Cardiac patient pathway, RHC Glasgow

• See pre-admission care pathway
• All patients listed for cardiac surgery or cardiac catheter will be offered attendance at the clinic unless:
  • Families live >2Hrs from Glasgow
  • Emergency surgical patients
• At the clinic the following will be undertaken:
  • Admission pro forma is completed
  • Investigations as per “Cardiac Pre-Assessment SOP”
  • MRSA screen
  • Parent / patient information provided

• Admission to ward 1E
  • Nursing admission paperwork and pre-operative care plan is completed
  • Medical clerk-in completed
  • Carer accommodation arranged if required during admission and making a Ronald McDonald referral if needed (this is only currently available to families out with the G postcode area).
  • Investigations
    • MRSA screening is completed if not undertaken in preadmission (swabs obtained from perineum or groin and nose)
    • If required (12 years and older) a urine sample will be obtained and pregnancy test is completed at ward level.
    • IV cannula if possible or fasting required
    • Clarify genetic investigations & results if required as per SOP
    • Bloods – FBC / U&E / Bone Screen / X-Match as per SOP (Coag & LFT only if clinically indicated)
    • ECG & ECHO
    • Chest x-ray
  • Observations
    • Baseline TPR, sa02 and BP is obtained, consideration at this time to sa02 level as fasting may require IV fluids.
    • Height and weight – to allow Nutrition Referral Pathway, PYMs, PPUDRA and ‘Active Care’ assessment to be completed and any relevant referrals are made if needed, such as dietician if BMI score indicates referral or if special feeds need to be ordered.
    • Prontosan soaks or bath - Patients must bathe or have prontosan soaks applied the evening before and the morning of surgery.
  • Communication
    • Anaesthetic review and agree fasting time
      • Fasting times are verbally discussed and a card with written confirmation is given to parents/patient. Nightshift nursing staff will then also reiterate fasting times at the start of their shift with parents.
      • Pre-med required?
    • Surgical consent obtained from parents (usually in evening before or morning of theatre) though often obtained in pre-admission clinic
    • Blood products - confirm availability on Trakcare of blood products as per SOP
    • Introduce Cardiac Liaison team
    • PICU information & visit
      • The evening before nursing staff provide parents with ‘picu talk’ basic post op information given such as what to expect the morning of theatre, what will happen in the days after the operation in particular focussing on when they return to the ward 1E. At this point a picu visit is offered.
• Morning of theatre preparations
  • Prontosan soaks
  • Consent form
  • Surgical site infection checklist
  • RHC Theatre checklist completed
  • Fasting as per SOP
  • Sacral pressure area dressing if required
  • Pre-med?
    • Yes - Sp02 monitoring & nurse escort to theatre.
    • No - support staff transfer patient to theatre
  • TED stockings - if required patients are measured for TED stocking and these are sent to theatres to be put on in theatre.

• Investigations
  • Echo / ECG / CXR
  • Clarify genetic investigations & results if required as per SOP
  • Bloods:
    • Cross match as per SOP in light of genetic investigations
    • FBC / UE / Bone screen / CRP / Coag / Anti-thrombin
  • MRSA screen
  • COVID swab
  • If 12yo or greater – urine sample for pregnancy test
• Theatre preparations
  • Introduce Cardiac Liaison team
  • Consent – Surgical & Anaesthetic
  • Surgical site infection checklist
  • RHC Theatre checklist (include height/length & weight)
  • Pre-op Prontosan soaks evening before and morning of theatre or bath
  • Fasting plan pre-op as per PICU Fasting SOP
  • Confirm blood product availability on Trakcare
  • Critical care to theatre handover sheet & A3 daily report
  • Sacral pressure area dressing if required
  • TED stockings?
    • If required patients are measured for TED stocking and these are sent to theatres to be put on in theatre.

• Confirm patient, CHI & procedure @ 0830Hrs Cardiac ward round
• Allocate bed-space & inform appropriate nurse & fellow @PICU Huddle (0930Hrs)
  • PICU Nurse to introduce themselves to family on ward 1e if possible
  • PICU Clerkess to print most recent Cardiac Conference & Echo notes and place at bed space
• Prepare patients bed & transport stack for theatre
  • Monitor & leads (ECG / NIBP / SpO2 / 2 pressure transducer leads)
  • Ensure appropriate size cot or bed
  • Full Air & O2 cylinders & Ambubag
    • Auxiliaries will do this but patients nurse should ensure it is completed
• Cardiac Theatre Handover process
  • Stage 1 (planning of case)
    • Medics & patient nurse to review & discuss recent Cardiac Conference & Echo notes to plan for case
  • Stage 2 (preparation of bed-space)
    • Cardiac Handover form delivered from theatre team & printed in large printer at POD2
    • Prepare bed-space for patient:
      • PICU Nurse:
        Vent with appropriate vent tubing size & complete pre-use check
        Suction low-flow for drains (set for number of drain chambers)
        Chest drain clamps x2
        Accidental chest drain removal pack
        Sleek
        Infusions & fluids prepared
        NIRS monitor & connect Vuelink module
        Blood bottles
        NGT & bile bag
        Splints
        Prepare WAIT board / Intubation & resusc charts
      • Medics:
        Complete Ventilator pre-use check
        Prescribe medications & fluids (use cardiac order set)
        Order bloods & CXR on Trakcare
  • Stage 3 (patient handover)
    • Patients PICU nurse records initial observations on transport monitor
    • 2^nd PICU nurse puts drains on suction
    • Hands-off handover with Anaesthetist keeping patient on T-Piece
      • Anaesthetist
      • Surgeon
      • Questions & agreed plans (ECMO watcher, wake and wean etc)
      • PICU assume command of patient management & agree targets
      • Theatre team leave bedspace
      • PICU fellow attaches ventilator – confirms etCO₂, chest movement & tidal volumes
    • Post-handover
      • Record & document initial observations from transport monitor
      • Transfer monitoring
      • Transfer infusion pumps
      • Transfer pressure transducers
      • Confirm PICU patient plan @ the bedside with PICU nurse, fellow & consultant

• On arrival in PICU
  • Investigations
    • Bloods (FBC, Coag, UE, LFT, Mg, CRP, Arterial & Venous Gases) – by 2^nd PICU Nurse/Medic
      • ABG 4 hourly & VBG 6 hourly - unless clinical concern
    • 12 lead ECG (unless paced) – by Cardiac Physiology
    • CXRay
      • Site NGT (unless on fast-track pathway) prior to CXRay & attach bile bag
  • Observations
  • ECG, SpO₂, etCO₂, Core & peripheral temperature, CVP, BP (IABP)
    
    • Arterial line (until at least morning of Day 1 post-op)
    • Target temp 36-37^oC
  • Read & record chest drain losses & type of fluid (record theatre discard)
    • Every 15 mins for hours 0- 6 post-op, then every 30 mins for hours 7-12 then hourly thereafter
  • NIRS (Renal & bilateral Cerebral if <6 months) keep on until off respiratory and inotropic support
  • Record Pacing if in use in tempory pacing chart on CIS
  • Read & record urine output hourly (record theatre discard)
  • Capillary refill 6 hourly & auscultate chest hourly if intubated
  • Assess pupils are equal and reactive bilaterally 6 hourly
  • Bed 30^O head up tilt & dependant vent tubing
  • Assess pressure areas
  • Medications
    • Check drug dosages and rates - use CIS order set
      • Antibiotic prophylaxis as per SOP
      • Electrolyte targets: iCa2+ > 1.2mmol/l, Mg2+ >1.5mmol/l, K+ 4-4.5mmol/l (consider adding to iv fluids if low)
    • Consider iv Esomeprazole if not starting feeds
    • Start diuretics ~2400Hrs Day 0 if stable
  • Fluid & nutrition
    • Max 50% of maintenance fluids if bypass case (70% if non-bypass case)
    • Heparinised saline for pressure lines at 1-1.5ml/hr
      • NB if 24G arterial line in use should have separate flush bag due to risk of clotting
    • Enteral nutrition may start 6hrs after theatre, if on standard risk nutrition pathway
  • Pain control
    • Regular iv paracetomol (check with PICU Fellow if LFT outwith reference range)
    • Morphine NCA / PCA / ivi
    • Record pain score (hourly)
    • Comfort score 4 hourly (unless paralysed)
  • Clinical examination & admission paperwork to be completed
  • Discharge plans?
    • If yes proceed to “day of discharge from PICU to Ward 1e” section
  • Parents
    • Updated by Ward 1e staff prior to arrival in PICU
    • Updated by Surgeon post-op, with the PICU nurse if possible

• Investigations
  • Bloods (FBC, UE, Bone screen, LFT, CRP, Mg, Arterial & Venous Gases)
    • Only need coag if on heparin or concerns re bleeding
    • Ongoing blood gases as clinically indicated
  • CXRay – after drains removed unless clinical concern or drains not being removed
  • Echo as routine (no ECGH needed unless specific clinical concern or patient is paced)
  • Pacing check (including 12 lead ECG) if patient is paced
• Observations
  • ECG, SpO2, etCO2, Core & peripheral temperature, CVP, BP (IABP or NIBP) hourly
    • Arterial line (until at least morning of Day 1 post-op)
  • NIRS (Renal & bilateral cerebral if <6 months)
    • Continue till off respiratory and inotropic support for at least 6 hours
  • Read & record chest drain losses & type of fluid
  • NIRS (Renal & cerebral if <6 months)
  • Record Pacing if in use
  • Read & record urine output hourly
  • Capillary refill 6 hourly & auscultate chest hourly if intubated
  • Assess pupils are equal and reactive bilaterally 6 hourly
  • Bed 30^O head up tilt & dependent vent tubing
  • Assess pressure areas
• Medications
  • Antibiotic prophylaxis as per SOP
  • Electrolyte targets: iCa2+ > 1.2mmol/l, Mg2+ >1.5mmol/l, K+ 4-4.5mmol/l
  • Diuretics if not started already (set times as per CIS order set)
  • Consider iv Esomeprazole if not starting feeds
• Fluid & nutrition
  • Max of 50% maintenance fluids, even if extubated
  • All patients will have a formal dietetic assessment to set appropriate nutrition goals
  • Enteral nutrition agree on PICU bedside ward round: standard vs high risk nutrition pathway
• Pain control
  • ? change paracetamol to regular enterally (check with PICU Fellow if LFT out with reference range)
  • If > 3 months possibly add Ibuprofen prn if feeding >5ml/hr (unless on heparin or aspirin)
  • Morphine NCA / PCA / ivi
  • Record pain score (hourly)
  • Comfort score 4 hourly (unless paralysed)
• #MoVE - Assessment for early mobility (“MoVE”) as part of routine nursing care plan
• Can we remove:
  • Drains - removed under orders of the PICU Consultant unless surgical concern highlighted. Drains will be kept in till at least day 3 for patients on the RVOTO pathway, Fontan & Glenn physiologies.
  • Central line? Is there a PVC for ongoing fluids / pain relief etc?
  • Arterial line?
  • Urinary catheter?
  • Pacing wires? Remove as per pacing wire SOP - sinus rhythm on 12 lead ECG needs to be confirmed prior to removal
• Discharge plans?
  • If yes - proceed to “Day of discharge from PICU to Ward 1e”
  • Highlight planned discharge for tomorrow at 3pm Hospital huddle

• Investigations
  • Bloods (FBC, UE, Bone Screen, CRP, LFT, Mg)
    • Only need coag if on heparin or concerns re bleeding
    • Ongoing blood gases as clinically indicated
  • Only target electrolytes as Day 0 & 1 if dysrhythmic or on inotropes
  • CXRay only if clinical concern or drain removed
  • Echo / ECG – not routine but at the request of PICU, Cardiac Surgical or Cardiology Consultant as discussed at cardiac handover – Cardiology will arrange if agreed
  • Pacing check, including 12 lead ECG, if patient is paced
• Observations
  • ECG, SpO2, etCO2, Core & peripheral temperature, CVP, BP (IABP or NIBP) hourly
  • NIRS (Renal & bilateral cerebral if <6 months) - continue till off respiratory and inotropic support for at least 6 hours
  • Read & record chest drain losses & type of fluid
  • NIRS (Renal & cerebral if <6 months)
  • Record Pacing if in use
  • Read & record urine output hourly
  • Capillary refill 6 hourly & auscultate chest hourly if intubated
  • Assess pupils are equal and reactive bilaterally 6 hourly
  • Bed 30^O head up tilt & dependant vent tubing
  • Assess pressure areas
  • Review & revise sternal dressings as per SOP
• Fluid & nutrition
  • Max of 75% maintenance fluids, even if extubated
  • Nutrition plan & targets agreed on PICU bedside ward round aiming for 75% enteral fluids if on the standard risk nutrition pathway otherwise follow High Risk pathway
• Medications
  • Electrolyte only targetted as Day 0 & 1 if dysrhythmic or on inotropes
• Pain control
  • Change Paracetamol to regular enterally (check with PICU Fellow if LFT out with reference range)
  • If > 3 months possibly add Ibuprofen prn if feeding >5ml/hr (unless on heparin
  • Morphine NCA / PCA / ivi
  • Record pain score (hourly)
  • Comfort score 4 hourly (unless paralysed)
• #MoVE - Assessment for early mobility (“MoVE”) as part of routine nursing care plan
• Can we remove:
  • Drains – to be removed under orders of the PICU Consultant unless surgical concern highlighted. Drains will be kept in till at least day 3 for patients on the RVOTO pathway, Fontan & Glenn physiologies
    • Wound dressing should be changed on Day 2,5 & 7. Record date of change on the dressing.
  • Central line? Is there a PVC for ongoing fluids / pain relief etc?
  • Arterial line?
  • Urinary catheter?
  • Pacing wires? Remove as per pacing wire SOP - sinus rhythm on 12 lead ECG needs to be confirmed prior to removal
• Discharge plans?
  • If yes proceed to “Day of discharge from PICU to Ward 1e” section
  • Highlight planned discharge for tomorrow at 3pm Hospital huddle

• Investigations
  • Bloods (FBC, UE, Bone Screen, LFT, CRP, Mg)
    • Only need coag if on heparin or concerns re bleeding
    • Ongoing blood gases as clinically indicated
  • Only target electrolytes as Day 0 & 1 if dysrhythmic or on inotropes
  • CXRay only if clinical concern or drain removed
  • Echo / ECG – not routine but at the request of PICU, Cardiac Surgical or Cardiology Consultant as discussed at cardiac handover – Cardiology will arrange if agreed
  • Pacing check, including 12 lead ECG, if patient is paced
• Observations
  • ECG, SpO2, etCO2, Core & peripheral temperature, CVP, BP (IABP or NIBP) hourly
  • NIRS (Renal & cerebral if <6 months) - continue till off respiratory and inotropic support for at least 6 hours
  • Read & record chest drain losses & type of fluid
  • NIRS (Renal & cerebral if <6 months)
  • Record Pacing if in use
  • Read & record urine output hourly
  • Capillary refill 6 hourly & auscultate chest hourly if intubated
  • Assess pupils are equal and reactive bilaterally 6 hourly
  • Bed 30^o head up tilt & dependent vent tubing
  • Assess pressure areas
• Fluid & nutrition
  • Max of 75% maintenance fluids if ventilated
  • Nutrition plan & targets agreed on PICU bedside ward round aiming for 100% enteral fluids if on the standard risk nutrition pathway otherwise follow High Risk nutrition pathway
• Medications
  • Electrolyte only targetted as Day 0 & 1 if dysrhythmic or on inotropes
• Pain control
  • Change Paracetamol to regular enterally (check with PICU Fellow if LFT out with reference range)
  • If > 3 months possibly add Ibuprofen prn if feeding >5ml/hr (unless on heparin)
  • Morphine NCA / PCA / ivi
  • Record pain score (hourly)
  • Comfort score 4 hourly (unless paralysed)
• #MoVE - Assessment for early mobility (“MoVE”) as part of routine nursing care plan
• Can we remove:
  • Drains – to be removed under orders of the PICU Consultant unless surgical concern highlighted. Drains will be kept in till at least day 3 for patients on the RVOTO pathway, Fontan & Glenn physiologies
    • Wound dressing should be changed on Day 2, 5 & remove on day 7 unless still ventilated. Record date of change on the dressing.
  • Central line? Is there a PVC for ongoing fluids / pain relief etc?
  • Arterial line?
  • Urinary catheter?
  • Pacing wires? Remove as per pacing wire SOP - Sinus rhythm on 12 lead ECG needs to be confirmed prior to removal
• Discharge plans?
  • If yes proceed to “Day of discharge from PICU to Ward 1e” section
  • Highlight planned discharge for tomorrow at 3pm Hospital huddle

• Communication
  

  0300—0400Hrs	Brief nursing handover between 0300 – 0400Hrs to enable bed-space to be set-up in Ward 1e Medical handover written & drug chart / PCA prescribed, set-up & started Aim for drug delivery during the day - especially diuretics (aim for 0800 & 1800Hrs)
  0800Hrs	Discharge time agreed at morning huddle, as early as possible & before 5pm unless extenuating circumstances
  0830-0900Hrs	Patient plan discussed at PICU cardiac round
  0900-0930Hrs	Pacing check, including 12 lead ECG, if patient is paced PICU Medical handover to Cardiology Ward Fellow on Ext 84874 & Saturday/Sunday on  84440       Place filed notes & drug Kardex & NCA/PCA forms at bedside for patient to discharge - NB aim to have set times 0600 / 1200 / 1800 / 2400Hrs Inform pain team of discharge, if follow-up required
  Bedside nursing handover in Ward 1e on discharge to Ward 1e

• Tasks in Ward 1e
• Investigations
  
  • Nil required unless planned by Cardiology medical team

• Observations
• Baseline observations are obtained
• ECG, SpO2, NIBP monitoring commenced & recorded 2 hourly for 24 hours from time of arrival. 
• Assessment of
  • Wounds & dressings - Full inspection of patient is carried out to identify any wounds and dressings in situ and also to ensure identification of any groin cut down sites. Sacral dressing removed at this time if still in situ. 
  • Lines - Full inspection also aids us in identifying what IV access the patient has and allows us to ensure PVC/CVC’s are working and safety checks completed.
  • Drains - If patient has chest drain(s) in situ and has been having large losses or has had an operation likely to result in large losses, the chest drains will be split upon transfer to allow accurate monitoring of losses and therefore speed up potential removal in the days to come.
• Fluid & nutrition
  • Nutrition assessment undertaken as standard by Cardiac Ward Dietician for all post-operative cardiac patients
  • Weight obtained morning after transfer and at least every 2 days thereafter
  • Fluid restriction is reviewed upon transfer and intake prior to transfer is determined and a new remaining volume is worked out to last until 8am the following morning.
  • Feeds generally normalised soon after transfer (within restriction) bolus and oral offered as soon as possible.
• Medication
• Reviewed by Cardiology team & PICU transfer pro-forma completed
• Pain control
• NCA/PCA reviewed continuously and removed as soon as able, oramorph prescribed if required
• Early rehabilitation (MoVE)
• Encourage mobilisation and up to sit in chair etc
• Ongoing physiotherapy assessment as required

• Investigations
• Nil required unless planned by Cardiology medical team
• Daily U&E if on TPN
• Coagulation investigation as per SOP if on Enoxaparin / Warfarin
• Pacing check, including 12 lead ECG, if patient is paced

• Medical review – daily assessment & examination
• Observations
• ECG, SpO2, NIBP monitoring commenced & recorded 2 hourly for 24 hours from time of arrival. 
• Assessment of
  • Wounds & dressings - Wound care is given day 2, 5 and exposed day 7.
  • Lines - Full inspection also aids us in identifying what IV access the patient has and allows us to ensure PVC/CVC’s safety checks are completed.
  • Drains - If patient has chest drain(s) in situ and has been having large losses or has had an operation likely to result in large losses, the chest drains will be split upon transfer to allow accurate monitoring of losses and therefore speed up potential removal in the days to come.
• Fluid & nutrition
  • Weight obtained morning after transfer and at least every 2 days thereafter
  • Increase nutrition as able – refer as appropriate to the dietetic team via TRAKCare
  • Consider SALT referral if not feeding orally
• Medication
  • Reviewed by Cardiology team
• Pain control
  • NCA/PCA reviewed continuously and stopped as soon as able, oramorph prescribed if required
• Early rehabilitation (MoVE)
  • Encourage mobilisation and up to sit in chair etc
  • Ongoing physiotherapy assessment as required
• Remove?
  • Chest drains removed depending on losses.  Chest drain sutures removed 5 -7 days post removal. Drains will be kept until at least day 3 for patients on the RVOTO pathway, Fontan & Glenn
  • Pacing wires removed as per SOP on instruction of medical staff - ensure normal 12 lead ECG prior to removal (may have been done on PICU)
  • Can vascular access be removed?
• Discharge planning
  • Investigations pre-discharge - as clinically indicated
  • Discharge medications ordered
  • Discharge summary prepared & signed
  • Arrange follow-up 4-6 weeks or as per Consultant instructions 
• Other areas
  • Parental training takes places in days post operatively if required such as home monitoring programme, Ng feeding and passing of Ng if appropriate and subcut injection and INR training.
  • Health visitors contacted for every patient pre-school age as courtesy and updated on admission and treatment, regular weights arranged if required.
  • Community nursing team referrals made for patients going home prior to 7 days post op – for suture and wound care.

Fluid maintenance calculations:

• 0-10kg = 100ml/kg
• 11-20kg = 50ml/kg
• >20kg = 25ml/kg

Immunisations advice:

• All routine immunisations should be given where indicated 4 weeks after cardiopulmonary bypass except MMR which should be delayed for 3 months post-bypass, as it is a live vaccine.