cardiac monitoring of adult cardiac patients in nsw public ...functional sub group clinical/ patient...

Guideline

Ministry of Health, NSW73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

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Cardiac Monitoring of Adult Cardiac Patients in NSW PublicHospitals

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Document Number GL2016_019

Publication date 17-Aug-2016

Functional Sub group Clinical/ Patient Services - Medical TreatmentClinical/ Patient Services - Nursing and Midwifery

Summary The clinical Guideline on cardiac monitoring of adult cardiac patients inNSW public hospitals provides the recommended minimum standards forcardiac monitoring for adult patients with a primary cardiac diagnosis,regardless of the clinical area in which they are managed. Compliancewith the Guideline will improve patient outcomes and timely dischargethrough the appropriate use of cardiac monitoring. This Guidelinereplaces PD2008_055.

Replaces Doc. No. Cardiac Monitoring in Adult Cardiac Patients in Public Hospitals in NSW[PD2008_055]

Author Branch Agency for Clinical Innovation

Branch contact Agency for Clinical Innovation 02 9464 4620

Applies to Local Health Districts, Board Governed Statutory Health Corporations,Chief Executive Governed Statutory Health Corporations, SpecialtyNetwork Governed Statutory Health Corporations, Government MedicalOfficers, Ministry of Health, Private Hospitals and Day ProcedureCentres, Public Hospitals

Audience Nurses, doctors (including VMOs), GPs working in rural hospitals

Distributed to Public Health System, Divisions of General Practice, GovernmentMedical Officers, Health Associations Unions, NSW Ambulance Service,Ministry of Health, Tertiary Education Institutes

Review date 17-Aug-2021

Policy Manual Not applicable

File No. ACI/D16/5041

Status Active

Director-General

GUIDELINE SUMMARY

CARDIAC MONITORING OF ADULT CARDIAC PATIENTS IN NSW PUBLIC HOSPITALS

PURPOSE Over time, individual hospitals have developed a range of protocols and standards for cardiac monitoring resulting in practice variance between hospitals and local health districts (LHDs). The clinical Guideline provides the recommended minimum standards for cardiac monitoring of adult patients with a primary cardiac diagnosis in NSW hospitals, regardless of the clinical area in which they are managed. Compliance with the Guideline will improve patient outcomes and timely discharge through the appropriate use of cardiac monitoring in public hospitals in NSW. This Guideline replaces PD2008_055 - Cardiac Monitoring in Adult Cardiac Patients in Public Hospitals in NSW.

KEY PRINCIPLES Cardiac monitoring is a useful diagnostic tool for managing patients with cardiac arrhythmia or acute ischaemic changes (actual or potential). However, it has no therapeutic value unless the clinicians supervising the patient are skilled in the recognition and management of these abnormalities. Registered nurses (RN) may allocate a patient to a monitoring category in the absence of medical direction, however, the final responsibility for risk assessment of patients requiring cardiac monitoring rests with the treating medical officer. Clinical areas designated as appropriate for the management of patients requiring continuous cardiac monitoring (see Glossary, page 10) should have central monitoring capability with all cardiac monitors (apart from those used for transfers) connected to the central monitor. In the absence of a local policy, alarm parameters should be set as per ‘Between the Flags Yellow Zone’. At the end of the minimum recommended monitoring period, a daily re-assessment of the patient’s clinical indication for continued monitoring is necessary to ensure that monitoring is ceased when it is no longer required. This assessment should be performed by the treating medical team for group A patients (see page 7) or an appropriately skilled delegate (e.g. CNC, CNE, NUM) for group B patients (see page 8). It is preferable that patients who require continuous cardiac monitoring (see Glossary, page 10) remain monitored at all times. However, if cardiac monitoring must be interrupted for any reason, patients must be under direct visual observation (see Glossary, page 10) by clinical staff with the appropriate skill set (see Table 1, page 6) during the entire period that central cardiac monitoring is unavailable. Clinical areas managing patients listed in the Guideline should have at least one nurse on duty at all times who meets competency requirements for the relevant escort skill sets (see Table 1, page 6). If facilities are unable to meet this standard, the patient should be transferred to a facility that is able to provide this level of care.

GL2016_019 Issue date: August-2016 Page 1 of 3

GUIDELINE SUMMARY If a patient is being transferred, direct visual observation must be maintained by a clinician with the appropriate skill set (see Table 1, page 6).

Each LHD should determine the required competency assessments for each facility to ensure availability of adequate staffing skill mix.

USE OF THE GUIDELINE Chief Executives

• Should provide the document to staff working in areas where cardiac monitoring may be used for example cardiac wards, emergency departments.

Directors of Clinical Governance and Patient Flow Managers • Should monitor the implementation of the Guideline and its impact on patient

experience, outcome and patient flow within their facilities. Nurse Unit Managers

• Should support their staff to implement the Guideline. Nursing Staff

• Should provide cardiac monitoring for patients according to the recommendations in the Guideline

• Should have the required basic or advanced skill set for patient escort (see Table 1, page 6)

• Should discontinue cardiac monitoring for group B patients after the recommended monitoring period if the patient is stable after discussion with a senior registered nurse, unless there is a written medical order to continue (see Table 3, page 8).

Medical Staff (including general practitioners) • Should review the requirement for cardiac monitoring daily for all patients (see

Table 2, page 7; see Table 3, page 8)

• Should document in the patient’s medical record if cardiac monitoring is to continue after the recommended monitoring period stating the clinical indications and specific timeframe (see Table 2, page 7; see Table 3, page 8)

• Should document in the patient’s medical record if cardiac monitoring is to discontinue (see Table 2, page 7).

REVISION HISTORY Version Approved by Amendment notes August 2016 (GL2016_019)

Deputy Secretary, The original document was published as a Policy Directive. It has now been revised to a Guideline by the ACI. It provides the skill set and competency requirement for staff escorting cardiac patients.

September 2016 (PD2008_055)

Director General, Health NSW

New policy


GUIDELINE SUMMARY ATTACHMENTS 1. Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals – Guideline 2. Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals – Poster


Collaboration. Innovation. Better Healthcare.

CLINICAL GUIDELINE

Cardiac monitoring of adult cardiac patients in NSW public hospitalsCardiac Network

Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals Page 2

The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers to design and promote better healthcare for NSW. It does this by:

• service redesign and evaluation – applying redesign methodology to assist healthcare providers and

consumers to review and improve the quality, effectiveness and efficiency of services

• specialist advice on healthcare innovation – advising on the development, evaluation and adoption of

healthcare innovations from optimal use through to disinvestment

• initiatives including guidelines and models of care – developing a range of evidence-based healthcare

improvement initiatives to benefit the NSW health system

• implementation support – working with ACI Networks, consumers and healthcare providers to assist

delivery of healthcare innovations into practice across metropolitan and rural NSW

• knowledge sharing – partnering with healthcare providers to support collaboration, learning capability and

knowledge sharing on healthcare innovation and improvement

• continuous capability building – working with healthcare providers to build capability in redesign, project

management and change management through the Centre for Healthcare Redesign.

ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across clinical

specialties and regional and service boundaries to develop successful healthcare innovations.

A priority for the ACI is identifying unwarranted variation in clinical practice and working in partnership with

healthcare providers to develop mechanisms to improve clinical practice and patient care.

www.aci.health.nsw.gov.au

AGENCY FOR CLINICAL INNOVATION

Level 4, Sage Building

67 Albert Avenue

Chatswood NSW 2067

PO Box 699 Chatswood NSW 2057

T +61 2 9464 4666 | F +61 2 9464 4728

E [email protected] | www.aci.health.nsw.gov.au

SHPN (ACI) 160069, ISBN 978-1-76000-391-3.

Produced by: Cardiac Network

Further copies of this publication can be obtained from

the Agency for Clinical Innovation website at www.aci.health.nsw.gov.au

Disclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproduced

in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not be

reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written

permission from the Agency for Clinical Innovation.

Cover image courtesy of GE Healthcare.

Version: V1.3. Date of review: August 2016. GL2016_019

Date Amended: 26/04/2016

© Agency for Clinical Innovation 2016


Contents

Introduction 4

Scope 5

Principles – minimum standard 5

Table 1: Skill sets for staff escorts and required competencies 6

Table 2: Group A: conditions where monitoring is required 7

Table 3: Group B: conditions where monitoring is required 8

Table 4: Other conditions when cardiac monitoring MAY be required 9

Table 5: When is cardiac monitoring NOT required? 9

Abbreviations 10

Glossary 10

Additional resources and reference material 11

Acknowledgements 11


Introduction

Cardiac monitoring is a routine clinical activity

carried out in hospitals throughout NSW.

Over time individual hospitals have developed

a range of protocols and standards for cardiac

monitoring which has resulted in variance in

practice between hospitals and between local

health districts (LHDs). This guideline replaces

the NSW Health Policy Directive on Cardiac

Monitoring in Adult Cardiac Patients in Public

Hospitals in NSW (PD2008_055).

There is limited available evidence relating to cardiac

monitoring and practice remains unchanged since the

publication of the original cardiac monitoring policy.

Therefore, this document is based on the best available

evidence(a) and consensus opinion. The guideline has

been produced in consultation with cardiac nurses and

cardiologists in rural and metropolitan areas, consumer

representatives, cardiothoracic surgeons, the Agency

for Clinical Innovation Cardiac Network, the Heart

Foundation, the Cardiac Society of Australia and New

Zealand, the Australian Commission for Safety and

Quality in Health Care and NSW Ambulance.

The guideline represents the recommended minimum

standards for cardiac monitoring for adult patients with

a primary cardiac diagnosis, regardless of the clinical

area in which they are managed. Compliance with the

guideline will improve patient outcomes and timely

discharge through the appropriate use of cardiac

monitoring in public hospitals in NSW.

This document may be used by LHDs to inform the

development of their own policies incorporating the

minimum standards described in this guideline and

additional information from other sources. The skill set

and competency requirements should be interpreted in

the context of the local clinical environment.

The numbers in superscript in this document relate to

definitions in the glossary.


Scope

This guideline applies only to adult patients with a primary cardiac diagnosis. Clinical staff should

refer to local guidelines for the use of cardiac monitoring in the management of patients with

non-cardiac medical or surgical conditions.

Principles – minimum standard

1. Cardiac monitoring is a useful diagnostic tool for

managing patients with cardiac arrhythmia or

acute ischaemic changes (actual or potential).

However, it has no therapeutic value unless the

clinicians supervising the patient are skilled in the

recognition and management of these

abnormalities.

2. Registered nurses (RN) may allocate a patient to a

monitoring category in the absence of medical

direction, however, the final responsibility for risk

assessment of patients requiring cardiac monitoring

rests with the treating medical officer.

3. Clinical areas designated as appropriate for the

management of patients requiring continuous

cardiac monitoring1 should have central monitoring

capability with all cardiac monitors (apart from

those used for transfers) connected to the central

monitor. In the absence of a local policy, alarm

parameters should be set as per ‘Between the Flags

Yellow Zone’.

4. At the end of the minimum recommended

monitoring period, a daily re-assessment of the

patient’s clinical indication for continued monitoring

is necessary to ensure that monitoring is ceased

when it is no longer required. This assessment

should be performed by the treating medical team

for group A patients or an appropriately skilled

delegate (e.g. CNC, CNE, NUM) for group B patients.

5. It is preferable that patients who require

continuous cardiac monitoring1 remain monitored

at all times. However, if cardiac monitoring must

be interrupted for any reason, patients must be

under direct visual observation2 by clinical staff

with the appropriate skill set (see Table 1 on page

6) during the entire period that central cardiac

monitoring is unavailable.

6. Clinical areas managing patients listed in this

guideline should have at least one nurse on duty at

all times who meets competency requirements for

the relevant escort skill sets (see Table 1 on page 6).

7. If facilities are unable to meet this standard, the

patient should be transferred to a facility that is

able to provide this level of care.

8. If a patient is being transferred, direct visual

observation must be maintained by a clinician with

the appropriate skill set (see Table 1 on page 6).

9. Each LHD should determine the required

competency assessments for each facility to

ensure availability of adequate staffing skill mix.


Skill sets for staff escorts and required competencies

Table 1

Basic escort skill set Competency requirements

A Basic life support Holds current, facility endorsed BLS accreditation that includes the use of an AED

B Recognition and management of the deteriorating patient

Successful completion of training in the recognition and management of the deteriorating patient e.g. DETECT

C Assessment and management of angina/angina equivalent

In this context, the ability to administer supplemental oxygen, nitrates and analgesia

D Basic cardiac rhythm interpretation Can recognise VT/VF and other arrhythmias commonly considered to be life-threatening

E Management of the infusion pump (if in use) Can demonstrate the ability to adjust flow rates if required and troubleshoot pump function

Advanced escort skill set Competency requirements

F Airway management Holds current, facility endorsed accreditation for ventilation using bag and mask

G Administration of ALS drugs Holds current, facility endorsed ALS accreditation that includes administration of intravenous ALS drugs

H Cardiac defibrillation Holds current, facility endorsed ALS accreditation that includes the use of a manual defibrillator

I Management of a temporary cardiac pacemaker Holds current, facility endorsed accreditation for managing a patient with a temporary cardiac pacemaker (transvenous, transthoracic or epicardial electrodes in situ) including the ability to troubleshoot pacemaker function

J Management of IV medications requiring titration

Can demonstrate the requisite knowledge to manage a patient with an infusion of medication requiring titration e.g. inotropes, nitrates and other drugs

K External cardiac pacing Holds current, facility endorsed accreditation for initiation and management of transcutaneous cardiac pacing, including troubleshooting pacemaker function


• Patients require continuous cardiac monitoring1 OR direct visual observation2 until cardiac monitoring is discontinued.• Patients need to be escorted by trained staff as specified, with resuscitation equipment, for all internal and

inter-facility transfers. • A written medical order is required to discontinue cardiac monitoring.• At the end of the recommended monitoring period, patients in group A require daily re-assessment of the clinical

indications for continued monitoring and documentation of these indications in the health care record.

Clinical indication for monitoring Recommended monitoring duration Escort skill set

Confirmed accute coronary syndrome • All STEMI and NSTEMI must be monitored for • Basic and advanced (A – K)• Confirmed STEMI/NSTEMI a minimum of 24 hours

< 24 hours • ST segment monitoring may be useful if • Confirmed STEMI/NSTEMI available

> 24 hours but considered • At the end of the recommended monitoring clinically unstable3 period, patients who are clinically stable4

should have cardiac monitoring discontinued. NB: This will require a written medical order.

Pre-operative cardiac surgery • Continue cardiac monitoring until successful • Basic and advanced (A – K)• Critical left main disease (or coronary revascularisation occurs

equivalent) awaiting urgent surgical revascularisation

Post-operative cardiac surgery • Monitor for a minimum of 48 hours • Basic and advanced (A – K)

Post cardiac arrest • Monitor for a minimum of 24 hours and until • Basic and advanced (A – K)cause has been identified and treated

Life-threatening arrhythmias / • Monitor until reversible cause is identified 1. Patients who are considered implantable devices and treated, cardiac symptoms have been clinically unstable3

• Wide complex tachyarrhythmia stabilised by medical therapy and/or device is • Basic and advanced (A – K)including VT, VF or SVT implanted and satisfactorily tested 2. Patient who are considered with aberrancy • NB: Cardiac monitoring is always required clinically stable4

• Narrow complex tachyarrhythmia during temporary cardiac pacing even if • Basic (A – E)with haemodynamic instability device implant is not planned

• Syncope of unknown origin• Second and third degree AV blocks• Symptomatic bradyarrhythmia• Awaiting insertion of implantable

cardiac device (ICD, PPM) +/- temporary cardiac pacing

Pharmacotherapy • Continue cardiac monitoring during the • Basic and advanced (A – K)Intravenous drug therapy course of therapy • Inotropes, vaso-active drugs,

anti-arrhythmics, fibrinolytics Other• Ingestion of pro-arrhythmic drugs • Duration of monitoring must be determined

causing actual or potential QT by medical officer based on type of drug, prolongation or ventricular dose and time since ingestionarrhythmias

Cardiogenic shock, haemodynamic or • Continue cardiac monitoring during the • Basic and advanced (A – K)respiratory compromise course of therapy• Requiring support with inotropes

or intra-aortic balloon pump

Group A: conditions where monitoring is required

Table 2


Group B: conditions where monitoring is required

Table 3

• Patients require continuous cardiac monitoring1 OR direct visual observation2 until cardiac monitoring is discontinued.• Patients should have cardiac monitoring discontinued by registered nursing staff at the completion of the

recommended monitoring period if they are assessed as clinically stable4, unless there is a written medical order to continue. NB: the decision to discontinue cardiac monitoring should be discussed with the RN in charge or another competent registered nurse (as described in Table 1).

• If cardiac monitoring continues after the end of the recommended monitoring period, the patient should be re-assessed daily by the medical team with the clinical indication for continued monitoring documented in the patient’s health care record.

• When writing an order for cardiac monitoring beyond the recommended monitoring period, medical staff should specify the time period that additional monitoring will be required or stipulate clinical criteria that necessitate continued monitoring. In the absence of a specified timeframe or listed clinical criteria, the order will be determined to apply for 24 hours only.

Clinical indication for monitoring Recommended monitoring duration Escort skill set

Suspected acute coronary syndrome• NSTEACS (intermediate risk)

awaiting second troponin level

• Monitor until second troponin is available. If second troponin is negative and there are no acute ECG changes or recurrence of symptoms of suspected myocardial ischaemia, cardiac monitoring may be discontinued.

• Basic (A – E)

Arrhythmias• Supraventricular arrhythmias

(including rapid AF) with haemodynamic stability requiring commencement of intravenous therapy with pro-arrhythmic potential (e.g. amiodarone, sotalol, flecainide)

• Monitor until reversion of rhythm or control of ventricular rate.

• Basic (A – E)

Acute severe electrolyte imbalance • Monitor until the acute electrolyte imbalance has been corrected and there are no related arrhythmias present.

• Basic (A – E)

Post PCI, post EPS and post catheter ablation

• Monitor for a minimum of 4 hours post-procedure (or as per local policy).

• Monitor for up to 24 hours if there are procedural complications, arrhythmias, chest pain or haemodynamic compromise.

• Basic (A – E)


Condition Management

• Patients with low risk NSTEACS • There is no evidence to support the • Patients with chronic AF without haemodynamic compromise need for cardiac monitoring for • Patients with chronic AF without haemodynamic compromise who are receiving these conditions

intravenous digoxin temporarily in place of oral therapy• Patients with chronic ventricular premature beats, who are clinically stable• Patients with a stable functioning ICD/PPM who have had a post implant check

Other conditions when cardiac monitoring MAY be required

Table 4

Condition Monitoring duration

• Pericardial effusion• Suspected cardiac trauma• Electrocution

• Monitor according to the direction of the treating medical team or local guidelines

Inflammatory/infective cardiac conditions• For example, endocarditis, myocarditis or pericarditis

• Monitor according to the direction of the treating medical team or local guidelines

When is cardiac monitoring NOT required?

Table 5


Abbreviations

Abbreviation Description Abbreviation Description

ACS Acute coronary syndrome ICD Implantable cardioverter defibrillator

AED Automated external defibrillator NSTEMI Non ST elevation myocardial infarction

ALS Advanced life support NSTEACS Non ST elevation acute coronary syndrome

AF Atrial fibrillation NUM Nurse unit manager

AV Atrio-ventricular PCI Percutaneous coronary intervention

BLS Basic life support PPM Permanent pacemaker

CNC Clinical nurse consultant STEMI ST elevation myocardial infarction

CNE Clinical nurse educator SVT Supraventricular tachycardia

DETECT Detecting Deterioration, Evaluation, Treatment, Escalation and Communication in Teams

VF Ventricular fibrillation

EPS Electrophysiology study VT Ventricular tachycardia

Glossary

In the context of this document the following

definitions apply:

1 Continuous cardiac monitoring means that the patient

is connected to a cardiac monitor that is a component

of a system with central monitoring functionality

(including active alarms).

2 Direct visual observation means that the clinician can

see and assess the patient at all times.

3 Clinically unstable means that the patient has

exhibited one or more of the following during the

previous 24 hours:

• recurrence of symptoms of myocardial ischaemia

• cardiac arrhythmias requiring intervention

• haemodynamic instability requiring supportive

therapy (i.e. intravenous vasoactive medications or

temporary cardiac pacing).

4 Clinically stable means that the patient has not

exhibited any of the following during the previous

24 hours:

• recurrence of symptoms of myocardial ischaemia

• cardiac arrhythmias requiring intervention

• haemodynamic instability requiring supportive

therapy (i.e. intravenous vasoactive medications

or temporary cardiac pacing.5 Medical Officer means the most senior doctor, or their

delegate, responsible for the care of the patient.

6 Supportive therapy means IV medications that may

require titration, or temporary external pacing.

7 Management of angina means administration of

oxygen (if clinically indicated), nitrates and analgesia.

8 External cardiac pacing means transcutaneous pacing.


Additional resources and reference material

(a) Drew B, Dempsey J, Joo ED et al. Pre-hospital

synthesized 12-lead ECG ischemia monitoring with

trans-telephonic transmission in acute coronary

syndromes. Journal of Electrocardiology. 2004.

37: p214 -221.

The Health Education and Training Institute (HETI)

module on Introduction to Cardiac Monitoring focuses

on the professional obligations of staff caring for

patients during monitoring and is useful for junior staff

new to working in cardiology. This course can be

accessed at http://www.heti.nsw.gov.au/heti-online-

modules/

The Australian Resuscitation Council has provided

guidelines relating to the required skills and knowledge

for advanced life support. These guidelines may be

accessed at http://resus.org.au/

An interactive, electronic ECG resource has been

developed by CIAP which is available by accessing the

CIAP website, selecting ‘Tools’ and clicking on the link

for ‘Interactive ECG’ or following the link http://ecg.hcn.

com.au/?acc=36422

Information on atrial fibrillation after coronary artery

bypass surgery is available at http://www.uptodate.

com/contents/atrial-fibrillation-and-flutter-after-

cardiac-surgery?source=preview&language=en-US&anc

hor=H9&selectedTitle=3~150#H9

Acknowledgements

This guideline has been updated thanks to the support, advice and collaborative efforts of many people and

organisations and, in particular, the Agency for Clinical Innovation Cardiac Monitoring Working Party, which

includes the following people:

Virginia Booth CNC Cardiology Royal Prince Alfred Hospital

Bridie Carr Cardiac Network Manager Agency for Clinical Innovation

Karen Lintern CNC Cardiology Liverpool Hospital

Dawn McIvor CNC Cardiology John Hunter Hospital

Glenn Paull CNC Cardiology St George Hospital

Jill Squire CNC Cardiology Westmead Hospital

http://www.heti.nsw.gov.au/heti-online-modules/

http://www.heti.nsw.gov.au/heti-online-modules/

http://resus.org.au/

http://ecg.hcn.com.au/?acc=36422

http://ecg.hcn.com.au/?acc=36422

http://www.uptodate.com/contents/atrial-fibrillation-and-flutter-after-cardiac-surgery?source=preview&language=en-US&anchor=H9&selectedTitle=3~150#H9




Cardiac monitoring of adult cardiac patients in NSW public hospitals Principles

Cardiac monitoring has no therapeutic value unless the

1. supervising clinicians can recognise and manage cardiac abnormalities.

The treating medical officer has the final responsibility for 2. risk assessment of patients requiring cardiac monitoring

and allocation to the appropriate monitoring category.

3.All cardiac monitors should be connected to a central monitor. In the absence of local policy, alarm parameters should be set as per ‘Between the Flags Yellow Zone’.

4.A daily re-assessment of the clinical indication for continued monitoring should be performed by the treating medical team for group A or skilled delegate (e.g. CNC, CNE, NUM) for group B.

5.Patients should remain monitored at all times. If monitoring is interrupted for any reason, patients must be under direct visual observation by appropriately skilled staff until monitoring is recommenced.

6. One nurse who meets competency requirements for the relevant escort skill sets should be on duty at all times.

7.Each LHD should determine the required competency assessments to ensure a safe skill mix is available at all times.

If the facility cannot meet these standards, the patient should be transferred to a facility able to provide this standard of care.

.

If a patient is being transferred, direct visual 8. observation must be maintained by a clinician with the

appropriate skill set.

9

CLINICAL INDICATION RECOMMENDED MONITORING DURATION ESCORT SKILL SET REQUIREMENTS

GROUP A

Confirmed acute coronary syndrome

•

•

•

All STEMI and NSTEMI must be monitored for a minimum of 24 hours.

ST segment monitoring may be useful if available.

At the end of the recommended monitoring period, patients who are clinically stable should have cardiac monitoring discontinued. NB. This will require a written medical order.

Basic and advanced (A – K)

•

•

•

•

Require continuous cardiac monitoring OR direct visual observation until cardiac monitoring is discontinued.

Escort by trained staff as specified with resuscitation equipment for all internal and inter-facility transfers.

Require a written medical order to discontinue cardiac monitoring.

At the end of the recommended monitoring period, Group A patients require daily re-assessment of the clinical indications for continued monitoring and documentation of these indications in the health care record.

Pre-operative cardiac surgery • Continue cardiac monitoring until successful coronary revascularisation occurs. Basic and advanced (A – K)

Post-operative cardiac surgery • Monitor for a minimum of 48 hours. Basic and advanced (A – K)

Post cardiac arrest • Monitor for a minimum of 24 hours and until cause has been identified and treated. Basic and advanced (A – K)

Life threatening arrhythmias/Implantable devices

• Monitor until reversible cause is identified and treated, cardiac symptoms have been stabilised by medical therapy and/or device is implanted and satisfactorily tested. NB: Cardiac monitoring is always required during temporary cardiac pacing even if device implant is not planned.

1.

2.

Patients who are considered clinically unstable: Basic and advanced (A – K)

Patients who are considered clinically stable Basic (A – E)

Pharmacotherapy•

•

Continue cardiac monitoring during the course of therapy.

Duration of monitoring must be determined by medical officer based on type of drug, dose and time since ingestion.

Basic and advanced (A – K)

Cardiogenic shock, haemodynamic or respiratory compromise • Continue cardiac monitoring during the course of therapy. Basic and advanced (A – K)

GROUP B

Suspected acute coronary syndrome

• Monitor until second troponin is available. If 2nd troponin is negative and there are no acute ECG changes or recurrence of symptoms of suspected myocardial ischaemia, cardiac monitoring can be discontinued.

Basic (A - E)•

•

•

•

Require continuous cardiac monitoring OR direct visual observation until monitoring is discontinued.

Unless there is a written medical order to continue, cardiac monitoring should be discontinued by RNs at the end of the recommended monitoring period if patients are clinically stable. Discontinuation of cardiac monitoring should be discussed with the RN in charge or another competent RN (see competency requirements A – K in the guideline).

If monitoring continues after the completion of the recommended period, daily re-assessment and documentation of the indications for monitoring is required.

Medical staff should specify the time period for additional monitoring, or stipulate clinical criteria that necessitate continued monitoring. If no timeframe or clinical criteria are listed, the order will apply for 24 hours only.

Arrhythmias • Monitor until reversion of rhythm or control of ventricular rate Basic (A - E)

Acute severe electrolyte imbalance

• Monitor until the acute electrolyte imbalance has been corrected and there are no related arrhythmias present Basic (A - E)

Post PCI, post EPS and post catheter ablation

•

•

Monitor for a minimum of 4 hours post-procedure (or as per local policy).

Monitor for up to 24 hours if there are procedural complications, arrhythmias, chest pain or haemodynamic compromise.

Basic (A - E)

Further information For information on other conditions when monitoring MAY be required and when cardiac monitoring is NOT required, please refer to the clinical guideline on cardiac monitoring of adult cardiac patients in public hospitals in NSW. V.1 April 2016

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