NUTS and BOLTS for orders:



NUTS and BOLTS for orders:

1. LABS:

• Troponins and CPK Q6 hours until they trend down

• Lipid panel

• Liver Enzymes

• TSH

• A1c

• Chem 10

• PT/PTT/INR

• CBC/Diff

• BNP, UA, Uric acid, PA + LAT, TTE for CHF patients

2. SERIAL ECG’s for acute coronary patients

3. ECHOCARDIOGRAM: for patients with new onset CHF, ACS.

• If chronic CHF, and no suspicion for new valvular dysfunction, and recent echocardiogram in past 6 months, no need for routine repeat.

4. STRESS TESTING:

• When ordering an exercise stress test, do not start de novo beta blockers as this will lead to an inconclusive test.

• When ordering ANY stress test especially a dipyridamole (dipy) cardiolite (nuclear) stress test, discontinue all caffeine from diet.

5. DIET:

• If you believe a patient will be undergoing a stress test or cardiac catheterization, make them NPO.

• Discontinue caffeine from diet if the patient is going for a dipy cardiolite.

6. DISCHARGE Medication Reconciliation/Orders:

As on all other inpatient services, you must complete medicine reconciliation

• For ACS patients:

1. Must have Aspirin at discharge

2. Plavix at discharge if stent placed, must know if patient had a bare metal stent or drug coated stent as it will change length of time patient must remain on Plavix.

3. Statin

4. Smoking cessation counseling/referral

5. Beta blocker

• For CHF patient:

1. Beta blocker (carvedilol or metoprolol XL, carvedilol more affordable)

2. Ace inhibitor/ARB

3. Heart Failure education for new HF patients.

4. Diet salt restriction counseling for all patients (this is included in the HF education).

5. Diuretic (patient needs to be on an oral dose and responding 24 hours prior to discharge, anticipate this need to facilitate efficient discharges)

6. Smoking cessation counseling/referral if the patient has smoked in the last year.

7. IF THE PATIENT IS NOT DISCHARGED WITH ONE OR MORE OF THESE PLEASE DOCUMENT WHY IN THE DISCHARGED SUMMARY AND THE DISCHARGE NOTE.

a. If the patient is not discharged on an ACEi or an ARB please document:

i. “ACEi/ARB was held due to elevated creatinine.”

ii. “ACEi/ARB was not initiated due to hyperkalemia, will continue to monitor and start when appropriate.”

8. REVIEW MEDICATION LIST found in Clinic Notes ( Inpt Discharge Documentation (Inpt Depart Summary after completion of med-reconciliation to ensure the pt is being discharged on the correct medications (dose, frequency, quantity) and that there are no duplications.

THIS LIST MUST MATCH THE DISCHARGED SUMMARY TO MEET CORE MEASURES.

FOLLOW UPS:

1. All CHF patients need a 7 day follow up and a 72 hours phone call. Please call the Heart Failure educator (Lorena Beeman) 24 hours prior to discharge for assistance with this:

a. (505) 307-1242 (cell)

b. (505) 951-3113 (Pager)

2. General Cardiology Clinic 272- 2273

3. UNMH Coumadin Clinic 272-6202

|Core Measures |

|Measure |Definition | |Measure |Definition |

|HF1 |Discharge Instructions | |AMI1 |Aspirin at Arrival |

|HF2 |Evaluation of LVS Function | |AMI2 |Aspirin prescribed at discharge |

|HF3 |ACEI or ARB for LVSD | |AMI3 |ACEI or ARB for LVSD |

|HF4 |Smoking Cessation Advice | |AMI4 |Smoking Cessation Advice |

| |72 hr phone call and 7 day f/u | |AMI5 |Beta Blocker prescribed at Discharge |

| | | |AMI8a |PCI received wi/n 90 minutes of arrival |

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