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Complex Care Day NURS 4617 1 CEC/Sim Workbook 1

Complex Care NURS 4617 Day 1

Clinical Education Center and Simulation

Learning Activities

Clinical Education Center – 3rd

Floor Simulation Center – 5th

Floor

Welcome, Attendance and Questions/Answers Welcome, Attendance and Questions/Answers

Activity #1 Non-invasive mechanical ventilation interactive learning

Simulation #1

Activity #2 EKG Rhythm Interpretation and review

Simulation #2

Activity #3 STEMI video and guided discussion

Simulation #3

Simulation #4

The Clinical Education Center has new clinical content and nursing application.

Please prepare for the simulation scenarios as you would for a clinical day. Read through the material, look up pathophysiology, and medications regarding your patient.

Be prepared to provide knowledgeable, effective, and safe patient care in each of the simulation scenarios today.

To prepare for the Complex Care simulation experience, please:

Review the “Get with the Guidelines” PowerPoint (provided) and prepare a discharge teaching plan (what are the key items that the patient will need to know prior to going home) for Mr. Pierce utilizing the patient data provided in this workbook.

Read before the experience:

This workbook

Selected procedures as indicated

The assigned article(s): Overbaugh, Kristen J. Acute Coronary Syndrome. American Journal of Nursing. 2009; 109(5): 42-52. Ecklund, M. Noninvasive Positive Pressure Ventilation Requires Healthcare Team Spirit. CE Course. Nursing Center.

Bring to this experience:

This workbook. Please review the simulations in detail. You should be familiar with the patient’s PMH, admitting diagnosis, and possible interventions, which include medications

Stethoscope

Clinical resources i.e. pen, penlight, clipboard

Davis Drug book


Clinical Education Center

Activity #1 Non-invasive and Invasive Mechanical Ventilation and Oxygenation.

There will be a guest speaker, Jerome Piccoli, RRT, who will review oxygenation and introduce advanced modes of oxygenation such as CPAP and BiPap. Your role as a student nurse: Review your lecture notes regarding oxygenation as well as mechanical ventilation, both non-invasive and invasive. Procedures: Review Lewis Textbook (Medical-Surgical Nursing), Chapter 66, pp.1703-1713.

Activity #2

EKG Rhythm Interpretation and Review Your role as a student nurse: In small groups, interact with team members and actively participate in learning activities regarding rhythm interpretation. You will be provided with EKG rhythm strips. Answer the questions below.

1. What other assessment data would be helpful for you at this time, as it relates to your patient? 2. What are your priorities at this time? What nursing interventions you would like to implement? 3. What medications you can anticipate preparing for your patient, or potentially obtaining an order for? 4. Create an SBAR Report about your patient.

Activity #3 Acute Coronary Syndromes

Your role as a student nurse: Actively participate in assessment and nursing care for a patient experiencing a Acute Coronary Syndrome event “MONA” is the common acronym used for initial interventions and treatment of Acute coronary Syndromes.

M -- Morphine

O -- Oxygen

N -- Nitroglycerin

A – Aspirin Risk Factors

Expected Unexpected

Smoking (i.e. cigarettes)

Obesity

Age (men 45 years or older, women 55 years or older

Diabetes

Hypertension

Stress

NSAIDS (particularly after previous MI; COX-2 inhibitors – Celebrex)

Poor oral hygiene

Chlamydia infection

Stimulants (e.g., cocaine, methamphetamine, caffeine, ephedra, etc.)

Women 50 years or younger (e.g. cigarette


Hypercholestremia

Alcohol (i.e., chronic heavy drinking)

Sex (male > female)

Diet (e.g., high fat, sodium)

Sedentary Lifestyle

Family history

Ethnicity and Race (i.e. African-Americans)

smoking)

Trauma

Chronic steroid use (rheumatoid arthritis, psoriasis, etc.)

Depression

Thyroid disease (i.e., hypo-, hyperthyroidism)

Sleep Apnea

You will be provided with a patient scenario. Answer the questions below.

1. What are some modifiable risk factors for ACS? Non-modifiable? 2. What symptoms might you expect from your patient who is experiencing ACS? 3. What are your nursing priorities?

Simulation

Your role as a student nurse:

Be familiar with the patient’s medical orders, MAR, and EMS (hard copy) report

The instructor will give you a minute to pre-brief and review the scenario’s objectives

Be prepared to work for 15 minutes in groups of 3 to complete objectives for each scenario

Three students will actively participate in simulation and 3 students will actively observe

All 6 students will actively participate for 15 minutes with an instructor guided debrief Guiding points:

3 active simulation participants should divide into nursing roles to meet the patient’s needs and scenario objectives

You are working with an interdisciplinary team and may consult by phone a Physician, Provider, Charge Nurse, CNA, Pharmacist, Case Manager, Respiratory Therapist, Social Worker, Chaplin, Physical Therapist and others as indicated

Role recommendations: o Student 1: Assessment/VS nurse: Role to complete basic assessment, vital signs and

communicate findings with team members o Student 2: Interventions/Medication administration nurse: Role to implement nursing

interventions to include medication administration o Student 3: Intervention/Primary nurse: Role as leader, situational awareness, communication

with provider and to implement nursing interventions

3 active observers should focus on observing simulation and be able to highlight successes and deficits in patient assessment, nursing interventions, and safety.


General Patient Medical Information for All Scenarios Today Primary Medical Diagnosis: Anterolateral MI

History of Present Illness: Mr. Martin Pierce is a 62 year-old patient

Situation: Mr. Martin Pierce is a 62 year-old patient brought in by ambulance for acute onset chest pain at 0530.

His wife called 911 when Mr. Pierce began complaining of tingling in his left arm. Additionally, he was clutching his

chest with his fist, and she became concerned. The 911 operator advised her to have him chew a regular strength

Aspirin; she stated she did not have any in the home. Once in the ambulance, EKG changes were noted on the

monitor, so the Paramedics gave him the Aspirin to chew. Paramedics contacted the Emergency Department (ED)

to notify them that Mr. Pierce was having an MI, most likely anterior-lateral.

Background: History of Hypertension (HTN), Nicotine use/abuse.

Allergy: Iodine

Medication(s): Hydralazine 25 mg PO twice daily

Assessment:

Neuro: Alert & Oriented, no neuro deficits. Respiratory: lungs clear, on 2 liters n/c sats about 90%

Cardiac: Chest pain treated on scene with Nitroglycerin 0.4 mg with result of pain dropping to 4/10 for 7/10. Rhythm remains SR with ST elevation. Pulses 2+/2+ bilaterally upper and lower extremities. Capillary refill <3 seconds.

GI: Abdomen rounded, soft. Bowel sounds active in all quads to auscultation. Non-tender to palpation.

GU: He has not voided at this point in time.

Msk: Gait steady, smooth movement noted. No crepitation, pain noted on palpation of all joints. Muscle strength 5/5 upper and lower extremities.

For access, he has an IV in his right antecubital space. Both lines are saline locked at this time.

Recommendations: See Simulation Scenarios Below

Scenario #1 New Admission

Sim room 3

Recommendations: Admit to the ED by verifying orders as well as implementing them, and educating the patient on the plan of care. As a team please admit this patient to your clinical area and provide any nursing care he may need. Your role as a student nurse:

A basic assessment including any needed focused assessments. Please include a set of vital signs.

Provide patient education to hospital environment, safety issues and overall plan of care.

Verify admission orders, verify MAR, and IV fluids

Also provide any nursing care for patient and communication to provider as needed.

In preparation for patient transfer to the Cath Lab, prepare and provide report to Cath Lab RN.


Clinical Education and Simulation Lab

Chest Pain/Acute Coronary Syndrome

Emergency Department Orders

General

Date: Today Time: 0600

Admit to: CCU Telemetry ⊠ Cath Lab __________ SERVICE: Cardiology

Diagnosis ⊠ STEMI Non-STEMI Unstable Angina Chest Pain Other __________

Condition Good Fair ⊠ Guarded

Allergies NKDA ⊠ Allergy: Iodine

Nursing

Vital Signs ⊠ Per unit routine ⊠ Every 15 min in ED

⊠ Call MD if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____;

RR > _____ or RR < _____; T > _____

Activity ⊠ Bed rest Bed rest with commode privileges

Out of bed to chair with assistance (BID, TID) Ambulate in hall with assistance (BID, TID) Physical therapy consultation Cardiac rehabilitation consultation

Diet ⊠NPO (except for meds)

_____ calorie-restricted diet, no caffeine CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine Heart Failure Diet (2 gram Na), no caffeine Other ______________________________________________

IV Fluids HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) ⊠ 500 ml_ NS with _____ mEq KCL/L @ 25__mL/hour x _____ hours

I/O and Weight Strict recording of Ins and Outs with running totals of urine output to be recorded Daily AM weights; record in chart

Foley ⊠ If patient is unable to void, place Foley catheter

Monitoring ⊠ Pulse oximetry: ⊠ continuous Q _____

Accucheck Q _____

Oxygen ⊠ O2 4 L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%

MD Signature: ___R. Bowler, MD_____________________ Pager: ___555-321-4567______________

Date/Time: __Today / 0600_________________________________________



Chest Pain/Acute Coronary Syndrome

Emergency Department Orders (Cont’d)

Laboratory

Laboratory Draw the following labs and run STAT:

⊠CBC with differential and platelets

⊠Basic metabolic panel

⊠Cardiac Troponin I NOW

⊠ PT/INR ⊠ PTT

Other:__________________________________________________________________ Other:__________________________________________________________________

Medication

(ACC/ AHA Guideline Class I Recommendations Indicated in Bold)

Aspirin

⊠Aspirin 325 mg PO NOW chewed Given by EMS

Other: ______________________________

Clopidogrel per Cardiology

Clopidogrel 600 mg PO NOW

Beta-Blocker per Cardiology

Metoprolol tartrate 5 mg IVP over 2 min NOW, repeat Q 5 min X 2 (hold for SBP < 90 mmHg, symptomatic bradycardia, severe reactive airway disease, decompensated HF) Metoprolol 50 mg PO NOW Hold Beta Blocker per MD order Nitroglycerin

⊠ Nitroglycerin 0.4 mg SL Q 5 min PRN chest pain; MR x 2

Nitroglycerin 100 mg/250 mL D5W IV @ 20 mcg/min, titrate to relief of CP, keep SBP > 100 mmHg

⊠Morphine Sulfate 1 mg IVP PRN severe pain__

____________________________________________ ____________________________________________ ____________________________________________

MD Signature: ___R. Bowler, MD_____________________ Pager: ___555-321-4567______________

Date/Time: __Today / 0600__________________________________________



Medication Reconciliation Inpatient Admission

Allergies: _Iodine_______________________________________

Source of medication list (circle all that apply) patient medication list, patient/family

recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility

Reviewed on Transfer by _______________________ Date_____________

Reviewed on Discharge by ______________________ Date_____________

Scan to pharmacy

Medication Name Dose Route Frequency Last Dose Continue/DC

1. Hydralazine 25 mg PO Twice daily Yesterday

PM C DC

2. C DC

3. C DC

Signature Provider R. Bowler, MD Print Name Bowler Date Today

Signature RN K.Reid, RN Print Name Reid Date Today


Scenario #2

Post Procedure Sim room 3

Recommendations: It is 90 minutes later and Martin Pierce is being transferred from the Cath Lab, post Percutaneous Coronary Intervention (PCI) to your Cardiac clinical area. He received angioplasty and a stent placed to Left Anterior Descending (LAD) coronary artery.

He requires a basic assessment, monitoring of PCI puncture site, and, as a team, any nursing care he may need.



Cath Lab Post Procedure

Admission Orders

MD Signature: R. Bowler, MD _______ Pager: 555-321-4567

Date/Time: ______Today_/ 0830________________________

General

Date: Today Time: 0830 Ht: 72 inches Wt: 90 Kg

Inpatient Admit to: ⊠ CICU Telemetry Other __________ SERVICE: Cardiology

Diagnosis ⊠ STEMI Non-STEMI Unstable Angina Chest Pain Other __________

Condition Good ⊠ Fair Guarded

Allergies NKDA ⊠ Allergy: Iodine

Nursing

Vital Signs ⊠ VS every 15 min x 4, every 30 min x 2, then every 1 hour x 4. Then, unit routine if stable.

Call MD if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____;

RR > _____ or RR < _____; T > _____

⊠ Groin checks, dorsalis pedis, and post tibial pulses every 15 min x 4, every 30 min x 2, then every

1 hour x 4. Call MD for bleeding, loss of pulses

Activity ⊠ Bed rest until morning Bed rest with commode privileges

Out of bed to chair with assistance (BID, TID) Ambulate in hall with assistance (BID, TID) Physical therapy consultation ⊠ Cardiac rehabilitation consultation

Diet NPO (except for meds) _____ calorie-restricted diet, no caffeine

⊠ CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine

Heart Failure Diet (2 gram Na), no caffeine Other ______________________________________________

IV Fluids HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) ⊠ 500 mL NS with _____ mEq KCL/L @ _25_ mL/hours; discontinue in a.m.

I/O and Weight ⊠ Strict recording of Ins and Outs with running totals of urine output to be recorded

⊠ Daily AM weights; record in chart

Foley ⊠ If patient is unable to void, place Foley catheter

Monitoring ⊠ Pulse oximetry: ⊠ continuous Q _____

Accucheck Q _____

Oxygen ⊠ O2 __4___ L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%



Cath Lab Post Procedure Admission Orders (cont’d)

Labs / Tests

On Admission to Nursing Unit

⊠ EKG on arrival and 6 hours later and with CP

Portable Chest X-ray on arrival

In A.M. ⊠Basic metabolic panel

CBC with differential

PT/INR

⊠ PTT (see unit admission order)

⊠ Portable Chest X-ray in a.m.

⊠ EKG

⊠ Others: Fasting Lipid Panel____________________________________________________

Others:___________________________________________________________________

Medications

⊠ Aspirin 325 mg PO daily

Enteric coated Aspirin 81 mg PO QAM

⊠ Clopidogrel 75 mg PO daily

Metoprolol Tartrate 25 mg PO daily (hold for SBP < 90 mmHg, HR < 50)

⊠ Metoprolol Tartrate 50 mg PO daily (hold for SBP < 90 mmHg, HR < 50)

Other: _______________________________________________ Statin

⊠ Simvastatin 40 mg PO daily

Other lipid lowering agent _______________ ______ mg PO _____________ (if indicated)

⊠ Cardiac Heparin Protocol (see attached order)

⊠ Nitroglycerin 0.4 mg SL every 5 min PRN chest pain; MR x 2

Nitroglycerin 100 mg/250 mL D5W IV @ 20 mcg/min, titrate to relief of CP, keep SBP > 100 mmHg Other:

⊠ Morphine Sulfate 1 mg IVP Q 2H PRN severe chest pain

⊠ Docusate Sodium (Colace®) 100 mg PO BID

⊠ Lisinopril 5 mg PO daily

____________________________________________

MD Signature: R. Bowler, MD Pager: 555-321-4567 ______

Date/Time: Today / 0830 ________________________________


Scenario #3 Day 2

Sim Room 2

Recommendations: It is 1 day post PCI (Hospital Day 2) at 0900. Martin Pierce is anxious and uncomfortable. Your role as a student nurse:

A basic assessment. Evaluating the Heparin infusion.

Evaluate lab values provided during the simulation.

Provide nursing care for patient and communication to provider as needed.

You can utilize the order set from Scenario #2 as needed.



Cardiac Heparin Orders

Date / Time Orders

Date:

Yesterday

Time: 1200

Cardiac Heparin Orders

⊠ • Nurse to make calculations based on actual body weight in Kg

Pt weight _90 Kg

Make all changes as soon as possible

Document all heparin adjustments and PTT results

⊠ Notify Provider if heparin infusion exceeds 2500 units/hour; for any signs of

bleeding; for two consecutive aPTT levels > 120 seconds

□ Heparin bolus 60 units/Kg (Max 4000 units): bolus = ______________units IV

⊠ No bolus

⊠ Begin continuous heparin infusion at 18 unit/Kg/hr

HEPARIN ADJUSTMENTS FOR ALL SUBSEQUENT PTTs:

aPTT Value in Seconds

Dosage Change

If less than 30 Increase infusion by 3 units/Kg/hr

If 30 - 39 Increase infusion by 2 units/Kg/hr

If 40 - 49 Increase infusion by 1 unit/Kg/hr

If 50 - 80 Goal range: no change

If 81 - 90 Decrease infusion by 1 unit/Kg/hr

If 91 - 100 Decrease infusion by 2 units/Kg/hr

If greater than 100 Stop infusion for 1 hour; decrease by 3 unit/Kg/hr

□ STAT CBC without Diff, aPTT, PT/INR prior to start of heparin (if not done within

past 24 hours

⊠ aPTT every 6 hours x 2 after any dosage change; Once two consecutive aPTTs

(drawn 6 hours apart) are therapeutic, order aPTT every a.m.

⊠ CBC without Diff every 48 hours while on heparin

Physician signature:____ R. Bowler, MD __________________________________

Printed Physician Name:_Bowler_____________________

Pager/Phone:_555-321-4567


Scenario #4

Day 3, discharge Sim Room 2

Recommendations: It is now hospital day 3 at 1600. Discharge orders have been placed on Mr. Pierce’s chart. Your role as a student nurse:

Complete any assessment data as needed for patient prior to discharge.

Complete the discharge checklist

Prepare the patient for discharge. Utilize the teaching plans that you developed in preparation for the simulation.

Resources:

Get with the Guidelines (GWTG) PowerPoint presentation (provided)

Website for Core Measures Acute Myocardial Infarction (able to access through AMC library) http://www.nursingconsult.com/nursing-images/core-measures/AMI_Core_Measure.pdf?from=core-measure/

http://www.nursingconsult.com/nursing-images/core-measures/AMI_Core_Measure.pdf?from=core-measure/

http://www.nursingconsult.com/nursing-images/core-measures/AMI_Core_Measure.pdf?from=core-measure/



Medication Reconciliation Inpatient Discharge Form

Allergies: _Iodine_______________________________________

Source of medication list (circle all that apply) patient medication list, patient/family

recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility

Medication Name Dose Route Frequency Last Dose Continue/DC

1 ASA EC 325 mg PO Once Daily Yesterday

0900

C DC

2 Docusate 100 mg PO Twice Daily Yesterday

1800

C DC

3 Simvastatin 40 mg PO Daily Yesterday

0900

C DC

4 Lisinopril 5 mg PO Daily Yesterday

0900

C DC

5 Metoprolol 50 mg PO Daily Yesterday

0900

C DC

6 Clopidogrel 75 mg PO Daily Yesterday

0900

C DC

7 Coumadin 2.5 mg PO Each day

with evening

meal

Yesterday

1800

C DC

8 Nitroglycerin 0.4 mg SL As needed

for Chest

Pain

Yesterday

0915

C DC

9 Hydralazine 25 mg PO Twice daily 3 days ago

PM

C DC

Signature Provider R. Bowler, MD Print Name Bowler Date Today

Signature RN Print Name Date

Reviewed on Discharge by ______________________ Date_____________

Scan to pharmacy



Acute MI Discharge Orders

Date / Time Orders

Date: Day 3

Time: 1500

AMI Discharge Orders

Discharge to: ⊠ Home □ SNF □ LTAC □ Rehab □ Other: _______________

Medications:

⊠ Aspirin _325___mg enteric coated PO daily

OR □ CONTRAINDICATED – Rationale: ______________________________________________

⊠ Beta Blockade Agent: Metoprolol 50 mg PO daily ___________________________

OR □ CONTRAINDICATED – Rationale: _________________________________________

⊠ Statin prescribed: Simvastatin 40 mg PO daily _____________________________

OR □ CONTRAINDICATED – Rationale: _________________________________________

⊠ Other (list separately):

____Clopidogrel 75 mg PO daily_____________________________________________

Lisinopril_5mg PO daily________________________________________________

____Docusate 100 mg PO twice daily________________________________________

____Coumadin 2.5 mg PO daily_____________________________________________

____Nitroglycerin 0.4 mg SL as needed for chest pain________________________

⊠ Activity: _Follow up with primary care physician___________________________

Vaccinations

Pneumococcal Vaccine INDICATED FOR ALL ACS PATIENTS (Adult) CONTRAINDICATIONS: Previous SEVERE reaction to vaccine

INDICATED: Administer 0.5 mL IM x 1 dose on day of discharge

NOT INDICATED: previously vaccinated, Date _______ Other reason:_____________

Patient refusal

Influenza Vaccine INDICATED FOR ALL ACS PATIENTS (October thru February)

CONTRAINDICATIONS: Allergy to eggs; previous SEVERE reaction to vaccine; history of Guillain-Barre Syndrome

INDICATED: Administer 0.5 mL IM x 1 dose on day of discharge

NOT INDICATED: previously vaccinated, Date _______ Other reason:_____________

Patient refusal

Physician Signature: ____ R. Bowler, MD _________________ Pager: _555-321-4567____________

Date/Time: Day 3 / 1500 __________________________________



Acute MI Discharge Orders (cont’d)

Patient Education

⊠ Cardiac Risk Factor Modification Teaching and Documentation

⊠ ACS Education and Documentation

⊠ Smoking Status: ⊠ current former nonsmoker unknown

⊠ Smoking Cessation Counseling and Patient Education Materials

⊠ Outpatient Cardiac Rehabilitation Assessment and Referral

⊠ Nutrition Consultation and Counseling

Physician Signature: __ R. Bowler, MD _____________________ Pager: 555-321-4567________

Date/Time: Day 3 / 1500_________________________________


Discharge Summary Checklist

Heart Failure/Post MI with or without Left Ventricular Dysfunction

Patient Name: Pierce, Martin Discharge Date: Day 3

Designated follow-up physicians/follow-up dates:

Brief medical history/discharge diagnosis: Hypertension/STEMI, Anterior-lateral w/PCI

Ejection fraction at discharge: 68% Method: □ Echocardiogram X Cardiac catheterization □

MUGA scan

Were the following discharge medications prescribed?

Y N Not Indicated

Agent Prescribed

Contra-indication

Comments/ Reasons for Not

Prescribing

Initials

Y N

Ace inhibitor □ □ □ □ □ ARB (if ACE inhibitor intolerant or in addition to ACE inhibitor)

□ □ □ □ □

Beta-Blocker (evidence based*) □ □ □ □ □ Aldosterone antagonist □ □ □ □ □ Loop diuretic □ □ □ □ □

Thiazide diuretic □ □ □ □ □

Digoxin □ □ □ □ □ Nitrates, prescribed dosage: Sublingual/PRN

□ Topical/Oral

□ □ □ □ □

Hydralazine □ □ □ □ □ Warfarin (specify indication and target INR in comments)

□ □ □ □ □

ASA □ □ □ □ □

Clopidogrel

3 months □ 6 months

□ 12 months □ Indefinite

□ □ □ □ □

Lipid-lowering agents

Statin:

Other:

□

□ □

□ □

□ □

□ □


Were the following interventions and counseling measures addressed?

Y N Not Applicable

Date Performed

Comments Initials

Treatment and adherence education

□ □ □ Will need to reinforce healthy lifestyle choices as it relates to diet and exercise

Risk-modification counseling (general)

□ □ □ Will need to reinforce healthy

lifestyle choices

Blood pressure controlled □ □ □ Diabetes controlled □ □ □ Smoking cessation recommended □ □ □ Provided with information

regarding smoking cessation

Dietitian/nutritionist interview □ □ □ Weight reduction counseling □ □ □

Cardiac rehabilitation interview and enrollment

□ □ □

Physical activity counseling □ □ □ Possible need for ICD and/or CRT □ □

Which follow-up services were scheduled?

Y N Not

Applicable

Date

Scheduled

Comments Initials

Cardiologist follow-up X □ □ 111

Primary care follow-up □ X □

Cardiac rehabilitation X □ □ Start Date: 1 week

Stress test follow-up X □ □

Echocardiogram follow-up, EF determination (assess need for ICD or CRT)

□ □ X

Electrophysiology referral or follow-up (assess need for ICD or CRT)

□ □ X

Lipid profile follow-up X □ □

Anticoagulation service follow-up X □ □

Electrolyte profile/serum lab work follow-up

X □ □

Clinical summary and patient education record faxed to appropriate physicians

X □ □

Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the OPTIMIZE-HF registry toolkit.

Sponsored by Medtronic, Inc. April 2007

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