Download West Midlands Centre for Innovation and Training in Elective Care

West Midlands Centre for Innovation and Training in
Elective Care (CITEC)
Inter Professional Clinical Skills Collaboration
Simulation Training for Chest Pain
Facilitator & Role Player Notes
1
Scenario Overview
The patient is Mohammed Chohan, a patient who initially presents to his GP surgery with a history
of recent onset of chest pain. After assessment from his GP, Mr Chohan is then referred to the
Rapid Access Chest Pain Clinic (RACPC) at his local district general hospital, where he
undergoes further assessment. He is then referred for an angiography, but experiences a severe
allergic reaction to the contrast media which results in cardiac arrest during the procedure (though
this should not initially be revealed to the students).
Four separate ‘sets’ are required for this simulation (though this does not necessarily mean 4
separate rooms are required):
Scenario 1 - GP surgery
Scenario 2 - Rapid access chest pain clinic suite (RACPC)
Scenario 3 – Medical Assessment Unit/Ward
Scenario 4 - High Dependency Unit/Ward
The first two scenarios are to be run with an actor and the second two with a human patient
simulator (e.g. SimMan).
2
Documentation/Resources Required
Listed below are important pieces of information which need to be available for students to view.
Where noted these can be found in the Appendices to this document. Documents not included
should be prepared in advance using blank, Trust specific forms.
Scenario
1

Documentation
Initial Observations sheet (Appendix 1)

Blank History sheet (Appendix 1)

RACPC Referral form (Appendix 1)

Request form for Low Risk Clinical Exercise
Location
All contained in tray on desk
Tolerance Test (Appendix 1)

Pre-test patient questionnaire for Low Risk
Clinical Exercise Tolerance Test (Appendix 1)
2

ETT request forms (Appendix 2)

Three ECG printouts:- (Appendix 2)
o
o
o
3
One showing ischaemic changes
One improving
One normal

Imaging Request form (facilitator to provide)

Patient notes folder (to be provided by Trust)

Completed Imaging Request form (from
Scenario 2)
All contained in tray on desk
All at end of trolley

Cardiac Arrest checklist (Appendix 3)

Chest Pain Care Plan (facilitator to provide)

Waterlow Assessment chart (facilitator to
provide)
4

Nutrition Risk Score

Clinical Continuation sheet

Observation chart (facilitator to provide)

All in drawers by nurse base
Fluid Balance chart (facilitator to provide)
Posters, leaflets and guidelines that may be useful to have available (on notice boards or with the
patient):
 Current ALS guidelines

Recording a standard 12-lead electrocardiogram

Clinical Exercise Tolerance Test guidelines

Management of chest pain guidelines

Infection Prevention and Control Policy
3

Infection Control leaflets
Other items to use in the clinical area:

British National Formulary

Oxford Handbook of Medicine

Royal Marsden handbook of clinical nursing procedures textbook

The Physiotherapist's Pocket Book: Essential Facts at Your Fingertips

ECG Made Easy
Allocate students into one of four groups, as per the matrix below.
Scenario
Students Required
Total No of Students
Medical
Nursing
Radiography
GP Surgery
2
2
0
4
RACPC
2
2
0
4
MAU
2
2
2
6
Ward Area
2
2
0
4
4
Specific Learning Outcomes
Knowledge

Demonstrate the knowledge required to care for patients presenting with a history of chest pain
Clinical Skills

Perform appropriate, systematic clinical assessment and provide a clear rationale for actions

Act appropriately in an emergency situation, recognising one’s limitations
Attitudes

Understand why good written and verbal communication skills are important to clinical care

Describe the essential aspects of good record keeping

Understand why team work is essential when dealing with patient pathways
Generic Learning Outcomes
At the end of the session the student should be able to:

Recognise the prime importance of considering patient safety in all clinical activity

Describe the patient experience as a continuous ‘journey’ rather than a series of isolated and
disjointed events

Incorporate the patient’s perspective when considering their care and treatment

Work collaboratively with students from other health care professions to complete a given task

Apply appropriate clinical skills to ensure successful assessment, planning, implementation
and subsequent evaluation of patient care

Make decisions relating to patient care as appropriate to your course and year of study

Communicate effectively with patients, other health professionals and relatives/carers

Recognise the seriously ill patient for whom urgent action is required and act appropriately

Acknowledge the limitations of your current level of competence

Utilise principles of good record keeping and documentation in order to maximise team
communication, patient safety and quality of patient care

Use resources appropriately

Participate in feedback sessions; giving and receiving feedback from fellow students
5

Reflect on your practice, in order to apply learning to your clinical areas
6
Chest Pain Scenario
Mr Chohan is 55 years old and has lived in the Midlands for the last 20 or so years after having
emigrated from the Indian subcontinent. He lives with his wife, Safina, and has two teenage sons
who are living away at University. He owns his own fast food restaurant franchise and the business
is a success, but requires him to work long hours and sometimes causes him stress when he has
staffing issues.
Recently Mr Chohan has been experiencing chest pain on and off for the last few months,
particularly at work when he is performing heavy work or feeling stressed. He has also noticed the
pain when walking uphill to his local shops. Each episode of pain lasts about 5 minutes and is
relieved when he sits down and rests. None of the episodes of chest pain have lasted any longer
than about 5 minutes and this is the first time he has sought help with this issue. The pain is “tight
and squeezing” in nature, felt in the centre of his chest. If specifically asked by the Dr or Nurse
whether the pain radiates elsewhere, then Mr Chohan states he has also felt it in the left side of his
neck, but hadn’t thought that this was related to his chest pain.
Mr Chohan was previously generally fit and well and does not currently take any medications,
prescribed or otherwise, and states that he has not been to see his GP for about 3 years. He does
not believe that he has any allergies. If asked, he drinks about 2 pints of normal strength beer most
days of the week and regularly smokes about 15-20 cigarettes per day (and has smoked for the
past 20 years). If asked, he does not take regular exercise as he is “too busy with work”.
He has been prompted to seek medical advice by his wife, who is worried about his condition and
has made an appointment for him to see his GP.
Mr Chohan’s brother (57 years old) had a heart attack 8 months ago and his father (76 years old
and still alive) had a bypass graft 2 years ago. Mr Chohan, whilst an intelligent person, is trying to
ignore his ill health, hence why he has not sought medical advice so far. He feels that if his health
is in question he may not be able to maintain his business, and he is concerned that if his business
suffers then he won’t be able to maintain his son’s University education which he is largely funding.
His wife does not work and as he is the family’s main bread winner he is concerned that his whole
lifestyle is potentially in turmoil. This is amplified by the example of his brother who has had to give
up his job as a Police Sergeant following his heart attack 8 months ago.
7
During the first scenario, Mr Chohan is quite guarded and dismissive of his potential health
problem as he tries to downplay its significance due to the potential lifestyle implications. He
suggests that he thinks that the pain may even be indigestion, as he doesn’t eat regular meals due
to his job, and he also mentions that he had a chest infection 3 weeks ago (but didn’t see his GP)
and suggests the pain might even be related to this.
During the second scenario in the chest pain clinic, Mr Chohan is anxious about his potential
diagnosis of coronary heart disease and frequently questions the healthcare professionals about
what this means for his lifestyle and job etc.
Props – Mr Chohan is required to wear “normal clothes” for this first scenario. For the second
scenario he can wear “normal clothes”, but have a tracksuit and trainers with him for the exercise
tolerance test.
Mr Chohan is an articulate speaker who respects healthcare professionals, but at the initial
consultation appears a little dismissive due the fear about his condition. During the second
scenario Mr Chohan is more receptive, but is openly anxious about what a diagnosis of coronary
heart disease might mean for him and his family.
8
Student Activities and Running Order
Each student will be given the information below and also told what exactly they are required to do
in the first few minutes of the scenarios. Other activities in these tables are procedures that would
also be considered to be relevant in this stage of the scenario:
Scenario 1 - GP Surgery
Background
Mr Chohan has presented to his GP with a 2 month history of intermittent chest pain, and this is
the first time he has sought help. He is concerned and anxious as his brother recently had a heart
attack and had to retire from his job. His father also had a coronary bypass graft. He is playing
down the significance of his symptoms and thinks he may just have overworked himself and be
suffering from the after effects of a chest infection.
Layout
Representing a GP surgery. Desk and chairs must be positioned in clear shot of the camera.
Equipment

Manual sphygmomanometer

Stethoscope

Tympanic thermometer
Documentation
See page 3.
Personnel
Patient
Comments
The patient should be dressed in normal clothes and be played by
a role player who has been briefed on the patient’s condition, date
of birth, PMH etc.
Nursing student under
supervision of “mentor”
The student should introduce and identify themselves as a nurse.
The student should then undertake initial observations on the
patient on arrival in the GP surgery; using the ABCDE systematic
approach and document using the single patient record document.
The nurse should hand over to the GP (medical student) when
complete.
Medical student
under supervision of
“mentor”
The student should introduce and identify themselves as a doctor;
taking a history and examining the patient once the nurse has
completed initial observations. They are then to decide on an
appropriate course of action with regard to the patients’ condition
(referral to the RACPC, complete referral and inform patient
accordingly).
9
Scenario 2 - RACPC
Background
Mr Chohan presents to the rapid access chest pain clinic following referral from his GP. He is
anxious about the potential diagnosis of coronary heart disease and what this might mean for him,
his family and his business.
Layout
Room 1 and Room 2.
Equipment

Sphygmomanometer

Stethoscope

RACPC documentation

Bed

Cardiac monitor

Selection of oxygen masks and tubing

Mock GTN

Venflons

Sterets

Alcowipes

Blood sampling tubes

IV training arm (preferably with blood supply)

Venflon dressings

Mock morphine/maxalon
Documentation:
See page 3.
Personnel
Patient
Nursing student under
supervision of “mentor”
Comments
The patient should be dressed in normal clothes and be played
by a role player who has been briefed on the patient’s condition,
date of birth, PMH etc.




Invite patient in to Room 1
Introduce yourself to the patient and explain the RACPC
process; confirm details on referral form
Perform initial assessment:
Vital signs (student nurse to do)
Symptom history
Risk factor review
Accompany patient to “Room 2” for ECG
10
Personnel
Medical student
under supervision of
“mentor”
Nursing student under
supervision of “mentor”
Medical student
under supervision of
“mentor”
Nursing student under
supervision of “mentor”
Patient
Nursing student under
supervision of “mentor”
Comments
Waiting in “room 2”
Perform 12 lead ECG* (an ECG will be provided) *This could be
omitted if required
Handover to Doctor
Perform physical examination & history
On set but not actively involved with patient.
A few minutes into assessment, patient begins to complain of
chest pain.




Medical student
under supervision of
“mentor”







Nursing student under
supervision of “mentor”
Assesses patient - Oxygen, vital signs, pain assessment,
cardiac monitor (if available)
Perform 12 lead ECG* (an ECG will be provided)
Call Doctor
Handover to Doctor
Assess Patient / ECG (interpretation will be provided – shows
ischaemic changes)
Administer GTN as prescribed (show awareness of
indications / contraindications)
Reassess after 5 minutes (now pain free)
Repeat and reassess ECG (interpretation will be provided –
shows ischaemic changes easing)
Admit to cardiology ward for further assessment /
angiography
Explain situation to patient
Discuss need for angiography – risks/benefits/consent
Confirm patient understanding of situation and plan. Arrange
admittance and handover
11
Scenario 3 – Medical Assessment Unit / Ward
Background
The patient (now represented by a human patient simulator, i.e. SimMan) should be on a
trolley/procedure table in a room representing an assessment ward (e.g. MAU). The SimMan
should be connected to a control PC so that the vital signs can be changed. Another facilitator
should be available to operate the human patient simulator as required.
Layout
To represent the layout of a Medical Admissions Unit/Ward with notes for the patient placed on a
trolley at the end of the patients’ trolley space.
Equipment

Hospital bed

Cardiac monitor with automated external defibrillator

Emergency equipment in trolley or grab bag consisting of a bag valve mask resuscitator,
selection of airway adjuncts; nasopharyngeal airways, Guedel airways, laryngeal masks, mock
emergency drugs; atropine, adrenaline

Selection of peripheral venous cannulae

Mock x-ray machine
Documentation
See page 3.
Personnel
Comments
Patient
Once x-ray machine in place, the patient develops chest pain
and suffers a cardiac arrest. If no x-ray machine available,
radiographers can accept request card, check details with
patient, then cardiac arrest occurs.
Nursing student under
supervision of “mentor”
Complete pre-procedure checklist with patient; verify identity
and ensure consent obtained. To assist with emergency
situation.
Radiographers
To be responsible for chest x-ray procedure and assist with
emergency situation.
Medical student[s]
To act in capacity of medical team and act as team leader for
the procedure. To ideally act as team leader during the
emergency situation.
12
Personnel
Students working as a team
Comments
Students should confirm cardiac arrest (facilitator to hand team
leader the cardiac arrest checklist).
Presenting rhythm: Ventricular fibrillation
ENSURE SAFE USE OF DEFIBRILLATOR AT ALL TIMES
Initiate safe defibrillation, under the direct supervision of the
ILS/ALS trained facilitator.



After two cycles of VF , rhythm returns to sinus rhythm (after
2 shocks)
Students should continue CPR for 2 mins then re-check
signs of life – no pulse/breathing = Pulse less electrical
activity (PEA)
Students to continue further 2 mins of CPR then recheck
signs of life = return of spontaneous circulation, patient
starts to groan
During this time, the facilitator can question students on the
potentially reversible causes of cardiac arrest:








Hypoxia (unlikely in this case)
Hypovolaemia (unlikely in this case)
Hypothermia (unlikely in this case)
Hypo/hyperkalaemia (unlikely in this case)
Tension pneumothorax (unlikely in this case)
Toxins (unlikely in this case)
Thromboembolic ( most likely in this case due to MI)
Tamponade (cardiac) (unlikely in this case, but possible
Students should repeat ABCDE assessment and think about
post-resus care and disposal (HDU)
13
Human patient simulator should be set to represent the following observations:
A – Airway
Clear (voice provided by facilitator controlling manikin)
B - Breathing
RR = 14
Depth = normal
Breath sounds= vesicular
Saturations = 96%
Use of Accessory Muscles = No
C -Circulation
Blood Pressure = 145/85
Pulse = 82, strong, regular
Skin Colour = normal
Mucus Membranes = Normal
Cap refill < 2 secs
D - Disability
Neuro assessment GCS 15/15
Eyes 4, Motor 6, Verbal 5
AVPU
PEARL (pupils equal and reactive to light)
No focal neurology, normal power/strength in limbs
E - Exposure
No obvious physical injuries/bruising
Presenting rhythm Ventricular fibrillation
After two cycles of VF , rhythm returns to sinus rhythm (after 2
shock)
Students should continue CPR for 2 mins then re-check signs of life
– no pulse/breathing = Pulse less electrical activity (PEA)
Students to continue further 2 mins of CPR then recheck signs of
life = return of spontaneous circulation, patient starts to groan
14
Scenario 4 High Dependency Unit / Ward
Background
The patient (now represented by a human patient simulator, i.e. SimMan) should be on a bed in a
simulated ward environment.
Layout
Simulated ward environment. The notes for the patient should be placed on a trolley at the end of
the patients’ trolley space
Equipment

Hospital bed

Cardiac monitor with automated external defibrillator

Emergency equipment in trolley or grab bag consisting of a bag valve mask resuscitator,
selection of airway adjuncts; nasopharyngeal airways, Guedel airways, laryngeal masks, mock
emergency drugs; atropine, adrenaline

Selection of peripheral venous cannulae
Documentation
See page 3.
Personnel
Patient
Nursing student under
supervision of “mentor”
Medical student[s]
Comments
The patient (represented by a human patient simulator, i.e.
SimMan) should be on a bed in a simulated ward environment.
To receive handover in HDU from MAU nurses. Set-up patient on
monitoring and assist with assessment.
To assess patient and formulate care plan; identify necessary
diagnostic tests.
15
Human patient simulator should be set to represent the following observations
A – Airway
Clear (voice provided by facilitator controlling manikin)
B - Breathing
RR = 14
Depth = normal
Breath sounds= vesicular
Saturations = 96%
Use of Accessory Muscles = No
C -Circulation
Blood Pressure = 110/70
Pulse = 90, strong, regular
Skin Colour = normal
Mucus Membranes = Normal
Cap refill < 2 secs
D - Disability
Neuro assessment GCS 15/15
Eyes 4, Motor 6, Verbal 5
AVPU
PEARL (pupils equal and reactive to light)
No focal neurology, normal power/strength in limbs
E – Exposure
No obvious physical injuries/bruising (though chest appears red
from CPR)
16
Appendix 1 – Scenario 1 documents
1. Observations Sheet
2. Blank history sheet
3. RACPC Referral form
4. Request form for Low Risk Clinical Exercise Tolerance Test
5. Pre-test patient questionnaire for Low Risk Clinical Exercise Tolerance Test
17
Birmingham Virtual NHS Primary Care Trust
Single Patient Assessment Record
For completion by all healthcare professionals
Patient name:
DOB :
Address:
ID number:
………………………………………………………………………………………….
Initial Assessment
RR…………(min)
HR……………(bpm)
BP…………/……………mm/hg
Sp02..........% CNS....... A V P U.....
Urinalysis (if appropriate)
Capillary blood glucose (if appropriate)
Pain score (no pain) 1 2 3 4 5
(worst possible pain)
…………………………………………………………………………………………
Presenting Complaint
…………………………………………………………………………………………
Referred to (circle)
GP
Physio
Nurse
Disposal Home
18
Hospital (please state location)
Out Patient
HMR 4a
HISTORY SHEET
Name (in full)
PID No:
Date
Clinical Notes
Weight
Height
URINE
Protein
19
Sugar
Date
Clinical Notes
20
21
RAPID ACCESS CHEST PAIN CLINIC
REFERRAL FORM
DATE IF G.P.
APPOINTMENT
DATE
RECEIVED
APPOINTMENT
DATE
PATIENT DETAILS
GP DETAILS
GP Name: -----------------------------------------------------
Name: ------------------------------------------------------------SEX: Male/Female
Practice Name: ----------------------------------------------
DOB: ---------------------------------
NHS Number: --------------------------------------------------
Practice Address (Practice stamp):
Address: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Post Code: ----------------------------------------------------Tel: ---------------------------------------------------------------
Tel No: ------------------------------------------ (Mandatory)
Fax: --------------------------------------------------------------
Hospital Number: ----------------------------------------------
E:mail: ----------------------------------------------------------
1st Language ----------------------------------------------------
ESSENTIAL CRITERIA FOR REFERRAL (All answers must be YES)
1. General Chest Pain on exertion
YES / no
3a. If MALE, aged over 30 years
YES / no
2, Duration less than TWELVE weeks YES / no
3b. If FEMAL, aged over 40 years
YES / no
CONTRAINDICATIONS FOR FAST TRACK ANGINA CLINICAL (If YES, refer to Cardiology out patients)
1, Atypical Chest Pain
2. Uncontrolled Hypertension
3. Heart Failure
4. Arrhythmia
NO / yes
NO / yes
NO / yes
NO / yes
5, Valvular Heart Disease
6. Unstable / Crescendo Angina
7. Suspected Myocardial Infarct
NO / yes
NO / yes*
NO / yes*
*If 6 or 7 contact hospital to consider admission
If any questions are unanswered or contrary to criteria, the form will be returned and
NO APPOINTMENT WILL BE MADE
OTHER HISTORY if available. Please indicate tests undertaken
1 ------------------------------------------------------ 2 ---------------------------------------------- 3 --------------------------------Risk Factors
Diabetes YES/ NO
Smoker: YES/ Never/ Ex-smoker > 1 year
Examination and Investigations (If available in last 3 months)
1.
2.
3.
4.
□
Weight ---------------------------------- kg
□
Haemoglobin -------------------------- g/d
□
Total cholesterol --------------------- mmol/l □
Pulse ------------------------------------/ min
6.
7.
8.
Current Medication
1.
□
BP ----------------------------------------- mm/Hg □
BMI --------------------------------------- kg/m
□
Creatinine ------------------------------ mmol/l □
5. ECG attached? YES/NO
2
Drug Sensitivity
----------------------------------------- 3. -------------------------------- 5. -------------------------- 1. --------------------------
2. ------------------------------------------ 4. -------------------------------- 6. -------------------------- 2. --------------------------
22
23
Request form for
Low Risk Clinical Exercise Tolerance Test
Incomplete forms are a contra-indication and will not be accepted
Incomplete forms will be returned and hence cause delay
Hospital number:
Date of request:
Name:
Ward/OPD:
Address:
Consultant:
DOB:
CONTRA-INDICATIONS
If any exist then consider a medically supervised ETT (tick to indicate not present)
Unstable angina
Angina <1month following MI, PTCA, CABG
Known left main stern stenosis
Aortic Stenosis/HOCM
BP <90mmHg or resting SBP>180mmHg or resting DBP >100mmHg
History of ventricular arrhythmias/ Tests for arrhythmia provocation
ECG demonstrates Left Bundle Branch Block, AF, WPW
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
RELEVANT MEDICAL DETAILS
What question would you want the test to answer? ------------------------------------------------------------------Would you require a symptom limited or maximal test?
Symptom Limited or Maximal
Bruce protocol is standard. If required please indication another? ------------------------------------------------
CURRENT MEDICATION
Certain medications may reduce the sensitivity of the exercise test to IHD. Do you wish the patient to
exercise on full medication?
Yes or No
MEDICAL CONSENT
I have seen and examined this patient and the resting ECG; and it is safe to proceed
with a medically unsupervised test; and that none of the contra-indications to ETT
exist.
Signed: Dr.------------------------------------------ Initials: ------------------------- Date: --------------OFFICE USE ONLY
Request form checked by: ----------------------------------------------------------------------- Date: ------------------If appropriate, reason for referral back to requesting physician:
24
Pre-test patient questionnaire for
Low Risk Clinical Exercise Tolerance Test
Incomplete forms are a contra-indication
DO NOT proceed with the test unless this form is completed
Hospital number:
Date of request:
Name:
Date of test:
Address:
Ward/OPD:
DOB:
Consultant:
SCST/BCS guidelines
Please indicate Yes or No. If answered NO to any question then consult a senior staff member before
proceeding.
Is the resuscitation equipment correct and functional?
Medical team informed of exercise test session?
Is the request form completed and signed by a physician?
Does the request form comply with SCST/BCS guidelines?
Are the patient’s notes present?
The patient has not seen a physician since the test request date?
Is the resting blood pressure >90mmHg or <180/100 mmHg?
There are no significant changes on the ECG since last recording?
There are no recent changes in medical history/treatment?
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Risk Assessment
These guidelines will aid in the risk management of the patient. If answered YES to any question then
consult a senior member of staff before proceeding.
Has the patient had chest pain related to angina in the last 24 hours?
Has the patient had a MI/CABG/PTCA in the last 4 weeks?
Has the patient been informed they have a heart murmur?
Does the patient have diabetes? If so is hypoglycaemia possible?
Does the patient have any breathing disorders?
Does the patient suffer from any knee, leg or ankles problems?
Does the patient suffer from any spine or muscle problems?
Does the patient suffer from any palpitations or dizziness spells?
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
If appropriate, indicate problems:
Signature of supervising GP
Signature of assisting GP
25
Date of test
Appendix 2 – Scenario 2 documents
1. ETT request forms
2. Three ECG printouts:
One showing ischaemic changes

One improving

One normal
26
Request form for
Low risk Clinical Exercise Tolerance Test
Incomplete forms are a contra-indication and will not be accepted
Incomplete forms will be returned and hence cause delay
Hospital number:
Date of request:
Name:
Ward/OPD:
Address:
Consultant:
DOB:
CONTRA-INDICATIONS
If any exist then consider a medically supervised ETT (tick to indicate not present)
Unstable angina
Angina <1month following MI, PTCA, CABG
Known left main stern stenosis
Aortic Stenosis/HOCM
BP <90mmHg or resting SBP>180mmHg or resting DBP >100mmHg
History of ventricular arrhythmias/ Tests for arrhythmia provocation
ECG demonstrates Left Bundle Branch Block, AF, WPW
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
NOT PRESENT
RELEVANT MEDICAL DETAILS
What question would you want the test to answer? ------------------------------------------------------------------Would you require a symptom limited or maximal test?
Symptom Limited or Maximal
Bruce protocol is standard. If required please indication another? ------------------------------------------------
CURRENT MEDICATION
Certain medications may reduce the sensitivity of the exercise test to IHD. Do you wish the patient to
exercise on full medication?
Yes or No
MEDICAL CONSENT
I have seen and examined this patient and the resting ECG; and it is safe to proceed
with a medically unsupervised test; and that none of the contra-indications to ETT
exist.
Signed: Dr.------------------------------------------ Initials: ------------------------- Date: --------------OFFICE USE ONLY
Request form checked by: ----------------------------------------------------------------------- Date: ------------------If appropriate, reason for referral back to requesting physician:
27
Pre-test patient questionnaire for
Low Risk Clinical Exercise Tolerance Test
Incomplete forms are a contra-indication
DO NOT proceed with the test unless this form is completed
Hospital number:
Date of request:
Name:
Date of test:
Address:
Ward/OPD:
DOB:
Consultant:
SCST/BCS guidelines
Please indicate Yes or No. If answered NO to any question then consult a senior staff member before
proceeding.
Is the resuscitation equipment correct and functional?
Medical team informed of exercise test session?
Is the request form completed and signed by a physician?
Does the request form comply with SCST/BCS guidelines?
Are the patient’s notes present?
The patient has not seen a physician since the test request date?
Is the resting blood pressure >90mmHg or <180/100 mmHg?
There are no significant changes on the ECG since last recording?
There are no recent changes in medical history/treatment?
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Risk Assessment
These guidelines will aid in the risk management of the patient. If answered YES to any question then
consult a senior member of staff before proceeding.
Has the patient had chest pain related to angina in the last 24 hours?
Has the patient had a MI/CABG/PTCA in the last 4 weeks?
Has the patient been informed they have a heart murmur?
Does the patient have diabetes? If so is hypoglycaemia possible?
Does the patient have any breathing disorders?
Does the patient suffer from any knee, leg or ankles problems?
Does the patient suffer from any spine or muscle problems?
Does the patient suffer from any palpitations or dizziness spells?
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
Yes or No
If appropriate, indicate problems:
Signature of supervising GP
Signature of assisting GP
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Date of test
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30
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Appendix 3 – Scenario 3 documents
1. Patient notes folder
2. Completed Imaging request form (from scenario 2)
3. Cardiac Arrest checklist
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CARDIAC ARREST ACTION CHECKLIST
START HERE
Initial Assessment and Response
Action
Completed
Check area is safe and remove dangers
Check response – shout / stimulate patient
If no response - shout for help
Remove pillows, back rest of bed, pull out bed if possible, Lay
patient flat
Open airway – head tilt / chin lift
Assess breathing – look, listen, feel for no more than 10 secs
Not breathing – confirmed arrest
Call 2222 and state situation and location
Request crash trolley or emergency bag
Commence CPR – 30 compressions then give 2 breaths
CPR In Progress
Action
Give ventilations via pocket mask with 15 litres of oxygen
attached, or Bag/valve/mask with 15 litres of oxygen attached
Insert correct size oropharyngeal airway
Continue chest compressions 30:2 – hands in centre of chest
Swap rescuer performing chest compressions every 2 min
Obtain patients medical and nursing notes; standby to
handover to crash team on arrival.
Assess how many rescuers present; do you need everyone
present around the bed space?
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Completed
Crash Team Arrival
Action
Do not stop CPR until instructed to do so by crash team,
follow instructions of crash team
Member of staff to hand over
Attach Automated Defib if not already (only trained
members of staff to use Defib) Stop CPR and assess
rhythm
Shock advised? Yes – administer shock (trained staff only)
No shock advised – recommence CPR for 2 mins – continue
to repeat above cycle
Obtain / verify: airway, IV access
Prepare emergency drugs; adrenaline 1:10000 (trained staff
only to give)
Consider reversible causes of cardiac arrest and positively
exclude 4H’s and 4 T’s;
Hypoxia, Hypovolaemia, Hypo/hyperkalaemia, Hypothermia
Tension pneumothorax, Tamponade (cardiac), Toxic,
Thromboebolic
Stop CPR and reassess rhythm / signs of life every 2 mins
If return of spontaneous circulation (ROSC) occurs, return to
ABCDE approach to assess patient
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Completed
Cardiac Arrest Team Roles and Stations
Role
1. Airway Manager
Responsibility
Perform airway manoeuvres, insert
airway adjunct, and support
respirations with pocket mask/BVM
as necessary. Assess breathing when
required
Assist Airway Manger with attaching
oxygen, selecting airway equipment
and assist with seal on BVM if
required
Perform chest compressions (swap
every 2 mins), assess pulse/BP as
required
Bring crash trolley to bedside, locate,
select and pass equipment to team as
required.
Initiate checklist and ensure all roles
allocated, record interventions, keep
time, hand over to crash team
2. Airway Assistant
3. Circulation
4. Crash trolley Manager
5. Team Leader/Record Keeper
Team Positions
1
2
Crash
trolley
4
3
5
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Appendix 4 – Scenario 4 documents
1. Nutrition Risk Score
2. Clinical Continuation sheet
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37
38
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