Patient: Staff CT Surgeon: Staff Cardiologist:

Clinical Pathway: Elective Coronary Artery

Bypass Graft PCM:
( CABG)
DRG:
Expected LOS: Allergies:
Level of Pre Operative Pre Op->OR OR->Extubation
Care

Location
CT Clinic/ SSC SSC/ OR ICU-W
Consults CATH conference: Placed on VSI list
film/cath results available
SWS for complicated DC needs Valve patients: TEE
PULMONARY CLINIC
PFTs on selected patients
ABGs
DENTAL consult for valve pts
NUTRITION CARE for preop
assessment
Consider autologous blood

CONSULTS COMPLETED
PRIOR TO SURGERY DATE
Tests LABS: CBC, CHEM-7, PT, Labs per Cardio-Thoracic STAT labs per protocol
PTT, ALK PHOS, SGOT BILI, OR protocol STAT Chest Xray, EKG
UA HCT q. 6 hrs and after PRBC transfusion
Chest Xray (with in 30 days of K+ q. 4 hrs X 3 and after PRBC transfusion
surgery) STAT serum K+ at least q. 1 hr if
EKG (within one week of urine output >400cc / hr
surgery) ABG as needed
T&C X 2units RBCs Diabetics: STAT Accucheck
repeat q. 4 & 8 hrs
then q. 8 hrs

LABS , EKG, XRAYS WITHIN EXPECTED LIMITS

RESULTS AVAILABLE DIABETICS : Glucose controlled
FOR PROVIDER REVIEW
PRE OP
Assessment Nursing-- DA 3888 History and Physical assessment per Hemodynamic monitoring:
Assessment intra-operative protocol Swan Ganz, EKG, A-line
Cardiac risk factors with Temporary pacemaker available
appropriate referrals (smoking VS q 15 min X 8, then
cessation, nutrition) q 1 hr
Physician--History and Physical Cardiac output:
Advance Directives inquiry q ½ hr X 4, then
Surgical consent signed/witnessed q 1 hr X 6, then
Anesthesia—Pre-anesthetic q 2 hr X 6, then
evaluation PRN until SGC dc’d
Pre-surgical multidisciplinary Pulse oximetry continuous
patient education Systems assessment q shift and PRN
Wound assessment
ASSESSMENTS
COMPLETED PRE-OP
PATIENT/FAMILY
VERBALIZE MANAGEABLE NORMAL THERMIC
ANXIETY CARDIAC NO EVIDENCE EXCESSIVE BLEEDING
SURGERY PRE OP HEMODYNAMICALLY STABLE
CHECKLIST COMPLETED ADEQUATE RESPIRATORY WEANING
AND REVIEWED PERAMETERS

This clinical pathway serves as a guideline. Variations based on the patient’s individual needs will be documented in the patient record.
DEC97
 Level of Pre Operative Pre Op->OR OR->Extubation
Care

Location
CT Clinic/ SSC SSC/ OR ICU-W
Hibiclens shower : Weigh t recorded: ICU- Foley cath
night prior to surgery W and 2S Oral/gastric tube to low cont suction
Treatments
morning of surgery I & O documented: Chest tube to 20 cm suction
Cardiopulmonary and care per protocol
Bypass fluids I & O q. 1 hr- include urine, chest
Anesthesia totals tubes
Surgical bra applied for Initiate early extubation protocol
female patients Endotracheal suction PRN
O2
Soft wrist restraints while pt is
intubated per protocol
Dressing changes per protocol
Pacer wire care per protocol
Pacemaker standby
Observe for bleeding:
CT output, wounds, lab values
Heat lamp/Bear Hugger to core temp 370C
PATIENT VERBALIZES
ABILITY TO COMPLETE PRE- MINIMAL CHEST TUBE OUTPUT
OPERATIVE SKIN PREP SUCESSFULLY WEANED FROM VENT
Medications Continue patient’s normal Ancef 1 GM IVPB with D5NS @ 20cc/hr via cordis
medications patient to OR Levophed 4mg/ 250cc D5W o/c
Discontinue NSAIDS, ASA, (if PCN allergy, Nitroglycerin 50mg/ 250cc D5W
Coumadin per order substitute Vancomycin o/c
Pre-operative medications per 1 GM IVPB) Sodium Nitroprusside 50mg/250cc
anesthesia orders For valve pts: D5W o/c
Vancomycin 1 GM. IVPB Antibiotic IV per orders
with patient to OR Analgesia IV per orders
Pre-op meds per Pepcid 20mg IVPB q. 12 hrs
anesthesia orders KCL replacement per orders
Anesthesia per Rapid MgSO4 replacement per orders
Extubation protocol Acetaminophen suppos. for T>38.4C
Plasmanate / Albumin/ Hespan for volume replacement
and notify House Officer
Sedation per protocol
Auto transfusion per protocol
PATIENT VERBALIZES
UNDERSTANDING OF MAINTAIN HEMODYNAMIC STABILITY WITH
MEDICATION INSTRUCTIONS MEDS AS NEEDED
Diet/ Continue normal diet NPO NPO
NPO AFTER MIDNIGHT Oral/gastric tube to low suction
Nutrition
___________(date)

PATIENT VERBALIZES
UNDERSTANDING OF DIET
ORDERS
Activity Activity as tolerated /as ordered Ambulatory
bedrest Cardiac position until weaned for extubation
pre- op
MEETS WEANING PROTOCOL:
Hold head up x 5 seconds
PRE-OP ACTIVITY LEVEL Follow simple commands
DOCUMENTED Move extremities x 4
Education Advance Directive information Surgical consent signed Reinforce teaching
provided and witnessed Review patient progress using Patient Plan
Pre-op teaching completed Reinforce pre-op
(Surgeon, nursing, Anesthesia, teaching
SSC) Initiate Patient Plan
Cardiac risk factors discussed Family OR updates prn
Explain patient calendar/ care per CT Nurse Specialist
pathway
PATIENT/HOME CARE
PROVIDER VERBALIZE
UNDERSTANDING OF
PATIENT/ FAMILY POST PROCEDURE
PARTICIPATE IN CARE PLAN
IDENTIFYING LEARNING
NEEDS

This clinical pathway serves as a guideline. Variations based on the patient’s individual needs will be documented in the patient record.
DEC97
 Discharge Home care needs assessed: ICU and RT notified of SWS Discharge Planning screening
support system, pending
Planning
home care provider patient transfer from
home care plan OR
Identify Primary Care Physician-
refer to Tricare Service Center for
PCM selection

ADDITIONAL
DISCHARGE
PATIENT/FAMILY PLANNING NEEDS
PARTICIPATE IN DISCHARGE IDENTIFIED
PLAN

Level of Extubation 1 POD 2 POD 3 POD
Discharge

Care

Location
ICU-W(
2S) (2S) 2S 2S
Consults Remove from VSI list

Tests CBC, Chem 10, a.m.
after surgery
PT, PTT if bleeding
Chest Xray, EKG in a.m.
and PRN
Diabetics: STAT
Accucheck q. 6 hrs until
on diet
Chest Xray , EKG in a.m. X Chem 7 in am
1 Chest Xray, EKG in a.m.
Diabetics: Accucheck 30 and PRN
min before meals and h.s. Diabetics: Accucheck 30
Coumadin patients: PT q. min
a.m. before meals and h.s.
Coumadin patients: PT
q. a.m.
CBC, Chem 7 third day after
transfer to 2S
Diabetics: Accucheck 30 min
before meals and h.s.
Coumadin patients—PT
q. a.m.

LABS, EKG, LABS, EKG, XRAYS, LABS, EKG, XRAYS, LABS, EKG, XRAYS, WITHIN
XRAYS WITHIN WITHIN EXPECTED WITHIN EXPECTED EXPECTED LIMITS
EXPECTED LIMITS DIABETICS : LIMITS DIABETICS :
LIMITS Glucose controlled DIABETICS : Glucose controlled
DIABETICS Glucose controlled
:Glucose controlled
Assessment D/C all central lines Cardiac/telemetry Telemetry monitoring Telemetry monitoring
VS q. 1 hour monitoring VS + pulse oximetry q. 4 VS + pulse oximetry q. 4 hrs
Cardiac monitoring VS + pulse oximetry q. 4 hrs hrs Systems assessment q. shift
Pulse oximetry Systems assessment q. shift Systems assessment q. and PRN
continuous and PRN shift and PRN Wound assessment
Systems assessment q. Wound assessment Wound assessment
shift and PRN HEMODYNAMICALLY
Pacer wire removal per STABLE
protocol NO DYSRYTHMIAS
Wound assessment AFEBRILE
+ BM
ADEQUATE COMFORT
LEVEL WITH ORAL
ANALGESIA
ADEQUATE
ANTICOAGULATION FOR
HEMODYNAMICALLY VALVE PATIENTS
STABLE WOUND CLEAN, DRY ,
MANAGEABLE PAIN/ INTACT
DISCOMFORT
Treatments Foley cath until 2200 Daily weight by 0500 Daily weight by 0500 Daily weight by 0500
eve of transfer Dressing changes per Shower daily after CT Shower daily (cover pacer
Daily weight by 0500 protocol removed (cover pacer wires)
I & O q. 1 hour Foley catheter removed at wires) Paint chest and leg incisions
CT – D/C as per MD 2200 hrs D/C chest and leg with Betadine q. day
orders Incentive spirometer q. 1 hr dressing If wound is draining,
Dressing changes per while awake Paint incisions with continue dressing changes
protocol C & DB Betadine using sterile technique q. shift
Pacer wire removal / care O2 @ 4L/NP. Wean as q. day and PRN
per protocol tolerated to maintain SAO2 > If wound is draining, Incentive spirometer q. 1 hr
Incentive spirometer 90% continue dressing changes while awake
supervised q. 1 hr while Wound care per protocol using sterile technique q C & DB
awake shift and prn O2 @ 4L/NP. Wean as
C & DB Replace Foley catheter if tolerated to maintain SAO2 >
O2 @ 4L/NP. Wean as no void by 0600 hrs 90%
tolerated to maintain
This clinical pathway serves as a guideline. Variations based on the patient’s individual needs will be documented in the patient record.
DEC97
 SAO2 > 90%
Wound care per protocol
MAINTAINS SAO2 >90%
ON NASAL CANNULA
NO EVIDENCE OF
BLEEDING S/P PACER
WIRE AND CHEST
TUBE REMOVAL
Level of Extubation
Care

Location
ICU-W (
2S)
Medications Hep lock IV for transfer to 2S
No IV drips
Analgesia P.O. per orders
BP and AFIB management per orders
Antibiotics per orders-
DC when CT removed
MSO4/ Tylox/ Tylenol #3 for
analgesia per orders
ECASA 325 mg P.O. q. day
NO VASOACTIVE DRIPS
Diet/Nutrition NPO
advance to ice chips, to
Clear Liquids, to
Post CABG diet as tolerated
CLEAR LIQ DIET TOLERATED
Activity OOB to chair
Ambulate PRN
HOB up 300 - advance as tolerated
MAINTAINS STERNAL
PRECAUTIONS TOLERATES
ACTIVITY WITH STABLE VS
Education Reinforce pulmonary toilet, activity,
pain management plans
Discharge Ongoing SWS assessment as needed
Planning
This clinical pathway serves as a guideline. Variations based on the patient’s individual needs will be documented in the patient record.
Incentive spirometer q. 1 Wound care per protocol
hr while awake
C & DB
O2 @ 4L/NP. Wean as
tolerated to maintain
SAO2 > 90% WEIGHT = PREOP LEVEL
Wound care per protocol PATIENT/HOME CARE
VOIDS QS PROVIDER DEMONSTRATE
APPROPRIATE WOUND CARE
1 POD 3 POD
Discharge
(2S) 2S
Enteric coated ASA 325mg P.O. q. day Enteric coated ASA 325mg P.O. q. day
for patients not receiving Coumadin for patients not receiving Coumadin
Tylenol #3/ Tylox 1-2 tabs P.O. q. 4hr Tylenol #3 /Tylox 1-2 tabs P.O. q. 4hr
PRN pain PRN pain (with food)
(with food) Colace 250mg P.O. BID
Colace 250mg P.O. BID MOM 30cc P.O. prn constipation
MOM 30cc P.O. PRN constipation Restoril 15mg P.O. PRN sleep
Restoril 15mg P.O. PRN sleep -may -may repeat X 1
repeat X 1 Beta Blocker:
Beta Blocker: Kdur:
Kdur: Lasix:
Lasix
NO MEDICATION ADJUSTMENTS
REQUIRED
TAKING MEDICATIONS
APPROPRIATE FOR OUTPATIENT
SETTING
Post CABG diet as tolerated Post CABG diet as tolerated
Attend dietary class on ward
POST CABG DIET TOLERATED POST CABG DIET TOLERATED
Stand to weigh Supervised ambulation in hallway at least
OOB to chair BID QID
Ambulate with assistance
INDEPENDENT /MINIMAL ASSIST FOR
ADLs
AMBULATING IN HALLWAYS AD LIB

Medications reviewed
Follow-up appointments reviewed
Printed Open Heart discharge instructions
reviewed with patient home care provider
per CT Nurse Specialist
Wound care instructions reviewed
Multidisciplinary Patient Education Form
reviewed
PATIENT/HOME CARE PROVIDER
VERBALIZE UNDERSTANDING OF
D/C INSTRUCTIONS
Ongoing SWS assessment as needed Ongoing SWS assessment as needed
Physical Therapy/OT per protocol
PATIENT/CARE PROVIDER
VERBALIZE/DEMONSTRATE ABILITY
TO PROVIDE CARE AT HOME
PATIENT VERBALIZES
UNDERSTANDING OF POST OP
CLINIC APPOINTMENTS:
5-10 days to Cardio/Thoracic-
(scheduled by C/T clinic)
2-4 weeks to Cardiology-
(scheduled by TRAC)
PCM appointment
for ongoing health promotion
Specialty clinic appointments as ordered
on Multidisciplinary discharge form
DEC97


Level of Care
Post Op Follow Up Post Op Follow Up Health Maintenance
(5-10 days) (2-4 weeks) (ongoing)
Location
Cardio Thoracic Clinic Cardiology Clinic Primary Care Manager
Consults Consider consult to Nutrition Seen by MD who scheduled surgery
Clinic
Make referral to outpatient
Cardiac Rehab Program when
appropriate
Tests Labs as indicated Echocardiogram-for valve patients Periodic surveillance for:
Chest x-ray Treadmill scheduled

Assessments Follow up phone consult by

Cardio Thoracic Nurse Specialist
2-5 days post discharge
Evaluate understanding of
D/C instructions and medications
Assess activity level
Assess wound status and wound
care
Treatments Suture/staple removal if required
Medications Review medications

Diet/ Periodic surveillance of Heart Healthy eating plan

Nutrition
Activity Evaluate activity tolerance Periodic surveillance of Heart Healthy activity
Reinforce no driving X 6 wks post level
op
Education Reinforce sternal precautions
Review wound care
Review medication instructions

Discharge Referred back to Cardiology Referred back to PCM for ongoing health
Clinic promotion and follow up
Planning

This clinical pathway serves as a guideline. Variations based on the patient’s individual needs will be documented in the patient record.
DEC97