Cardiac Monitoring Of Adult Cardiac Patients In NSW Public .
GuidelineMinistry of Health, NSW73 Miller Street North Sydney NSW 2060Locked Mail Bag 961 North Sydney NSW 2059Telephone (02) 9391 9000 Fax (02) 9391 ceCardiac Monitoring of Adult Cardiac Patients in NSW PublicHospitalsspaceDocument Number GL2016 019Publication date 17-Aug-2016Functional Sub group Clinical/ Patient Services - Medical TreatmentClinical/ Patient Services - Nursing and MidwiferySummary The clinical Guideline on cardiac monitoring of adult cardiac patients inNSW public hospitals provides the recommended minimum standards forcardiac monitoring for adult patients with a primary cardiac diagnosis,regardless of the clinical area in which they are managed. Compliancewith the Guideline will improve patient outcomes and timely dischargethrough the appropriate use of cardiac monitoring. This Guidelinereplaces PD2008 055.Replaces Doc. No. Cardiac Monitoring in Adult Cardiac Patients in Public Hospitals in NSW[PD2008 055]Author Branch Agency for Clinical InnovationBranch contact Agency for Clinical Innovation 02 9464 4620Applies to Local Health Districts, Board Governed Statutory Health Corporations,Chief Executive Governed Statutory Health Corporations, SpecialtyNetwork Governed Statutory Health Corporations, Government MedicalOfficers, Ministry of Health, Private Hospitals and Day ProcedureCentres, Public HospitalsAudience Nurses, doctors (including VMOs), GPs working in rural hospitalsDistributed to Public Health System, Divisions of General Practice, GovernmentMedical Officers, Health Associations Unions, NSW Ambulance Service,Ministry of Health, Tertiary Education InstitutesReview date 17-Aug-2021Policy Manual Not applicableFile No. ACI/D16/5041Status ActiveDirector-General
GUIDELINE SUMMARYCARDIAC MONITORING OF ADULT CARDIACPATIENTS IN NSW PUBLIC HOSPITALSPURPOSEOver time, individual hospitals have developed a range of protocols and standards forcardiac monitoring resulting in practice variance between hospitals and local healthdistricts (LHDs).The clinical Guideline provides the recommended minimum standards for cardiacmonitoring 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 dischargethrough the appropriate use of cardiac monitoring in public hospitals in NSW. ThisGuideline replaces PD2008 055 - Cardiac Monitoring in Adult Cardiac Patients in PublicHospitals in NSW.KEY PRINCIPLESCardiac monitoring is a useful diagnostic tool for managing patients with cardiacarrhythmia or acute ischaemic changes (actual or potential). However, it has notherapeutic value unless the clinicians supervising the patient are skilled in therecognition and management of these abnormalities.Registered nurses (RN) may allocate a patient to a monitoring category in the absenceof medical direction, however, the final responsibility for risk assessment of patientsrequiring cardiac monitoring rests with the treating medical officer.Clinical areas designated as appropriate for the management of patients requiringcontinuous cardiac monitoring (see Glossary, page 10) should have central monitoringcapability with all cardiac monitors (apart from those used for transfers) connected tothe central monitor. In the absence of a local policy, alarm parameters should be set asper ‘Between the Flags Yellow Zone’.At the end of the minimum recommended monitoring period, a daily re-assessment ofthe patient’s clinical indication for continued monitoring is necessary to ensure thatmonitoring is ceased when it is no longer required. This assessment should beperformed by the treating medical team for group A patients (see page 7) or anappropriately 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 beinterrupted for any reason, patients must be under direct visual observation (seeGlossary, 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 nurseon duty at all times who meets competency requirements for the relevant escort skillsets (see Table 1, page 6).If facilities are unable to meet this standard, the patient should be transferred to a facilitythat is able to provide this level of care.GL2016 019Issue date: August-2016Page 1 of 3
GUIDELINE SUMMARYIf a patient is being transferred, direct visual observation must be maintained by aclinician with the appropriate skill set (see Table 1, page 6).Each LHD should determine the required competency assessments for each facility toensure availability of adequate staffing skill mix.USE OF THE GUIDELINEChief Executives Should provide the document to staff working in areas where cardiac monitoringmay 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 patientexperience, 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 recommendationsin the Guideline Should have the required basic or advanced skill set for patient escort (see Table1, page 6) Should discontinue cardiac monitoring for group B patients after therecommended monitoring period if the patient is stable after discussion with asenior registered nurse, unless there is a written medical order to continue (seeTable 3, page 8).Medical Staff (including general practitioners) Should review the requirement for cardiac monitoring daily for all patients (seeTable 2, page 7; see Table 3, page 8) Should document in the patient’s medical record if cardiac monitoring is tocontinue after the recommended monitoring period stating the clinical indicationsand specific timeframe (see Table 2, page 7; see Table 3, page 8) Should document in the patient’s medical record if cardiac monitoring is todiscontinue (see Table 2, page 7).REVISION HISTORYVersionAugust 2016(GL2016 019)Approved byDeputy Secretary,September 2016(PD2008 055)Director General,Health NSWGL2016 019Amendment notesThe original document was published as a Policy Directive. Ithas now been revised to a Guideline by the ACI. It providesthe skill set and competency requirement for staff escortingcardiac patients.New policyIssue date: August-2016Page 2 of 3
GUIDELINE SUMMARYATTACHMENTS1. Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals – Guideline2. Cardiac Monitoring of Adult Cardiac Patients in NSW Public Hospitals – PosterGL2016 019Issue date: August-2016Page 3 of 3
CLINICAL GUIDELINECardiac monitoring ofadult cardiac patientsin NSW public hospitalsCardiac NetworkCollaboration. Innovation. Better Healthcare.
The Agency for Clinical Innovation (ACI) works with clinicians, consumers and managers todesign and promote better healthcare for NSW. It does this by: serviceredesign and evaluation – applying redesign methodology to assist healthcare providers andconsumers to review and improve the quality, effectiveness and efficiency of services s pecialist advice on healthcare innovation – advising on the development, evaluation and adoption ofhealthcare innovations from optimal use through to disinvestment i nitiatives including guidelines and models of care – developing a range of evidence-based healthcareimprovement initiatives to benefit the NSW health system i mplementation support – working with ACI Networks, consumers and healthcare providers to assistdelivery of healthcare innovations into practice across metropolitan and rural NSW k nowledge sharing – partnering with healthcare providers to support collaboration, learning capability andknowledge sharing on healthcare innovation and improvement continuouscapability building – working with healthcare providers to build capability in redesign, projectmanagement and change management through the Centre for Healthcare Redesign.ACI Clinical Networks, Taskforces and Institutes provide a unique forum for people to collaborate across clinicalspecialties 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 withhealthcare providers to develop mechanisms to improve clinical practice and patient care.www.aci.health.nsw.gov.auAGENCY FOR CLINICAL INNOVATIONLevel 4, Sage Building67 Albert AvenueChatswood NSW 2067PO Box 699 Chatswood NSW 2057T 61 2 9464 4666 F 61 2 9464 4728E info@aci.nsw.gov.au www.aci.health.nsw.gov.auSHPN (ACI) 160069, ISBN 978-1-76000-391-3.Produced by: Cardiac NetworkFurther copies of this publication can be obtained fromthe Agency for Clinical Innovation website at www.aci.health.nsw.gov.auDisclaimer: Content within this publication was accurate at the time of publication. This work is copyright. It may be reproducedin whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source. It may not bereproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires writtenpermission from the Agency for Clinical Innovation.Cover image courtesy of GE Healthcare.Version: V1.3.Date of review: August 2016. GL2016 019Date Amended: 26/04/2016 Agency for Clinical Innovation 2016Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitalsPage 2
ContentsIntroduction4Scope5Principles – minimum standard5Table 1: Skill sets for staff escorts and required competencies6Table 2: Group A: conditions where monitoring is required7Table 3: Group B: conditions where monitoring is required8Table 4: Other conditions when cardiac monitoring MAY be required9Table 5: When is cardiac monitoring NOT required?9Abbreviations10Glossary10Additional resources and reference material11Acknowledgements11Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitalsPage 3
IntroductionCardiac monitoring is a routine clinical activitycarried out in hospitals throughout NSW.Over time individual hospitals have developeda range of protocols and standards for cardiacmonitoring which has resulted in variance inpractice between hospitals and between localhealth districts (LHDs). This guideline replacesthe NSW Health Policy Directive on CardiacMonitoring in Adult Cardiac Patients in PublicHospitals in NSW (PD2008 055).The guideline represents the recommended minimumstandards for cardiac monitoring for adult patients witha primary cardiac diagnosis, regardless of the clinicalarea in which they are managed. Compliance with theguideline will improve patient outcomes and timelydischarge through the appropriate use of cardiacmonitoring in public hospitals in NSW.There is limited available evidence relating to cardiacmonitoring and practice remains unchanged since thepublication of the original cardiac monitoring policy.Therefore, this document is based on the best availableevidence(a) and consensus opinion. The guideline hasThe numbers in superscript in this document relate todefinitions in the glossary.This document may be used by LHDs to inform thedevelopment of their own policies incorporating theminimum standards described in this guideline andadditional information from other sources. The skill setand competency requirements should be interpreted inthe context of the local clinical environment.been produced in consultation with cardiac nurses andcardiologists in rural and metropolitan areas, consumerrepresentatives, cardiothoracic surgeons, the Agencyfor Clinical Innovation Cardiac Network, the HeartFoundation, the Cardiac Society of Australia and NewZealand, the Australian Commission for Safety andQuality in Health Care and NSW Ambulance.Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitalsPage 4
ScopeThis guideline applies only to adult patients with a primary cardiac diagnosis. Clinical staff shouldrefer to local guidelines for the use of cardiac monitoring in the management of patients withnon-cardiac medical or surgical conditions.Principles – minimum standard1.Cardiac monitoring is a useful diagnostic tool formanaging patients with cardiac arrhythmia oracute ischaemic changes (actual or potential).However, it has no therapeutic value unless theclinicians supervising the patient are skilled in therecognition and management of theseabnormalities.2.Registered nurses (RN) may allocate a patient to amonitoring category in the absence of medicaldirection, however, the final responsibility for riskassessment of patients requiring cardiac monitoringrests with the treating medical officer.3.4.Clinical areas designated as appropriate for themanagement of patients requiring continuouscardiac monitoring1 should have central monitoringcapability with all cardiac monitors (apart fromthose used for transfers) connected to the centralmonitor. In the absence of a local policy, alarmparameters should be set as per ‘Between the FlagsYellow Zone’.At the end of the minimum recommendedmonitoring period, a daily re-assessment of thepatient’s clinical indication for continued monitoringis necessary to ensure that monitoring is ceasedwhen it is no longer required. This assessmentshould be performed by the treating medical teamfor group A patients or an appropriately skilleddelegate (e.g. CNC, CNE, NUM) for group B patients.5.It is preferable that patients who requirecontinuous cardiac monitoring1 remain monitoredat all times. However, if cardiac monitoring mustbe interrupted for any reason, patients must beunder direct visual observation2 by clinical staffwith the appropriate skill set (see Table 1 on page6) during the entire period that central cardiacmonitoring is unavailable.6.Clinical areas managing patients listed in thisguideline should have at least one nurse on duty atall times who meets competency requirements forthe relevant escort skill sets (see Table 1 on page 6).7.If facilities are unable to meet this standard, thepatient should be transferred to a facility that isable to provide this level of care.8.If a patient is being transferred, direct visualobservation must be maintained by a clinician withthe appropriate skill set (see Table 1 on page 6).9.Each LHD should determine the requiredcompetency assessments for each facility toensure availability of adequate staffing skill mix.Cardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitalsPage 5
Table 1Skill sets for staff escorts and required competenciesBasic escort skill setCompetency requirementsABasic life supportHolds current, facility endorsed BLS accreditation thatincludes the use of an AEDBRecognition and management of thedeteriorating patientSuccessful completion of training in the recognition andmanagement of the deteriorating patient e.g. DETECTCAssessment and management ofangina/angina equivalentIn this context, the ability to administer supplementaloxygen, nitrates and analgesiaDBasic cardiac rhythm interpretationCan recognise VT/VF and other arrhythmias commonlyconsidered to be life-threateningEManagement of the infusion pump (if in use)Can demonstrate the ability to adjust flow rates ifrequired and troubleshoot pump functionAdvanced escort skill setCompetency requirementsFAirway managementHolds current, facility endorsed accreditation forventilation using bag and maskGAdministration of ALS drugsHolds current, facility endorsed ALS accreditation thatincludes administration of intravenous ALS drugsHCardiac defibrillationHolds current, facility endorsed ALS accreditation thatincludes the use of a manual defibrillatorIManagement of a temporary cardiac pacemakerHolds current, facility endorsed accreditation formanaging a patient with a temporary cardiacpacemaker (transvenous, transthoracic or epicardialelectrodes in situ) including the ability to troubleshootpacemaker functionJManagement of IV medicationsrequiring titrationCan demonstrate the requisite knowledge to manage apatient with an infusion of medication requiring titratione.g. inotropes, nitrates and other drugsKExternal cardiac pacingHolds current, facility endorsed accreditation forinitiation and management of transcutaneous cardiacpacing, including troubleshooting pacemaker functionCardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitalsPage 6
Table 2Group 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 andinter-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 clinicalindications for continued monitoring and documentation of these indications in the health care record.Clinical indication for monitoringRecommended monitoring durationEscort skill setConfirmed accute coronary syndrome Confirmed STEMI/NSTEMI 24 hours Confirmed STEMI/NSTEMI 24 hours but consideredclinically unstable3 All STEMI and NSTEMI must be monitored fora minimum of 24 hours ST segment monitoring may be useful ifavailable At the end of the recommended monitoringperiod, patients who are clinically stable4should 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 (orequivalent) awaiting urgentsurgical revascularisation Continue cardiac monitoring until successfulcoronary 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 untilcause has been identified and treated Basic and advanced (A – K)Life-threatening arrhythmias /implantable devices Wide complex tachyarrhythmiaincluding VT, VF or SVTwith aberrancy Narrow complex tachyarrhythmiawith haemodynamic instability Syncope of unknown origin Second and third degree AV blocks Symptomatic bradyarrhythmia Awaiting insertion of implantablecardiac device (ICD, PPM) /temporary cardiac pacing Monitor until reversible cause is identifiedand treated, cardiac symptoms have beenstabilised by medical therapy and/or device isimplanted and satisfactorily tested NB: Cardiac monitoring is always requiredduring temporary cardiac pacing even ifdevice implant is not planned1. Patients who are consideredclinically unstable3 Basic and advanced (A – K)PharmacotherapyIntravenous drug therapy Inotropes, vaso-active drugs,anti-arrhythmics, fibrinolyticsOther Ingestion of pro-arrhythmic drugscausing actual or potential QTprolongation or ventriculararrhythmias Continue cardiac monitoring during thecourse of therapy Basic and advanced (A – K)Cardiogenic shock, haemodynamic orrespiratory compromise Requiring support with inotropesor intra-aortic balloon pump Continue cardiac monitoring during thecourse of therapy2. Patient who are consideredclinically stable4 Basic (A – E) Duration of monitoring must be determinedby medical officer based on type of drug,dose and time since ingestionCardiac Network – Cardiac monitoring of adult cardiac patients in NSW public hospitals Basic and advanced (A – K)Page 7
Table 3Group B: conditions where monitoring is required Patients require continuous cardiac monitoring1 OR direct visual observation2 until cardiac monitoring is discontinued. Patie
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
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