surgery Date:__________________ Unit Tests

____

12 lead ECG – within 7 days_______ CXR PA & lateral – within 1 month _________ CBC ____________ Glucose – within 7 days ___________ Renal Panel___________ Calcium ___________ Magnesium__________ Phosphorus __________ Fasting Lipid Profile – within 2 months _________ PT / aPTT__________ Arterial Blood Gases_________ Flow Volume Loop_________ Group and crossmatch for 4 units packed cells_________ (expiry date:____________)

Urine for C&S________ Nasal Swab_________ Other _____________________________________________________________ DATE

____

Consults / Referrals ____ Completed: Cardiology Anaesthesia Other__________________________________________________________ ________

__________

Assessments / Treatments

______________________________

History and Physical or referral letter and consent from surgeon's office Old chart of past hospital admissions Vital Signs (See flow sheet) Height and weight measured and recorded Admission assessment and history completed Radial Artery identified: Rt. Lt. Both

________________

________________________

__________

_______________

Activity / Rest _____ No restrictions unless otherwise specified ________ _____

Medications ____________________

Continue on current meds including ASA unless otherwise indicated by MD. Discontinue Warfarin 5 days pre-operatively Discontinue all herbals and NSAIDS 7 days pre-operatively Mupirocin cream to nares initiated for nasal swab results positive for Staph. aureus

________________________

_______________

Nutrition ____ NPO after midnight prior to surgery – discussed with patient ________ _____

Teaching / Discharge Planning

____________________

_____

__________ _______________

Patient/family educated re: expected LOS, details of pre and post op period Breathing & ankle exercises reviewed with patient Videos viewed Confirm patient has received “Open Heart Surgery: What You Need to Know” booklet (CEAC 590) Patient Pathway (p.34-35) of “Open Heart Surgery: What you need to Know” reviewed with patient/family Chlorhexidine skin preparation discussed with patient Oral care discussed with patient Chlorhexidine oral rinse discussed with patient Patient given instructions of arrival time to DAS at_______________ Reinforce with patient/family discharge is planned for 5 days post-operative.

________________________________

________

________________________

________

____________________

_____

_______________

_____Desired Outcomes RN/LPN Initial

_____

_______________

_____

Patient/family verbalizes understanding of expected patient progress

Key Outcomes:Consent signed** Consults completed** Tests initiated from PAC or completed while on unit**

________

________________

________

_____

_______________

_____

Reason off Path and Action

If Key Outcomes (**) Not Met, Contact Appropriate Physician

Guidelines only: Modify according to the individual patient's needs

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RQHR 746 (04/11)



Open Heart Surgery Clinical Pathway

Component of Care D N Pre-Surgery Day for Open Heart Surgery – IP

Date: _______________

Tests

____ ____

Refer to pre-operative tests on Pre-Admission Clinic / Inpatient Day of pathway.Accuchecks qid if diabetic

Consults / Referrals Refer to pre-operative consults / referrals on PAC / Inpatient Day of pathway.

Assessments /Treatments

_______________

____________

Assess for chest pain or cardiac symptoms Treat & report chest pain or cardiac symptoms Vital Signs as per unit protocol (See flow sheet)

Activity / Rest ________

________

Self care No restrictions unless otherwise specified

Medications ____ ____ Medications as ordered

Nutrition ____ ____ Continue current diet


Refer to pre-operative Teaching / Discharge Planning on PAC / Inpatient Day f pathway o

Desired Outcomes RN/LPN Initial

__________

____

________

____

Patient experiencing no chest pain Vital signs stable

Use this pre-surgery day of the pathway for daily care of inpatients waiting to have open heart surgery. Document pre-operative preparation on the Pre-Admission Clinic / Inpatient Day of the pathway.

Guidelines only: Modify according to the individual patient's needs

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Health Care Team Progress Notes/Variance Tracking Record

Date/ Time

PARAMETER OF CARE

ASSESSMENTS, INTERVENTIONS, EVALUATIONS

Limb Edema Scale: degree of pitting

0 - None

+1 – Trace no visible distortion disappears rapidly

+2 – Moderate no visible distortion

disappears in 10-15 seconds

+3 – Deep visible change in limb

contour persists >1 minute

+4 – Very Deep grossly distorted limb persists 3 – 5 minutes

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Date/ Time

PARAMETER OF CARE



0 - None







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RQHR 746 (04/11)



Open Heart Surgery Clinical Pathway Presurgery / Intraoperative Day of Surgery

Component of Care DAS /

Unit OR

Date:__________________ DAS Arrival Time:___________ Tests _____

__________

Pre-operative checklist complete Operating Room: Verify presence of angiogram CD Verify blood group and cross match present in OR


_____

______________________________ ____

_____

_____

_______________

Inform attending surgeon if patient has elevated temperature > 38º or new neurological symptoms preoperative. Vital Signs (See flow sheet) Clip hair the morning of surgery as per hair removal protocol (time:_______________) Pre-op chlorhexidine skin preparation completed a.m. of surgery, post hair clipping Chlorhexidine 0.12% oral rinse completed a.m. of surgery Start IV as ordered O₂ @ 3 L/min. per nasal prongs 2 hours pre-op

Operating Room: OR time < 5 hours Yes No Pump time < 100 minutes Yes No Body temperature on transfer to ICU________ Procedure: On pump CABG Off pump CABG Aneurysm Repair ASD Bentall Procedure Other_____________________ Assist Device (LV) Pacing Wires X _____ Donor Graft: Radial Artery L R Mammary Artery Saphenous Vein Valve Replaced: Aortic Mitral Tricuspid Valve Implant: Tissue Mechanical Valve repair only

Activity / Rest _____ Restricted after pre-operative medications given

Medications _______________

_____

_____

__________

_____

_____

Pre-op medications given with sips water only Verify warfarin discontinued for previous 5 days. Inform surgeon if not discontinued. Verify herbal products & NSAIDS discontinued for previous 7 days. Inform surgeon if not discontinued Verify Mupirocin ointment started for staph aureus positive nare swabs at least 24 hours prior to surgery. Inform surgeon if not. Pre-op antibiotics as ordered: Cefazolin 2g labeled with patient’s name and sent with

patient to OR holding Vancomycin 1g started on call to OR ( to be infused over 1

hour)

Nutrition / Elimination

_____

NPO since midnight before surgery


_____ _____ Reinforce pre-op teaching

Desired Outcomes RN/LPN Initial

__________

__________

_____

__________

_____

Patient verbalizes understanding of pathway Patient transferred to Operating Room / Holding Area via stretcher @ ___________(time) Key Outcomes: Patient and family pre-op education complete** Patient's preparation complete for surgery**

Operating Room: Pre-op teaching reinforced Patient progresses through surgery and transferred to SICU**

Reason off Path and Action

If Key Outcomes (**) Not Met, Contact Appropriate Physician.

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RQHR 746 (04/11)



Open Heart Surgery Clinical Pathway Day One Post-Op Pathway

SICU Discharge Summary

Post Surgery ICU Admitting Date__________________ Time_______________

Post Surgery ICU Discharge Date_________________ Time_______________

How to use the OHS Clinical Pathway Discharge Summary

This patient is on the Open Heart Surgery Clinical Pathway. The pathway provides a guide to treatment

protocol based on the best clinical evidence available and best practice standards.

Although the pathway will not be used as core documentation in the SICU, it is imperative that the

SICU Discharge Summary be completed before transferring the patient to the step down unit.

Document variances, comments for indicators not met, and abnormal assessment findings on the

Health Care Team Progress Notes/Variance Tracking Record sheet located on the back of this page.

For variance reporting, include nursing observations and assessment rather than medical diagnosis.

Refer to the Documentation Legend at the top of the page for correct coding.

Legend Parameters of Care Continued ventilatory support was necessary for an extended period of time (> 18 hrs). Extubated: Date__________________ Time_______________ IntraAortic Ballon Pump (IABP) Duration___________________ Return to Operating Room Evidence of ischemia / infarct on post-operative ECG SICU Desired OutcomesPatient receiving antiplatelet therapy First dose given: Time______ Date________ Patient receiving oral beta blocker First dose given: Time______ Date________ Mediastinal tubes removed Adequate urine output Pain well controlled Patient dangled Patient comfort levels allow effective deep breathing and coughing Key OutcomesPatient is hemodynamically stable** (SBP>90 or no less than 20% of baseline, HR>50 unless paced, T>36.0)Patient weaned off inotropes** Respiratory status stable** (SpO2 >92%)Patient demonstrates appropriate neurological function** Pulmonary artery catheter discontinued** Arterial line discontinued**

______

If Key Outcomes (**) Met Patient Is Transferred To ST. Advance To Day 1 Post-Op Pathway,

SICU RN Initials

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RQHR 746 (04/11)



Open Heart Surgery Clinical PathwayComponents of Care D N Day 1 Post-Op Pathway

Date:___________________ Transfer Time_____________ Tests _____

__________

_____

__________

CXR ECG CBC Renal Panel, Mg, Ca, PO4 , Albumin PT/ INR Other _____________________________________________

Results of tests reported within normal limits Accuchecks qid if diabetic

Consults / Referrals ____ ____ Completed: Dietitian SWADD Physiotherapy Other__________________________________________


__________________________________________________

__________________________________________________

Review most recent CXR report for pleural effusion / atelectasis Titrate oxygen to SpO₂ > 92% while at rest Vital signs per unit standard ECG monitoring Verify Pacing wires grounded per protocol Patent peripheral IV in place Introducer discontinued Foley catheter discontinuedDeep breathing and coughing exercises q1h while awake Change dressings od & prn or if compression dressing ordered, change q3days &prn

_____ Daily weight in a.m. Activity / Rest _____ Up in chair for meals tid

_______________

_______________

Up in room with assist Progress to ambulation in hallway Keep SpO₂ >90% while ambulating

Medications __________

__________

Administer medications as ordered Analgesic / antiemetic as ordered

Nutrition _____ _____ Increase cardiac diet as tolerated

Elimination _____ _____ Initiate bowel care as needed

Teaching / Discharge/ Planning

__________ _____

Teach patient proper body mechanics for getting out of bed Review discharge concerns with patient and family Patient/family start planning for transportation home and home support if needed

Desired Outcome _____ Weight decreasing to pre-operative level

RN/LPN Initial

_____

_______________

_____

_____

_______________

_____

Afebrile

Key Outcomes:Hemodynamically stable** Respiratory status satisfactory** Pain well controlled**

Reason Off Path and Action

If Key Outcomes (**) Met, Advance To Day 2 Post-Op Pathway.

If Not, Repeat Day 1 Post-Op Pathway.

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Date/ Time

PARAMETER OF CARE



0 - None







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PARAMETER OF CARE



0 - None







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RQHR 746 (04/11)



Open Heart Surgery Clinical Pathway Components of Care D N Day 2 Post-Op Pathway

Date:___________________ Transfer Time_____________ Tests ____

________

____

________

CXR ECG CBC Renal Panel, Mg, Ca, PO4, Albumin PT / INR Other___________________________________________


Consults / Referrals ____ _____ Completed: Dietitian SWADD Physiotherapy Other___________________________________________


_____________________________________________

_____________________________________________

Vital signs as per unit standard Titrate oxygen to SpO₂ > 92% while at rest Patent peripheral IV in place ECG monitoring Verify Pacing wires grounded Foley catheter discontinued Introducer discontinued Deep breathing and coughing exercises q1h while awake Incisions: Dressing change od & prn Open to air 48 hours post op if not draining

compression dressing – change q3days & prn (last done:______________) _____ Daily weight in a.m.

Activity / Rest _____ Up in chair for meals tid _______________

_______________

Up in room with assist Progress ambulation in hallway with assistance, as needed Keep SpO₂ >90% while ambulating


__________

Administer medications as ordered Administer analgesic / antiemetics as required

Nutrition __________

__________

Cardiac diet Other diet_______________________

Elimination _____ _____ Initiate bowel care as needed


____________________

Reinforce proper body mechanics when getting out of bed Reinforce discharge date with patient and family Discuss discharge concerns with patient / family, assess need for community services. Assess need for dietitian, social work consult


RN/LPN Initial

____________________

____________________

_____

____________________

____________________

_____

Afebrile Chest incision healing Leg / arm incisions healing Nausea and pain well controlled

Key Outcomes:Vital signs stable** Rhythm stable** Pain well controlled** Mobilizing**




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Date/ Time

PARAMETER OF CARE



0 - None







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PARAMETER OF CARE



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RQHR 746 (06/10)


Date:___________________ Transfer Time_____________ Tests ____

____________

________________

CXR ECG CBC Renal Panel, Mg, Ca, PO4, Albumin PT / INR Other______________________________________


Consults / Referrals ____

Completed: Dietitian SWADD Other_______________________________


____________________

__________

____________________

__________

Vital signs as per unit standard Discontinue O₂ if SpO₂ on room air > 92% while at rest Verify pacing wires are grounded per protocol Incisions: Dressing change od & prn Open to air 48 hours post op if not draining

compression dressing – change q3days & prn (last done:______________) Deep breathing and coughing exercises q1h while awake Discontinue IV if not in use

_____ Daily weight in a.m.

Activity / Rest _______________

_______________

Up in chair for meals tid Ambulate in room independently Ambulate in hallway 3 – 4x with assistance as needed


__________



__________


Elimination ____ _____ Initiate bowel care as needed


______________________________

Identify discharge needs and make referral to SWADD Social Worker if required Initiate transfer process to Home Hospital if appropriateReinforce discharge date with patient and familyPatient/family to view discharge video Review booklet, “Open Heart Surgery: Your Continued Home Recovery” with patient Review Cardiac Rehab program information with patient

Desired Outcome _____ Weight decreasing to pre-operative level _____

__________

_______________

_______________

_______________

Afebrile Chest incision healing Leg / arm incision healingKey Outcomes:Vital signs stable** Pain well controlled** Mobilizing**

_____

_____

If patient progressing to Day 4 Post-Op Pathway, confirm CXR order for Day 4 is entered in Enovation. If patient develops arrhythmia, place patient back on Day 2 of the pathway

RN/LPN Initial _____ _____Reason Off Path and Action



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Date/ Time

PARAMETER OF CARE



0 - None







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Date/ Time

PARAMETER OF CARE



0 - None







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Date:____________________

Tests ____________ ____

____________ ____

CXR ECG CBC Renal Panel, Mg, Ca, PO4, Albumin PT / INR Others as ordered __________________________


Consults / Referrals ____ Completed: SWADD Other__________________________________


__________

_______________

__________

_______________

Vital signs as per unit routine Incisions: Dressing change od & prn Open to air 48 hours post op if not draining compression dressing – change q3days & prn (last done:______________) Discontinue IV if not in use Pacing wires removed as ordered Deep breathing and coughing exercises q1h while awake

_____ Daily weight in a.m.

_____ A.M. care per self Activity / Rest ____ _____ Ambulate in hallway X 3-4 per day


__________



__________

Cardiac diet ____________________ Other diet_______________________

Elimination _____ _____ Bowel care as needed


__________________________________________________

Verify Patient/family has viewed discharge video D/C teaching reinforced - discuss self management and when to call for medical advice Transportation home discussed Verify endocarditis prophylaxis teaching provided as necessary Verify patient medication booklet and medication teaching provided Verify anticoagulation teaching done if required Verify cardiac rehab program information reviewed with patient Confirm discharge plans with SWADD Social Worker Confirm discharge plans or transfer to Home Hospital with patient and family Confirm transfer with home hospital


RN/LPN Initial

_______________

_______________

_____

_______________

_______________

_____

Pain controlled Patient and family understands D/C plan. CVT discharge order for next day written

Key Outcomes:Vital signs stable** Wound dressings less than tid** Mobilizing independently


If Key Outcomes(**) Met and Patient eligible for discharge within 24 hours Advance To Day 5 Post-Op Pathway –

Discharge Day. If Not, Repeat Day 4 Post-Op Pathway

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PARAMETER OF CARE



0 - None







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0 - None







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Open Heart Surgery Clinical Pathway Components of Care D N Day 5 Post-Op Pathway (Discharge Day)

Date:____________________

Tests ________

________


Consults / Referrals ________

Cardiac Rehab Nurse Lipid Clinic Anticoagulation Management Service CHF Clinic Other_______________________________

_____ _____ Wound check prior to discharge. Assessments / Treatments

__________ _____

Verify Pacer wires removed Verify IV has been removed Daily weight in a.m.

Activity/Rest _____ _____ Activity as tolerated

Medications ____ _____ Administer medications as ordered_____ Medication review & teaching by pharmacist prior to discharge


__________


Elimination _____ _____ Normal bowel pattern


___________________________________ __________

_____

Cardiology review prior to discharge Instructions given for suture/staple removal, as necessaryVerify discharge instructions and when to call for medical advice has been reviewed Ensure prescriptions given to patient Verify that Medication and Discharge booklets given to patient Follow – up appointment with physician(s) arranged Follow-up for INR/anticoagulation therapy arranged if patient anticoagulated Copy of patient’s INR record or flowsheet sent with patient as necessaryCopy of Discharge Summary and medications given to patient

If transferred to Home Hospital: Copy of D/C summary, medications, anticoagulant flow sheet and interagency referral sent to Home Hospital

Desired Outcome

_____

_______________

Discharge teaching is complete

Key Outcomes:Patient and family understand instructions for post discharge course** Patient understands prescriptions** Community supports notified to facilitate patient / family to manage at home**

RN/LPN Initial _____ _____


If Key Outcome (**) Met–Discharge. If Not, Repeat Day 5 Post-Op

Pathway

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PARAMETER OF CARE



0 - None







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open heart surgery clinical pathway - saswh instructor semi secure area/rqhr... · open heart...

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