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/ space space Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals space 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 Approved by Amendment notes August 2016 Deputy Secretary, The original document was published as a Policy Directive. It (GL2016_019) 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 Director General, New policy (PD2008_055) Health NSW

GL2016_019 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

• 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

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

Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals Page 3 Introduction

Cardiac monitoring is a routine clinical activity The guideline represents the recommended minimum carried out in hospitals throughout NSW. standards for cardiac monitoring for adult patients with a primary cardiac diagnosis, regardless of the clinical Over time individual hospitals have developed area in which they are managed. Compliance with the a range of protocols and standards for cardiac guideline will improve patient outcomes and timely monitoring which has resulted in variance in discharge through the appropriate use of cardiac practice between hospitals and between local monitoring in public hospitals in NSW. health districts (LHDs). This guideline replaces This document may be used by LHDs to inform the the NSW Health Policy Directive on Cardiac development of their own policies incorporating the Monitoring in Adult Cardiac Patients in Public minimum standards described in this guideline and additional information from other sources. The skill set Hospitals in NSW (PD2008_055). and competency requirements should be interpreted in the context of the local clinical environment.

There is limited available evidence relating to cardiac The numbers in superscript in this document relate to monitoring and practice remains unchanged since the definitions in the glossary. 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.

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 5. It is preferable that patients who require managing patients with cardiac arrhythmia or continuous cardiac monitoring1 remain monitored acute ischaemic changes (actual or potential). at all times. However, if cardiac monitoring must However, it has no therapeutic value unless the be interrupted for any reason, patients must be clinicians supervising the patient are skilled in the under direct visual observation2 by clinical staff recognition and management of these with the appropriate skill set (see Table 1 on page abnormalities. 6) during the entire period that central cardiac monitoring is unavailable. 2. Registered nurses (RN) may allocate a patient to a monitoring category in the absence of medical 6. Clinical areas managing patients listed in this direction, however, the final responsibility for risk guideline should have at least one nurse on duty at assessment of patients requiring cardiac monitoring all times who meets competency requirements for rests with the treating medical officer. the relevant escort skill sets (see Table 1 on page 6).

3. Clinical areas designated as appropriate for the 7. If facilities are unable to meet this standard, the management of patients requiring continuous patient should be transferred to a facility that is cardiac monitoring1 should have central monitoring able to provide this level of care. capability with all cardiac monitors (apart from 8. If a patient is being transferred, direct visual those used for transfers) connected to the central observation must be maintained by a clinician with monitor. In the absence of a local policy, alarm the appropriate skill set (see Table 1 on page 6). parameters should be set as per ‘Between the Flags Yellow Zone’. 9. Each LHD should determine the required competency assessments for each facility to 4. At the end of the minimum recommended ensure availability of adequate staffing skill mix. 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.

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

C Assessment and management of In this context, the ability to administer supplemental angina/angina equivalent 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 Can demonstrate the requisite knowledge to manage a requiring titration 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 • 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 ingestion arrhythmias

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

Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals 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 • Monitor until second troponin is available. If • Basic (A – E) • NSTEACS (intermediate risk) second troponin is negative and there are no awaiting second troponin level acute ECG changes or recurrence of symptoms of suspected myocardial ischaemia, cardiac monitoring may be discontinued.

Arrhythmias • Monitor until reversion of rhythm or control • Basic (A – E) • Supraventricular arrhythmias of ventricular rate. (including rapid AF) with haemodynamic stability requiring commencement of intravenous therapy with pro-arrhythmic potential (e.g. amiodarone, sotalol, flecainide)

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

Post PCI, post EPS and post catheter • Monitor for a minimum of 4 hours post- • Basic (A – E) ablation procedure (or as per local policy). • Monitor for up to 24 hours if there are procedural complications, arrhythmias, chest pain or haemodynamic compromise.

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 • Monitor according to the direction of the treating medical • Suspected cardiac trauma team or local guidelines • Electrocution

Inflammatory/infective cardiac conditions • Monitor according to the direction of the treating medical • For example, endocarditis, myocarditis or pericarditis team or local guidelines

Table 5

When is cardiac monitoring NOT required?

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

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, VF Ventricular fibrillation Treatment, Escalation and Communication in Teams

EPS Electrophysiology study VT Ventricular tachycardia

Glossary

In the context of this document the following 4 Clinically stable means that the patient has not definitions apply: exhibited any of the following during the previous 24 hours: 1 Continuous cardiac monitoring means that the patient is connected to a cardiac monitor that is a component • recurrence of symptoms of myocardial ischaemia of a system with central monitoring functionality • cardiac arrhythmias requiring intervention (including active alarms). • haemodynamic instability requiring supportive 2 Direct visual observation means that the clinician can therapy (i.e. intravenous vasoactive medications see and assess the patient at all times. or temporary cardiac pacing.

5 3 Clinically unstable means that the patient has Medical Officer means the most senior doctor, or their exhibited one or more of the following during the delegate, responsible for the care of the patient. previous 24 hours: 6 Supportive therapy means IV medications that may • recurrence of symptoms of myocardial ischaemia require titration, or temporary external pacing. • cardiac arrhythmias requiring intervention 7 Management of angina means administration of • haemodynamic instability requiring supportive oxygen (if clinically indicated), nitrates and analgesia. therapy (i.e. intravenous vasoactive medications or 8 External cardiac pacing means transcutaneous pacing. temporary cardiac pacing).

Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals Page 10 Additional resources and reference material

(a) Drew B, Dempsey J, Joo ED et al. Pre-hospital The Australian Resuscitation Council has provided synthesized 12-lead ECG ischemia monitoring with guidelines relating to the required skills and knowledge trans-telephonic transmission in acute coronary for advanced life support. These guidelines may be syndromes. Journal of Electrocardiology. 2004. accessed at http://resus.org.au/ 37: p214 -221. An interactive, electronic ECG resource has been The Health Education and Training Institute (HETI) developed by CIAP which is available by accessing the module on Introduction to Cardiac Monitoring focuses CIAP website, selecting ‘Tools’ and clicking on the link on the professional obligations of staff caring for for ‘Interactive ECG’ or following the link http://ecg.hcn. patients during monitoring and is useful for junior staff com.au/?acc=36422 new to working in cardiology. This course can be Information on atrial fibrillation after coronary artery accessed at http://www.heti.nsw.gov.au/heti-online- bypass surgery is available at http://www.uptodate. modules/ 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

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

Cardiac monitoring has no therapeutic value unless the A daily re-assessment of the clinical indication for continued Each LHD should determine the required competency 1. supervising clinicians can recognise and manage cardiac 4. monitoring should be performed by the treating medical team for 7. assessments to ensure a safe skill mix is available at all  abnormalities.  group A or skilled delegate (e.g. CNC, CNE, NUM) for group B.  times.

The treating medical officer has the final responsibility for Patients should remain monitored at all times. If monitoring is interrupted If a patient is being transferred, direct visual 2. risk assessment of patients requiring cardiac monitoring 5. for any reason, patients must be under direct visual observation by  8. observation must be maintained by a clinician with the and allocation to the appropriate monitoring category.  appropriately skilled staff until monitoring is recommenced. appropriate skill set.

All cardiac monitors should be connected to a central If the facility cannot meet these standards, the patient One nurse who meets competency requirements for the relevant monitor. In the absence of local policy, alarm parameters should be transferred to a facility able to provide this 3. 6. escort skill sets should be on duty at all times. 9.  should be set as per ‘Between the Flags Yellow Zone’.  standard of care.

CLINICAL INDICATION RECOMMENDED MONITORING DURATION ESCORT SKILL SET REQUIREMENTS • All STEMI and NSTEMI must be monitored for a minimum of 24 hours. • ST segment monitoring may be useful if available. Confirmed acute coronary Basic and advanced (A – K) syndrome • 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. Pre-operative cardiac surgery • Continue cardiac monitoring until successful coronary revascularisation occurs. Basic and advanced (A – K) • Require continuous cardiac monitoring OR direct visual Post-operative cardiac surgery • Monitor for a minimum of 48 hours. Basic and advanced (A – K) observation until cardiac monitoring is discontinued. Post cardiac arrest • 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. GROUP 1. Patients who are • Require a written medical order to discontinue cardiac A • Monitor until reversible cause is identified and treated, cardiac symptoms have considered clinically monitoring. been stabilised by medical therapy and/or device is implanted and satisfactorily unstable: Life threatening arrhythmias/ tested. Basic and advanced (A – K) • At the end of the recommended monitoring period, Group Implantable devices NB: Cardiac monitoring is always required during temporary cardiac pacing even 2. Patients who are A patients require daily re-assessment of the clinical if device implant is not planned. considered clinically stable indications for continued monitoring and documentation of Basic (A – E) these indications in the health care record. • Continue cardiac monitoring during the course of therapy. Pharmacotherapy • Duration of monitoring must be determined by medical officer based on type of Basic and advanced (A – K) drug, dose and time since ingestion. Cardiogenic shock, haemodynamic • Continue cardiac monitoring during the course of therapy. Basic and advanced (A – K) or respiratory compromise • Monitor until second troponin is available. If 2nd troponin is negative and there • Require continuous cardiac monitoring OR direct visual Suspected acute coronary are no acute ECG changes or recurrence of symptoms of suspected myocardial Basic (A - E) observation until monitoring is discontinued. syndrome ischaemia, cardiac monitoring can be discontinued. • Unless there is a written medical order to continue, cardiac Arrhythmias • Monitor until reversion of rhythm or control of ventricular rate Basic (A - E) monitoring should be discontinued by RNs at the end of the recommended monitoring period if patients are clinically Acute severe electrolyte • Monitor until the acute electrolyte imbalance has been corrected and there are stable. Discontinuation of cardiac monitoring should be GROUP Basic (A - E) imbalance no related arrhythmias present discussed with the RN in charge or another competent RN (see B competency requirements A – K in the guideline). • If monitoring continues after the completion of the recommended period, daily re-assessment and documentation • Monitor for a minimum of 4 hours post-procedure (or as per local policy). Post PCI, post EPS and post of the indications for monitoring is required. Basic (A - E) catheter ablation • Monitor for up to 24 hours if there are procedural complications, arrhythmias, • Medical staff should specify the time period for additional chest pain or haemodynamic compromise. 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.

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