Unique Plan Description: ED ACS (STEMI, NSTEMI, Unstable Angina)
Plan Selection Display: ED ACS (STEMI, NSTEMI, Unstable Angina)
PlanType: Medical                                 
Version: 2          
Begin Effective Date: 2020-04-23 21:50:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2024-04-16 13:55:51
Available at all facilities: No

ED ACS (STEMI, NSTEMI, Unstable Angina)
Admit/Discharge/Transfer
	ED Request for Bed
		T;N
Diet
	NPO
		NPO Except for: Medications
Laboratory
	hs Troponin T - MH/WH/JE
		T;N, Stat, spec type = Blood
	CBC with Diff
		T;N, Stat, spec type = Blood
	Comprehensive Metabolic Panel
		T;N, Stat, spec type = Blood
	PTT - MH/WH/JE
		T;N, Stat, spec type = Blood
	Partial Thromboplastin Time (PTT) - FH
		T;N, Stat, spec type = Diagnostic Blood
	Basic Metabolic Panel
		T;N, Stat, spec type = Blood
	INR - MH/WH/JE
		T;N, Stat, spec type = Blood
	Prothrombin Time (PT) - FH
		T;N, Stat, spec type = Diagnostic Blood
		T;N, Stat, spec type = Therapeutic Blood
	Heparin Anti-Xa Heparin
		T;N, Stat, spec type = Blood
	Urinalysis
		T;N, Stat, Stat, spec type = Urine
	UA (Culture if Positive)
		T;N, Stat, Stat, spec type = Urine
	Pregnancy Test Urine
		T;N, Stat, Stat, Urine Random, spec type = Urine
	Pregnancy Test Whole Blood - JE
		T;N, Stat, spec type = Blood
	Beta-HCG Quantitative - Pregnancy
		T;N, Stat, spec type = Blood
	Magnesium Level
		T;N, Stat, spec type = Blood
	hsCRP
		T;N, Stat, spec type = Blood
	D-Dimer - MH/WH/JE
		T;N, Stat, spec type = Blood
	D-Dimer Level - FH
		T;N, Stat, spec type = Blood
	ProBNP
		T;N, Stat, spec type = Blood
	B-Type Natriuretic Peptide - FH
		
Diagnostic Tests
	ECG in ED
		Stat, Indication: Chest Pain
	Chest 1 View
		Stat, Abnormal EKG
IV Solutions
	Sodium Chloride 0.9%
		250 mL, IV, STAT, 1 Dose(s)/Time(s), 999 ml/hr
		1,000 mL, IV, STAT, 1 Dose(s)/Time(s), 125 ml/hr
	nitroglycerin 50 mg/D5W 250 mL Premix IV
		50 mg, EVERY BAG, 5 mcg/min
		250 mL, drug form: IV Large Volume, route of administration: IV, pharmacy order priority: Routine, requested start date/time T;N, Maintain Parameter: SBP> Parameter Goal: 90, Increment Dose Increase: 5 mcg/min, Increment Dose Decrease: 5 mcg/min, Incremen
			Comment: If no response at 20mcg/min, may increase by 10mcg/min every 5 min.  If the dose has been titrated twice within the specified timeframe and goal parameter is not achieved, the titration dose can be doubled until the ordered parameter is achieved or maximum dose is reached.  IV may be re-initiated after weaning within 12hours, re-initiate at the last dosing rate that maintained Goal parameter. Discontinue order after 12hr if patient does not require IV re-initiation.
	HEParin 25,000 units/premixed diluent 250 mL
		250 mL, IV, STAT, 1 Dose(s)/Time(s)
			Comment: conc: 100 units/mL. Titrate according to Low Dose Weight Based Heparin Protocol.  Maximum weight for dosing 110kg.  MAXIMUM INITIAL rate is 1000unit/hr.1)  Anti-factor Xa UFH <than 0.2 units/mL, bolus 60 units/kg & increase rate by 4 units/kg/hr.2)  Anti-factor Xa UFH = 0.2-0.29 units/mL, bolus 30 units/kg & increase rate by 2 units/kg/hr.3)  Anti-factor Xa UFH = 0.3-0.7 units/mL, (therapeutic range) Do not give bolus & do not change rate.4)  Anti-factor Xa UFH = 0.71-0.95 units/mL, do not bolus. Decrease rate by 2 units/kg/hr.5)  Anti-factor Xa UFH = 0.96 units/mL or more, do not give bolus. Stop infusion for 60 mins & decrease rate by 3 units/kg/hr.Upper hard limits for weight based and non-weight based infusions are as follows: 40 units/kg/hour and 3000 units/hour, respectively; if patient needs require exceeding these limits, contact pharmacy and prescriber.
		25,000 units, EVERY BAG, 12 unit/kg/hr
Medications
	aspirin
		324 mg, Tablet-Chew, BY MOUTH, Once, STAT
	Nitrostat
		0.4 mg, Tab, SUBLINGUAL, Q5MIN, chest pain, STAT, 3 Dose(s)/Time(s)
	morphine  IV
		1 mg, Syringe, IV PUSH, Once, STAT
		2 mg, Syringe, IV PUSH, Once, STAT
		3 mg, Syringe, IV PUSH, Once, STAT
		4 mg, Syringe, IV PUSH, Once, STAT
	ondansetron
		4 mg, IV Push, Once
	HEParin 1000 units/mL injectable soln
		60 units/kg, Injection, IV Push, Once, STAT
			Comment: Dose = 60 units/kg Bolus (Maximum dose 4000units).  Patient on Low Dose Heparin Protocol.  Pharmacy to calculate dose. Begin heparin bolus and infusion immediately after initial stat labs are drawn.
	Plavix
		600 mg, Tab, BY MOUTH, Once, STAT
	Lopressor
		5 mg, Solution-Injection, IV Push, Q5MIN, STAT, duration: 3 Dose(s)/Time(s)
			Comment: Caution if HR<50, SBP<90, moderate-severe LV failure, 2nd or 3rd degree heart block
	Brilinta (ticagrelor)
		180 mg, Tab, By Mouth, Once, STAT
	No NSAIDS (non steroidal anti-inflamatory)
		
Patient Care
	Notify MD
		PCP of patient's admission
	ED Cardiac Telemetry Monitoring
		T;N, Once, NOW
	Continuous Pulse Oximetry by Nurse
		
	Oxygen Therapy, Nurse to Administer
		Via Nasal Cannula
	Glucose POC - RN
		T;N, Once, NOW, in ED
	Obtain Consent/Permit for:
		Methodist: Left heart catheterization and coronary arteriography, possible percutaneous transluminal coronary angioplasty, possible stent placement
		MJE: left and /or right heart catheterization with select coronary angiogram, possible peripheral angiogram, percutaneous transluminal angioplasty, stent placement with conscious sedation
	Surgical Prep
		T;N
			Comment: to right groin
	Foley Catheter
		Insert, Once
	Avoid IM Injections if possible while on anticoagulants
		
	Straight Catheter
		Insert, Once
Consults/Follow-up
	Consult Cardiologist
		Reason for Referral: ACS
	Consult Hospitalist
		Reason for Referral: ACS
	Consult Cardio-Thoracic Surgery
		Reason for Referral: ACS
	Consult Intensivist
		Reason for Referral: ACS

ED Peripheral Lock Insert with Flush
Medications
	sodium chloride 0.9% flush injectable soln
		10 mL, Syringe, IV PUSH, Q5MIN, PRN, IV line flush, 4 hr
Patient Care
	Peripheral Lock-Insert
		T;N, Once

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase