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HEART
INVESTIGATION
UNIT
HAMILTON
HEALTH
SCIENCES
(GENERAL SITE)
INFORMATION HANDBOOK
(Updated: February 2013)
1
TRIAGE GUIDELINES
ADMITTED PATIENTS FROM ANY OF OUR
REFERRING HOSPITALS
Goal: to complete procedures within 24-48
hours of receiving referral
Factors affecting priority of in-hospital patients:
 Primary PCI and Rescue PCI
 Patient stability e.g. Hemodynamics, rhythm
changes, etc.
 STEMI or NSTEMI with ongoing angina
 Patient on IV nitroglycerine
 Aortic stenosis
 Dynamic ECG changes
 Previous CABG or PTCA
*Please call the HIU coordinator at 905-521-2100 ext.
46674 if you have any questions about your patient
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IMPORTANT CONSIDERATIONS PRIOR TO
ANGIOGRAM
Most recent blood work:
 CBC – particularly hemoglobin and platelet count
 Coagulation factors – specifically INR – must be < 1.8 (has coumadin
been stopped? Vit K ordered?)
 Creatinine (if >104 women or >120 men, IV fluid and mucomyst
started?)
Medications:
 Fondaparinux held two hours before the procedure
 Lovenox, Enoxaparin, Fragmin held day of procedure (check with
physician)
 All other anticoagulants require specific MD consultation
 Diabetics – Metformin held day of procedure; Insulin (require
specific MD consultation)
 If ordered, ASA taken the day of the procedure
 If ordered, Antiplatlet taken the day of the procedure
 All other scheduled medication should be given at the appropriate
times unless otherwise ordered by referring MD
 Call 46210 to clarify if there are questions, prior to the administration
of medications
Other issues:
 CHF status (Must be able to lie flat for at least one hour for the
procedure)
 Intubated (need MD to MD consult)
 Access site (Fistula in arm, Amputation)
 Language barrier/Sign consent (patient must be able to speak English
and sign a consent prior to procedure. If patient is unable, then power
of attorney/translator must be available/present)
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 IV access (please try to avoid the right wrist/ hand area as we many
access the right radial artery for the procedure)
 Isolation precautions
*test will NOT be deferred for any of the above issues if
it’s an emergency!
SENDING YOUR PATIENT
Physical Readiness:
 Patient must be in a hospital gown
 Patient must have at least one large bore functioning IV (if a
medication is infusing via IV, the patient must have a plain
line for potential medications given in HIU)
 Patient must have an ID band on
 If possible… a pair of non-slip slippers or shoes (and the
patient’s cane/walker, hearing aid, glasses, dentures if
required)
 Prefer NOT to have patient bring valuables to HIU
Required Documentation:
 Patient transfer record and FRI screening tool
 Copies of most recent history and physical (including OR
reports for any past heart surgeries/procedures, and/or
vascular surgery)
 Copies of ECGs (most recent and significant ones)
 Copies of most recent diagnostic heart tests… i.e. echo, stress,
nuclear, etc.
 Copies of lab values (within 24-48 hours)
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 Copies of MAR (medication administration record) with
dates and times of meds received… including prn meds
Please follow “Patient Transfer Checklist for Urgent
Inpatient to HIU”
When calling report to HIU… please follow “Template for
Sending Units’ Report”
“EMERGENCY” PATIENTS COMING TO
HIU
HIU HOTLINE (0700 – 2000 hours, Mon – Fri)
905-577-8007
Using the hotline will allow the referring physician to speak
directly to one of HIU’s interventional cardiologist
Using the algorithm provided on the HIU website or the
“STEMI & NSTEMI algorithm” provided in the
handbook, a referring physician can quickly determine the
most appropriate steps for an emergency referral.
Please fax patient’s ECG and referral form to
905-575-2649
If after hours (2000-0700 Mon.-Thurs), weekends or
holidays:
Please page the interventional cardiologist on call at:
905-521-2100 ext.46311
5
REPATRIATION
Once a patient is sent from your facility, expect
that patient to return within 24-48 hours if stable.
 Communication between physicians, nurses, and
admitting department needs to be ongoing
 Physician to physician dialogue is necessary. If a
patient is sent from ER, this physician should
inform their cardiologist or internist on-call to
expect this patient back
 Bed managers need to be aware of these patients
(especially those sent from ER)
 If a bed is not available, some hospitals will take
their stable patient back to their ER department
(this is sometimes necessary to ensure that our
CCU has a bed available for the next emergency)
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RECEIVING YOUR PATIENT BACK
POST-PROCEDURE
HIU will call a report to the receiving unit following “Template for HIU’s
Report Back to Sending Unit” (included in the handbook)
Once you receive your patient back post-procedure please assess the
arterial access site (groin or wrist) immediately (the ambulance ride and
transfers from bed to stretcher can cause re-bleeding and/or hematoma).
*Reference charts included
Patients will be sent back with a complete discharge summary that
includes:
 Summary of procedures performed
 Patient’s course while at HHS
Included in the discharge summary is a recommended on-going plan that
will include:
 Recommended medications
 Recommenced follow-up tests
 Recommended follow-up timeline for visits with the patient’s family
doctor and patient’s cardiologist/internist
Cardiac rehab is strongly recommended for your post MI patients. If one
is not available in your region the patient is more than welcome to attend
rehab at HHS.
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ACCESSING HIU WEBSITE
Information available on the HIU website is updated
frequently to give users the most accurate, up-todate news.
A separate section is dedicated to health care
providers. This information is specific to caring for
hospitalized patients who require cardiac
catheterization and/or PCI.
To access this information:
 http://www.hhsc.ca




next, click on “Clinics & Services”
next, click on “Cardiac & Vascular Units”
next, click on “Heart Investigation Unit”
next, click on “For Health Care Providers”
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Hamilton Health Sciences/Niagara Health System
Heart Investigation Unit
Template for Sending Units’ Report
CALL HIU BEFORE PATIENT LEAVES UNIT
Sending Hospital __________________ Unit: ____________
Phone Number/Ext.: __________________
Name of Nurse Calling Report: ________________________
Patient Pick up Time: _________________
Name, Age, Height, Weight
Allergy/Isolation:
Reason for procedure:
Previous cardiac Cath/PCI and or cardiac
surgery. Documents available?
Patient able to lie flat? CPAP?
Monitored/Non-Monitored
Code Status
Medications Given:
 ASA
 Antiplatelet
 Anticoagulants
 Diabetic Meds
 Oxygen
Blood work:
 INR
 K+
 CR
 WBC
 BS
 Hgb/platelets
IV’s (solutions, medications and rate)
Time of last:
Family Aware/Coming?
Able to sign consent?
#1
#2
Food _____________________ Oral fluids _______________
Language Barriers?
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Hamilton Health Sciences
Cardiac and Vascular Program
Heart Investigation Unit
Checklist
Personal Items/Assistive Devices
(Please send)
Cane
Yes
No
Hearing Aid (s)
Yes
No
Glasses
Yes
No
Dentures
Yes
No
Clothing
Yes
No
Footwear [non-slip
slippers or shoes]
Valuables
Yes
No
Prefer not to have patient bring valuables to
HIU
Other
Documentation (A copy MUST
accompany patient)
Recent ECG
Medication profile
Recent blood work [CBC, Lytes, Coagulation]
Clinical history, physical and assessment
Physician dictated note [if available]
Most recent diagnostic heart tests [echo, stress or nuclear tests]
Medications
Fondaparinux HELD TWO HOURS prior to procedure
Lovenox, Enoxoparin, Fragmin [HELD the day of procedure]
ALL other anticoagulants require specific MD consultation
Metformin [HELD the day of procedure]
Insulin [Require specific MD consultation]
If ordered. ASA TAKEN the day of procedure
If ordered, Antiplatlet TAKEN the day of procedure
OTHER MEDICATIONS SHOULD BE GIVEN AT
SCHEDULED TIME UNLESS OTHERWISE DIRECTED BY
REFERRING MD.
Call 46210 to clarify if there are questions, prior to
administration of medications
Confirm with physician as you
require an order to hold medication
Language Barrier
Patient must be able to speak English and sign a consent prior to
procedure. If patient is unable, then power of attorney/translator
must be available/present
IV access
Please try and avoid the right wrist/hand area as we may access
the right radial artery for their procedure
Fistula in arm or Amputation
Should be contacted [they are welcome to come]
Arterial Access Complications
Family
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Vital Signs, Monitoring/Assessment & Management for Diagnostic Procedures/PCI
Procedure
Femoral/Brachial
*If arterial and
venous sheaths
are insitu at the
SAME access site,
remove arterial
sheath FIRST
*BRACHIAL
ACCESS ONLY
Ambulate
according to
physician order
Femoral Venous
Access Only
Vital Signs
Diagnostic Procedure
ECG
Bed rest/ HOB Elevated
Sheath insitu
Q 15 min X 4
Q 30 min until sheath
removal
Sheath Removal
Follow Protocol
Sheath insitu
Remove immediately
Post sheath removal
Q 15 min X 2
Q 30 min X 2
(and/or prior to
discharge)
Radial Clamp
D/C ECG
- 1.5 hours after
sheath removal
Continuous ECG
- Sheath insitu
- During removal
D/C ECG
- Bed rest
completed
Dressing
Sterile
band-aid
Bed rest
- 30 minutes sheath
removal/hemostasis, then
ambulate
- First ambulation with
nurse
Sterile
band-aid
HOB
- Up to 45 degrees until first
ambulation
- Lateral position acceptable
[affected limb straight]
Post sheath removal
Q 15 min X 4
Q 30 min X 2
Q 1 hour X 4 (and/or
prior to discharge)
then Q 4
Continuous ECG
- 1.5 hours after
sheath removal
Radial Clamp insitu
Q 15 min X 4
until first clamp release
Continuous ECG
- Clamp insitu
- During removal
Clamp Removal
Follow protocol
D/C ECG
- 1.5 hours after
sheath removal
or upon first
ambulation
Post Radial Clamp
Removal
Q 15 min X 2
Q 30 min X 1 (and/or
prior to discharge)
then Q 4 h
Bed rest
- 3 hours post sheath
removal/hemostasis, then
ambulate
- First ambulation with
nurse
HOB
- Up to 30 degrees first two
hours of bed rest
- Up to 45 degrees after two
hours
- Lateral position acceptable
[affected limb straight]
- NO limitations for brachial
Post sheath removal
Q 15 min X 4
Q 30 min X 2
Q 1 hour X 4 (and/or
prior to discharge)
then Q 4 h
Sheath Removal
Follow protocol
Closure Device
Continuous ECG
- Sheath insitu
- During removal
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Bed rest
- 2 hours post device
insertion, then ambulate
- First ambulation with
nurse
HOB
- Up to 45 degrees after one
hour of bed rest
Bed rest
- Until post clamp
removal/hemostasis
- Ambulate 15 min post
hemostasis
-First ambulation with
nurse
HOB
- No restrictions
Tegaderm
Sterile
band-aid
Appendix: Vital Signs, Monitoring/Assessment and Management for
Diagnostic Procedures & PCI
Percutaneous Coronary Intervention (PCI)
Procedure
Femoral/Brachial
*BRACHIAL
ACCESS ONLY
Ambulate
according to
physician order
Closure Device
Radial Clamp
Vital Signs
Sheath insitu
Q 15 min X 4
Q 30 min until
sheath removal
Sheath Removal
Follow Protocol
Post sheath
removal
Q 15 min X 4
Q 30 min X 2
Q 1 hour X 4
(and/or prior to
discharge)
then Q 4 h
Post sheath
removal
Q 15 min X 4
Q 30 min X 2
Q 1 hour X 4
(and/or prior to
discharge)
then Q 4 h
Radial Clamp
insitu
Q 15 min X 4
until first clamp
release
Clamp Removal
Follow protocol
ECG
Continuous ECG
- Sheath insitu
- During removal
D/C ECG
- After first
ambulation
Bed rest/ HOB Elevated
Bed rest
- 3 hours sheath
removal/hemostasis, then
ambulate
- First ambulation with
nurse
Dressing
Sterile
band-aid
HOB
- Up to 30 degrees first two
hours of bed rest
- Up to 45 degrees after two
hours
- Lateral position acceptable
[affected limb straight]
- NO limitations for brachial
Continuous ECG
- While on
bedrest
D/C ECG
- After first
ambulation
Continuous ECG
- Clamp insitu
- During removal
D/C ECG
- After first
ambulation
Bed rest
- 2 hours post device
insertion, then ambulate
- First ambulation with
nurse
HOB
- Up to 45 degrees after one
hour of bed rest
Bed rest
- Until post clamp
removal/hemostasis
- Ambulate 15 min post
hemostasis
- First ambulation with
nurse
HOB
- No restrictions
Post Radial
Clamp Removal
Q 15 min X 2
Q 30 min X 1
(and/or prior to
discharge)
then Q 4 h
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Tegaderm
Sterile
band-aid
Bleeding/Hematoma Management Algorithm – Before and After Sheath
Removal
Post procedure Bleeding
at Sheath Site
or Hematoma formation
around Sheath Site
Diagnostic Catheterization
Remove Sheath immediately
 If bleeding/hematoma formation
continues – follow PCI pathway
PCI
Management
 Inform Cardiologist
 Apply direct pressure above site (first 2-3 fingers above
sheath site)
 Use as much pressure as patient will tolerate, enough
pressure to halt bleeding/hematoma development
Consider
 Check V/S
 Check labs (Hgb., INR/PTT)
*Nursing Interventions
 Manual pressure to stop bleeding or
decompress hematoma
 Consider mechanical device for
prolonged compression time in the
absence of a hematoma (inform
physician)
 Prolong bed rest (inform physician)
 After sheath removal a sandbag may
be used as a reminder for patient to
maintain hip/leg alignment
 Close monitoring of peripheral
perfusion and vital signs required
according to HIU standards
Anticipate
 Consultation with MRP
 Early removal of sheath
 Reduction of IIb/IIIa inhibitors
 Lab work (i.e. PTT/CBC)
 Prolonged bedrest
 Not suitable for same day
discharge
Follow up
 Follow usual
protocol/standards once
bleeding/hematoma
controlled
 May require ultrasound/CT
prior to discharge
* Document in Interdisciplinary Patient Care Notes
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