Download Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals

Guideline
Ministry of Health, NSW
73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059
Telephone (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 Public
Hospitals
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Document Number GL2016_019
Publication date 17-Aug-2016
Functional Sub group Clinical/ Patient Services - Medical Treatment
Clinical/ Patient Services - Nursing and Midwifery
Summary The clinical Guideline on cardiac monitoring of adult cardiac patients in
NSW public hospitals provides 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. This Guideline
replaces 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, Specialty
Network Governed Statutory Health Corporations, Government Medical
Officers, Ministry of Health, Private Hospitals and Day Procedure
Centres, Public Hospitals
Audience Nurses, doctors (including VMOs), GPs working in rural hospitals
Distributed to Public Health System, Divisions of General Practice, Government
Medical 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
August 2016
(GL2016_019)
Approved by
Deputy Secretary,
September 2016
(PD2008_055)
Director General,
Health NSW
GL2016_019
Amendment notes
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.
New policy
Issue date: August-2016
Page 2 of 3
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
GL2016_019
Issue date: August-2016
Page 3 of 3
CLINICAL GUIDELINE
Cardiac monitoring of
adult cardiac patients
in NSW public hospitals
Cardiac Network
Collaboration. Innovation. Better Healthcare.
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
•
s pecialist 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
•
i mplementation support – working with ACI Networks, consumers and healthcare providers to assist
delivery of healthcare innovations into practice across metropolitan and rural NSW
• k
nowledge 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
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 2
Contents
Introduction4
Scope5
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
Abbreviations10
Glossary10
Additional resources and reference material
11
Acknowledgements11
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 3
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).
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.
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
The numbers in superscript in this document relate to
definitions in the glossary.
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.
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.
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 4
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.
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 5
Table 1
Skill sets for staff escorts and required competencies
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
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 6
Table 2
Group A: conditions where monitoring is required
• 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
• Confirmed STEMI/NSTEMI
< 24 hours
• Confirmed STEMI/NSTEMI
> 24 hours but considered
clinically unstable3
• 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 stable4
should have cardiac monitoring discontinued.
NB: This will require a written medical order.
• Basic and advanced (A – K)
Pre-operative cardiac surgery
• Critical left main disease (or
equivalent) awaiting urgent
surgical revascularisation
• 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
• Wide complex tachyarrhythmia
including VT, VF or SVT
with aberrancy
• Narrow complex tachyarrhythmia
with haemodynamic instability
• Syncope of unknown origin
• Second and third degree AV blocks
• Symptomatic bradyarrhythmia
• Awaiting insertion of implantable
cardiac device (ICD, PPM) +/temporary cardiac pacing
• 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. Patients who are considered
clinically unstable3
• Basic and advanced (A – K)
Pharmacotherapy
Intravenous drug therapy
• Inotropes, vaso-active drugs,
anti-arrhythmics, fibrinolytics
Other
• Ingestion of pro-arrhythmic drugs
causing actual or potential QT
prolongation or ventricular
arrhythmias
• Continue cardiac monitoring during the
course of therapy
• Basic and advanced (A – K)
Cardiogenic shock, haemodynamic or
respiratory compromise
• Requiring support with inotropes
or intra-aortic balloon pump
• Continue cardiac monitoring during the
course of therapy
2. Patient who are considered
clinically stable4
• Basic (A – E)
• Duration of monitoring must be determined
by medical officer based on type of drug,
dose and time since ingestion
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
• Basic and advanced (A – K)
Page 7
Table 3
Group B: conditions where monitoring is required
• 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 postprocedure (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)
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 8
Table 4
Other conditions when cardiac monitoring MAY be required
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
Table 5
When is cardiac monitoring NOT required?
Condition
Management
• Patients with low risk NSTEACS
• Patients with chronic AF without haemodynamic compromise
• Patients with chronic AF without haemodynamic compromise who are receiving
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
• There is no evidence to support the
need for cardiac monitoring for
these conditions
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 9
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
4
ontinuous cardiac monitoring means that the patient
C
is connected to a cardiac monitor that is a component
of a system with central monitoring functionality
(including active alarms).
2
irect visual observation means that the clinician can
D
see and assess the patient at all times.
3
linically unstable means that the patient has
C
exhibited one or more of the following during the
previous 24 hours:
linically stable means that the patient has not
C
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
edical Officer means the most senior doctor, or their
M
delegate, responsible for the care of the patient.
6
upportive therapy means IV medications that may
S
require titration, or temporary external pacing.
• cardiac arrhythmias requiring intervention
7
• haemodynamic instability requiring supportive
therapy (i.e. intravenous vasoactive medications or
temporary cardiac pacing).
anagement of angina means administration of
M
oxygen (if clinically indicated), nitrates and analgesia.
8
External cardiac pacing means transcutaneous pacing.
• recurrence of symptoms of myocardial ischaemia
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 10
Additional resources and reference material
(a)
rew B, Dempsey J, Joo ED et al. Pre-hospital
D
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-onlinemodules/
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-aftercardiac-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
Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals
Page 11
Cardiac monitoring of adult cardiac patients in NSW public hospitals
Principles


1.
Cardiac monitoring has no therapeutic value unless the
supervising clinicians can recognise and manage cardiac
abnormalities.
 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.
2.
The treating medical officer has the final responsibility for
risk assessment of patients requiring cardiac monitoring
and allocation to the appropriate monitoring category.

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.
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’.
6.
One nurse who meets competency requirements for the relevant
escort skill sets should be on duty at all times.
CLINICAL INDICATION
ESCORT SKILL SET
Pre-operative cardiac surgery
• 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.
• 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)
• 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)
Confirmed acute coronary
syndrome
GROUP
A
RECOMMENDED MONITORING DURATION
Post cardiac arrest
Life threatening arrhythmias/
Implantable devices
Pharmacotherapy
severe electrolyte
GROUP Acute
imbalance
B
Post PCI, post EPS and post
catheter ablation
Further information

8.
If a patient is being transferred, direct visual
observation must be maintained by a clinician with the
appropriate skill set.

9.
If the facility cannot meet these standards, the patient
should be transferred to a facility able to provide this
standard of care.
REQUIREMENTS
Basic and advanced (A – K)
• Require continuous cardiac monitoring OR direct visual
observation until cardiac monitoring is discontinued.
• Monitor for a minimum of 24 hours and until cause has been identified and treated. Basic and advanced (A – K) • Escort by trained staff as specified with resuscitation
equipment for all internal and inter-facility transfers.
1. Patients who are
• Require a written medical order to discontinue cardiac
considered clinically
• Monitor until reversible cause is identified and treated, cardiac symptoms have
monitoring.
unstable:
been stabilised by medical therapy and/or device is implanted and satisfactorily
Basic and advanced (A – K) • At the end of the recommended monitoring period, Group
tested.
A patients require daily re-assessment of the clinical
NB: Cardiac monitoring is always required during temporary cardiac pacing even 2. Patients who are
indications for continued monitoring and documentation of
if device implant is not planned.
considered clinically stable
these indications in the health care record.
Basic (A – E)
Cardiogenic shock, haemodynamic
• Continue cardiac monitoring during the course of therapy.
or respiratory compromise
• Monitor until second troponin is available. If 2nd troponin is negative and there
Suspected acute coronary
are no acute ECG changes or recurrence of symptoms of suspected myocardial
syndrome
ischaemia, cardiac monitoring can be discontinued.
Arrhythmias
 7.
Each LHD should determine the required competency
assessments to ensure a safe skill mix is available at all
times.
Basic and advanced (A – K)
Basic (A - E)
• Monitor until reversion of rhythm or control of ventricular rate
Basic (A - E)
• Monitor until the acute electrolyte imbalance has been corrected and there are
no related arrhythmias present
Basic (A - E)
• 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)
• 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.
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