POLICY RESTRICTED CHANGI GENERAL HOSPITAL

TITLE : DOCUMENT NO. : REV NO. :

Acute Myocardial Infarction (AMI) PY/CARD/004 05
Program EFFECTIVE DATE : PAGE :
15 August 2016 1 of 5
DOCUMENT OWNER: APPROVAL:
AMI Program Director Chief, Cardiology

1.0 OBJECTIVE

1.1 To ensure that the clinical care of patients with Acute Myocardial Infarction (AMI)
conforms to current medical practice.
1.2 To provide an integrated medical, nursing and allied healthcare plan for these
patients.
1.3 To collect data and clinical quality indicators to evaluate process and improve
outcomes.

2.0 SCOPE

2.1 CRITERIA FOR ADMISSION TO THE ACUTE MYOCARDIAL INFARCTION

(AMI) PROGRAM

Eligibility:
2.1.1 All patients diagnosed to have AMI at presentation at the Accident and
Emergency Department or Cardiology inpatient ward. The diagnosis must be
verified with the Cardiology consultant on call.

2.1.2 Patients with suspected AMI as the primary medical problem referred by a non-
Cardiology department will be verified by the Cardiology consultant on call who
will decide to take over the management of the patient.

Exclusions:
2.1.3 Patients with significant pre-existing medical conditions whose life expectancy is
estimated to be less than 6 months.

2.1.4 Patients for withdrawal of treatment or not for active intervention.

2.1.5 Persistent vegetative state.

2.2 SERVICES PROVIDED IN THE AMI PROGRAM

2.2.1 Clinical assessment, acute management, risk stratification, and initiation of

cardiac rehabilitation as inpatient.

2.2.2 Streamlined and coordinated care as per AMI Clinical Pathway.

2.2.3 Refer to attached protocols for provision of emergency PCI services.

• Figure 1a for CGH ED STEMI Direct PCI Activation Protocol
• Figure 1b for Code Red Transfer to NHC Protocol
• Figure 1c for No In-House Interventionist Protocol

2.2.4 Continuous electrocardiography (ECG) monitoring and hourly monitoring of vital

signs in the Intensive Care Unit.

Original Effective Date: 1 September 2006

POLICY RESTRICTED CHANGI GENERAL HOSPITAL
TITLE : DOCUMENT NO. : REV NO. :
Acute Myocardial Infarction (AMI) PY/CARD/004 05
Program EFFECTIVE DATE : PAGE :
2016 2 of 5

2.2.5 Acute reperfusion therapy

a) Emergency Percutaneous Coronary Intervention (PCI) for patients
presenting with ST elevation within 12 hours of onset of chest pain.

b) Intravenous Thrombolysis Therapy for patients presenting with ST elevation

within 12 hours of chest pain.

2.2.6 Early initiation of antiplatelets, beta blockers, statins and ACE inhibitors for
patients without contra-indications

2.2.7 Early initiation of inpatient cardiac rehabilitation by team members comprising of

• AMI Program Registered Nurse
• Dietitian
• Physiotherapist
• Occupational Therapist
• Smoking Cessation Nurse

2.2.8 Smooth transition of care to the Cardiology ward

• Daily review by the Cardiology team (consultant-based)
• Continuous ECG monitoring for 24-48 hours
• Further up-titration of beta blocker and ACE inhibitor as tolerated
• Reinforcement of lifestyle changes by inpatient cardiac rehabilitation team
• Quantitation of ventricular function by echocardiography
• Early coronary angiography and revascularisation if clinically indicated

2.2.9 Discharge planning

• All patients are taught about recurrence of symptom.
• All patients are encouraged to provide feedback about the program before
discharge.

2.2.10 Outpatient Follow-up

a) All patients remain in the program for 1 year after discharge to maintain
lifestyle modification.
b) Patients are contacted with a follow-up call after discharge by AMI Program
Registered Nurses. Refer to Figure 2.
c) Patients are encouraged to return for outpatient rehabilitation if deemed
stable by the managing Cardiologist.
d) Patients are taught and encouraged to monitor their own risk factors
facilitated by the self-monitoring card.
e) Their 30-day mortality is tracked

Original Effective Date: 1 September 2006

POLICY RESTRICTED CHANGI GENERAL HOSPITAL
TITLE : DOCUMENT NO. : REV NO. :
Acute Myocardial Infarction (AMI) PY/CARD/004 05
Program EFFECTIVE DATE : PAGE :
2016 3 of 5

2.2.11 Significant Adverse Events (SAEs)

SAEs are identified, reported and documented by AMI Program members.

Appropriate corrective clinical and administrative actions will be taken as
needed to decrease the risk of subsequent events.

2.3 AVAILABILITY OF NECESSARY STAFF (STAFFING, HOURS OF

OPERATION, SPECIALITIES, CREDENTIALS)

2.3.1 The AMI program is available 24 hours a day where dedicated nursing and
medical staff provide care to the patients. Inpatient cardiac rehabilitation
program is available Monday to Friday and half-day on Saturday.

2.3.2 All Consultants and Associate Consultants are accredited specialists with the
Singapore Medical Council. Registrars have post-graduate degrees in Internal
Medicine and are under continuous supervision of the specialist.

2.3.3 Medical officers are all registered medical practitioners undergoing 6-monthly
posting in Cardiology. Refer to Figure 3 for AMI Program Team Coverage.

2.3.4 See Figure 4 for organisation chart on Acute Myocardial Infarction (AMI)
Clinical Care Program.

2.4 EXTENT TO WHICH THE LEVEL OF CARE OR SERVICE PROVIDED

MEETS PATIENTS’ NEEDS
2.4.1 Data for each patient is extracted from the clinical pathway and entered into the
AMI electronic Data Form upon discharge. Performance indicators such as time
to reperfusion, usage of important medications and mortality are used to
systematically review patient care.

2.4.2 Patient Feedback

Patients are encouraged to fill a feedback form before discharge. Information
from the feedback forms are used to assess patient satisfaction and identify
shortcomings of the program.

Original Effective Date: 1 September 2006

POLICY RESTRICTED CHANGI GENERAL HOSPITAL
TITLE : DOCUMENT NO. : REV NO. :
Acute Myocardial Infarction (AMI) PY/CARD/004 05
Program EFFECTIVE DATE : PAGE :
2016 4 of 5

2.5 RECOGNISED STANDARDS OR GUIDELINES FOR PRACTICE USED

(PROFESSIONAL STANDARDS, CLINICAL PATHWAYS,
MULTIDISCIPLINARY CARE PLANS, NATIONAL GUIDELINES)
2.5.1 § Changi General Hospital policies and guidelines in the management of
patients
§ Ministry of Health Clinical Practice Guidelines.
§ American College of Cardiology/ American Heart Association Practice
Guidelines

3.0 POLICY REFERENCE

Nil

4.0 DEFINITIONS

4.1 AMI Acute Myocardial Infarction

4.2 SAEs Significant Adverse Events are

• Intra-cranial hemorrhage after fibrinolytic therapy
• Non intra-cranial bleeding after fibrinolytic therapy
• Acute stent thrombosis after primary percutaneous
intervention (≤24 hours)
• Sub-acute stent thrombosis (>24hrs – 30 days)
• Acute renal failure requiring dialysis after primary
percutaneous intervention (within the index admission)

4.3 STEMI ST-Elevation Myocardial Infarction

4.4 ED Emergency Department
4.5 ECG Electrocardiogram
4.6 PCI Percutaneous Coronary Intervention
4.7 CCL Cardiac Catheterisation Lab
4.8 ICU Intensive Care Unit
4.9 SMS Short Message Service
4.10 CVM Cardiovascular Medicine
4.11 IV Intravenous
4.12 AC Associate Consultant
4.13 SR Senior Resident
4.14 ACE-I Angiotensin-Converting Enzyme Inhibitors
4.15 SCM Sunrise Clinical Manager
4.16 RN Registered Nurse
4.17 CCL Team Cardiac Catheterisation Lab Team comprises Cardiology
Doctors, Nurses, Clinical Physiologist, Radiographer

Original Effective Date: 1 September 2006

POLICY RESTRICTED CHANGI GENERAL HOSPITAL
TITLE : DOCUMENT NO. : REV NO. :
Acute Myocardial Infarction (AMI) PY/CARD/004 05
Program EFFECTIVE DATE : PAGE :
2016 5 of 5

5.0 REFERENCES

Nil

6.0 PROCEDURE SUMMARY

As per AMI Clinical Pathway

7.0 ENVIRONMENTAL

Nil

8.0 PERFORMANCE INDICATORS

• Patients have an initial review by cardiac case manager within 2 working days
• Eligible patients receive a follow-up call from the cardiac nurse manager within
10-14 days post discharge from the hospital.
• Median time to Primary Percutaneous Intervention (PCI)
• Primary percutaneous coronary intervention (PCI) received within 90 minutes of
hospital arrival
• Usage of ACE inhibitor/ Angiotensin receptor blocker for left ventricular
dysfunction
• Use of Aspirin on discharge
• Use of Beta-Blockers on discharge
• Use of Statin on discharge
• Smoking cessation brief advice
• 30-day mortality
• Usage of Aspirin within 3 hours of confirmed AMI diagnosis
• AMI patients screened positive for depression are reviewed by inpatient
psychiatric team
• Dual Antiplatelet at discharge

Original Effective Date: 1 September 2006

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Figure 1. Early Management of Acute ST-Elevation Myocardial Infarction (STEMI)

A&E first contact:

- By SCDF ambulance: Pre-hospital ECG transmission for patients arriving.
- By Self: ECG is to be done and reviewed within 10 minutes from first patient contact
(including registration counter time) for any patients presenting with chest pain or
shortness of breath.

- STEMI alert for patients with ECG suspicious for STEMI

- Patient brought to resuscitation room immediately

PCI Activation Fibrinolytic Therapy

For Classical For equivocal ED doctor to obtain

STEMI Cases STEMI Cases consent and initiate
see Figure 1a. therapy within
Target first 10minutes.
hospital contact Target first hospital
to reperfusion contact to drug
within 90 minutes If patient has suspected administration within 30
STEMI, ED doctor to contact minutes.
cardiologist on call review.
Repeat serial ECGs only at
discretion of the cardiologist.
ED doctor to call cardiologist
again if no decision after 10
minutes.

Original Effective Date: 1 September 2006

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Figure 1a. CGH ED STEMI Direct PCI Activation Protocol

Patient with STEMI and symptom onset < 12 hours as confirmed by ED AC and above.
1. Take consent for PCI

Office Hours (Mon-Fri) Non-Office Hours (Mon-Fri)

0800 hours -1730 hours 1730 hours - 0800 hours + whole day
Sat/Sun/PH

ED
• ED to call CCL (3612) and says “PCI
activation”
• ED to give 2 patient identifiers over the
phone
• ED to book ICU bed
CCL
• CCL to confirm when patient can be
sent to CCL
• CCL to call following and inform of PCI
Activation
- Interventionist
If CCL able to accept patient, ED to send
patient immediately (within 5 minutes), after
IV line, consent, and loading of aspirin
300mg and ticagrelor 180mg or clopidogrel
600mg. No need to wait for 2nd call.
ED
• ED to call interventionist on call and say “This
is a PCI activation. Are you available for the
PCI?”
• If accepted by interventionist on call, ED to call
Operator (1418) and says “PCI activation”
• ED to book ICU bed
• If patient refuses consent, ED to inform
operator to send a stand-down call to PCI
team
Operator
• Operator to SMS the following and inform of
PCI Activation:
- Interventionist on call
- CVM SR on call
- CCL personnel on duty
• Operator to do voice calls if team members do
not confirm receipt of SMS within 5 minutes of
activation.
PCI team
• PCI team to return and call patient within 30
minutes of activation
• A receiving doctor must be available at the
CCL before patient is called for.

1. Contact CVM Senior Resident on call if interventionist

not available
2. In event of Code Red or no available ICU bed to
activate Code Red transfer to NHC protocol (Figure 1b)
3. In event that ED is unable to contact the roster
interventionist on-call, to activate the NO- In-house
Interventionist Protocol (Figure 1c)

Original Effective Date: 1 September 2006

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Figure 1b. CODE RED TRANSFER TO NHC PROTOCOL

MICU 18 beds SICU 17 beds Code RED OR

No available ICU bed
(Full) (No available bed)

NB: Code Amber left 2 ICU beds

Code Red no ICU beds left
CVM Registrar/SR tries to decant
Inform Consultant on call that no ICU bed CCU patients &/or ask MICU SR to try
available to decant MICU patient

• Consultant on call to inform CMB/CEO

Decanted
• CMB/CEO decides to divert STEMI to NHC

Cardiology Registrar/SR to inform

1) ED to stop direct activation (Tel: 67877259) and call for ambulance standby (Tel: 68504510)
2) NHC CCU Registrar/SR on call (Tel: 63214440)

Patient’s ECG shows STEMI (confirmed by ED AC and above)

1. Symptom onset <12 hours

• ED to contact CGH CVM Registrar/SR on call

• CGH CVM Registrar/SR to review patient/ECG stat – confirms STEMI and that patient is agreeable
for PCI

If patient is agreeable for PCI, CGH CVM Registrar/SR to confirm transfer with CGH CVM Consultant.

CGH CVM Reg/SR Calls NHC CVM Registrar/SR to inform about activation and patient details for
NHC’s CCU bed availability – if CVM Registrar/SR agrees

CGH CVM Registrar/SR Calls SGH Operator 62223322 and directly activates Primary PCI

Transport to be arranged by ED and patient to be accompanied by CGH CVM MO to NHCS directly to

NHCS CCL. (MO to be arranged by CGH CVM Registrar/SR)

Original Effective Date: 1 September 2006

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Figure 1c. NO IN-HOUSE INTERVENTIONIST PROTOCOL

Patient’s ECG shows STEMI

ED unable to contact On-Call Interventionist

ED to contact CGH CVM Registrar/SR on call

CGH CVM Registrar/SR to call Interventionist on call again.

Failing which to call other Interventionists (Dr Goh YS, Dr Liew
BW, Dr Tan Svenszeat, Dr Ong SH, Dr Tan CH, Dr Tan KS, Dr
Jayaram, and Dr Stanley Chia in the above sequence)

Confirm no In-House intervention possible, to inform

CVM Registrar /SR to inform
Consultant on call who will decide to transfer to NHC or
patient of thrombolysis
thrombolysis

CVM Registrar/SR to inform patient of transfer & if agreeable

for PCI, to initiate transfer

CGH CVM Registrar/SR Calls SGH Operator

62223322 and directly activates Primary PCI

CGH CVM Registrar/SR Calls NHC CVM Registrar/SR to

inform about activation and patient details

Transport to be arranged by ED and patient to be

accompanied by CGH CVM MO to NHC directly to NHC CCL.
(MO to be arranged by CGH CVM Registrar/SR)

Original Effective Date: 1 September 2006

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Figure 2. POST DISCHARGE TELEPHONE CALL FOR AMI PROGRAM PATIENTS

Criteria
Patients who are discharged from the inpatient AMI program will be contacted within 2 weeks of
hospital discharge by the AMI Program RNs.

Exclusions
The following patients will be excluded :

• died or transferred to other hospitals or discharged to step down care

• admitted from Nursing home/sheltered home and prison

• are not living in Singapore

• no contactable number

• have cardiovascular follow-up with other institutions

• have significant mental condition

• decline follow-up calls

Three attempted calls will be made on different dates to contact the patient before the call is
discontinued. For cases of abscondment, the AMI program RNs will liaise with the ward nurse
to contact the patient.

Handling of Calls
• Verification of patient’s contact number and clinical information from the electronic
records.

• When the call is placed, the nurse will introduce herself /himself and verify identification
of the patient using two identifiers.

• Assess patient’s general condition, compliance to medication, dietary / physical activity

modification, clinic appointments as outlined in the AMI Program Telemanagement form
(Figure 2b).

• Provide education and re-enforcements as required.

• Manage identified symptoms as outlined in Figure 2a.

• Record assessment, action plans and advice in SCM using the Clinical Document.

Original Effective Date: 1 September 2006

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Figure 2a

Symptom Comments Actions

Chest pains or discomfort Symptoms of AMI/ Advise the patient to call ambulance
Unstable Angina (995).

Stable angina pectoris Bring forward TCU and inform primary

cardiologist

Atypical symptoms Advise the patient to go to see a primary

care doctor.

A follow-up call will be done in 1-2 days.

To bring forward TCU if necessary and

inform primary cardiologist.

Shortness of breath, Moderate severe Advise patient to go to A&E for

fatigue, edema, worsening symptoms (speaking assessment and treatment
appetite, cough, weight in short phrases,
gain of >/= 1.5 kg over 1 to orthopnea, NYHA III-
2 days and IV)

Abdominal distension or Mild-moderate Bring forward TCU and inform the

lower limb swelling symptoms with attending Cardiologist.
reduced effort
tolerance (NYHA I-II) A follow-up call will be done in 1-2 days.

Dizziness or light Near syncope/Loss of Advise patient to go to A&E.

headedness with consciousness
medication
Persistent/recurrent Bring forward TCU and inform attending
symptoms with cardiologist.
medications

Mild To see primary care doctor. A follow-up

phone call will be done in 1-2 days.

Other symptoms Advise patient to go to see a primary

care doctor for review.

Original Effective Date: 1 September 2006

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Figure 2b. AMI PROGRAM TELEMANEGEMENT FORM

Name of person spoken to:

Language spoken:

1. How do you feel since your discharge from the hospital? E.g. Same/better/worse.
Details:
Action plan:

2. Are you taking medication as prescribed? (Emphasise importance of Dual anti-

platelets adherence. To inform doctor if planned for procedures. Assess for bleeding
symptoms e.g. GI bleed)
Details:
Action plan:

3. Do you follow your dietary modification as advised by dietitian?

Details:
Action plan:

4. Do you follow your physical activity modification as advised by Physiotherapist and

Occupational therapist?
Details:
Action plan:

5. Could you recall the warning signs of heart attack, what to do when having warning
signs, and how to use your sublingual GTN?
Details:
Action plan:

6. Reminder on appointments and investigations on arrival.

7. For active smoker: Have you stopped or cut down on smoking?

Details:
Action plan:

8. Cardiac Rehabilitation Program (CRP)

I. For eligible patients who declined outpatient CRP e.g. Undecided/other reasons.
Details:
Action plan:
II. Reminder to decide on outpatient CRP after staged percutaneous coronary
intervention or Coronary artery bypass grafting done.

9. Other issues:

Original Effective Date: 1 September 2006

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Figure 3
AMI Program Team Coverage
Job Responsibilities Description
The director of the AMI program, in collaboration with other key stakeholders, will provide overall direction, goal setting; and input to important
AMI Program Director
strategic, clinical, and operational issues facing the AMI program. The director will work with the AMI core team members to achieve the goals of the
program.
The assistant director of the AMI program will assist the director of the AMI program, in collaboration with other key stakeholders, to provide overall
Assistant Program Director
direction, goal setting; and input to important strategic, clinical, and operational issues facing the AMI program. The assistant director of the AMI
program will assist the director of the AMI program and work with the AMI core team members to achieve the goals of the program.
AMI Program Registered Refer to AMI Program Registered Nurse Job Description.
Nurse

Physiotherapist Assessment of physical activity level, functional mobility and capacity. Prescription of home exercise program for secondary prevention of
cardiovascular disease.

Occupational Therapist Intervention includes functional assessment, equipment prescription, home modification and patient education on lifestyle modifications after a Heart
Attack. Patients are also screened for depression and other stressors and referred on to the Psychiatric Occupational Therapist if further intervention
is required. The Psychiatric Occupational Therapist can educate further on relaxation techniques, stress/worry/emotion management and coping
skills.

Pharmacist Daily review of medication charts. Patient/family education regarding possible drug interactions whenever necessary.

Dietitian Patient education on diet for cardiovascular disease risk reduction.

Smoking Cessation Nurse Intensive Smoking Cessation Counselling.

CCL Team Refer to Acute PCI activation work instruction.

Clinical Physiologist Performing 2D echocardiograph.

Recruitment and retention of qualified staff is delegated to the respective staff’s professional head of the department

Original Effective Date: 1 September 2006

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Figure 4
Organisation Chart
Acute Myocardial Infarction (AMI) Clinical Care Program

Chairman
Medical Board

Chief
Cardiology

Director
AMI Program

Assistant Director
AMI Program

Clinical Administration
Clinical Services
Representatives
Doctors

Senior Nurse Clinician, Case Data Management

Management
Administrative Support
Senior Nurse Manager
Cardiac Catheterisation Lab
Information Technology
Nurse Managers
Medical Intensive Care Unit
General Wards

Head
Clinical Measurement Unit

Physiotherapist Representative

Occupational Therapist
Representative

Dietitian Representative

Smoking Cessation Nurse

Coordinator

Original Effective Date: 1 September 2006